I have to admit the glucocorticoids are amongst my favorite medications that we use regularly in the ICU. Whether it be hydrocortisone, dexamethasone, or methylprednisolone, I have order sets built into my EMR with the dosing for the respective indications. The indications appear to be endless. Today, I am going to be discussing an article that was published on 03/21/23 in the New England Journal of Medicine. It is titled “Hydrocortisone in Severe Community-Acquired Pneumonia (CAP)”. As always, I state to read these data for yourself and that nothing that I write or say is medical advice.
Why We Care.
Community-acquired pneumonia (CAP) is a problem. It’s the 9th leading cause of death in the US and the number one cause of infectious death. Patients who end up on the vent because of CAP are said to have a mortality rate around 30%. Here’s the kicker: we have all these fancy antibiotics, ventilators and such here in the United States. The rest of the world may not be so fortunate. This is why looking at using something as inexpensive and readily available such as hydrocortisone is so appealing to me. Not every will be able to afford the fancy immunomodulators when they are created.
The History of Glucocorticoids for other ailments.
Over the several years that I have been running this content machine I’ve created, there have been numerous pieces of content where I have broken down other beneficial data of using glucocorticoids. These include you-know-what, ACLS, and as stress-dose steroids in metabolic resuscitation. Other indications that have recently been developed include ARDS which thankfully came out in either February or March of 2020.
Which CAP patients did they provide hydrocortisone to?
These authors created a “double-blind, randomized, controlled superiority trial”. A definite hat tip to them. They took patients who had severe pneumonia and either gave them hydrocortisone or placebo. How they defined the severity of pneumonia was of interest to me because in the ICU we only tend to see the worst of the worst. They had to have at least one of four criteria: intubated, on NIV, on HFNC/NRB, or a pneumonia severity index (PSI) of 130 or greater. Not going to lie, I had to look up the PSI as I had forgotten all about it. They were going to try to enroll more than the 800 who ended up being in the trial, but, spoiler-alert, the trial was stopped early.
Dosing the Hydrocortisone
These patients received 200mg IV of hydrocortisone, as a gtt, daily during the first four days. As a point of reference, when giving stress-dose steroids in septic shock, we provide patients with either 50mg IV q6h or 100mg q8h. Lately, I tend to provide the latter as that’s one fewer bag the nurse has to hang in the patients IV pump. On day 4, the team would decide whether to continue for a total of 8 days or 14 days. The hydrocortisone in these patients with CAP was eventually tapered off.
Primary outcomes of Hydrocortisone in CAP.
The primary outcomes was defined as death from any cause at day 28. In the group that received hydrocortisone, 6.2% of patients died. In the control group, 11.9% of patients died. My take on this is that overall, these patients did really well. One thing that was considered to be in the exclusion criteria were patients who were in septic shock. It is my opinion that is why the mortality rates are so low. If you plug this into your nifty number-needed to treat calculator, you get 17.5. Not bad.
Secondary Outcomes
The secondary outcomes were plentiful and almost all statistically significant. Death at day 90 was also 9.3% vs. 14.7%. This slightly inflated the NNT to 18.5. Fewer patients were intubated if they received the hydrocortisone for their CAP. This is possibly my favorite part of the trial. Don’t wait until the patient is basically asking for the endotracheal tube to go ahead and give the Hydrocortisone. The NNT to avoid the tube was 8.7. I LOVE single digit NNT’s. The hydrocortisone also helped patients NOT go into shock with a NNT of 10.3. All good things. So good that the trial, as mentioned, was stopped early.
Adverse effects of Hydrocortisone in CAP
Prior trials of glucocorticoids in sepsis and other pathologies have almost-all found increases in hyperglycemia. Well, we have insulin for that is my response. Concerns of increases in secondary infections, delirium, GI bleeds, etc. have not been seen in the larger trials with glucocorticoids. Well, history repeats itself. No increases in infections nor GI bleeds were seen here. What was seen? Hyperglycemia. And guess what? We have insulin for that.
Should we provide our Severe CAP patients with hydrocortisone?
I believe the answer is yes. Also, patients with septic shock from pneumonia should also get it. That’s not medical advice. That has been seen in numerous previous studies to either improve mortality or decrease the duration of shock. Nonetheless, I definitely felt the need to share this paper and my thoughts on it as it could be a game-changer in the lives of our patients.
Citation
Dequin PF, Meziani F, Quenot JP, Kamel T, Ricard JD, Badie J, Reignier J, Heming N, Plantefève G, Souweine B, Voiriot G, Colin G, Frat JP, Mira JP, Barbarot N, François B, Louis G, Gibot S, Guitton C, Giacardi C, Hraiech S, Vimeux S, L’Her E, Faure H, Herbrecht JE, Bouisse C, Joret A, Terzi N, Gacouin A, Quentin C, Jourdain M, Leclerc M, Coffre C, Bourgoin H, Lengellé C, Caille-Fénérol C, Giraudeau B, Le Gouge A; CRICS-TriGGERSep Network. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023 Mar 21. doi: 10.1056/NEJMoa2215145. Epub ahead of print. PMID: 36942789.
Link to (NOT FREE) Article
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