© 2005 American Thoracic Society
Steroid Infusion for Severe PneumoniaNot so Fast...To the Editor:The study by Dr. Confalonieri and colleagues (1) suggested that hydrocortisone infusion therapy for patients with severe community-acquired pneumonia (CAP) significantly improved clinical outcomes and survival. The authors recognized that the small sample size may have biased their results. We believe that this bias goes beyond the sample size and that the patients randomized to each group were not similar. First, a large number of the patients assessed for eligibility did not meet the inclusion criteria (69/121, 57%). Second, the differences in the number of patients that required invasive mechanical ventilation, 16/23 (70%) in the placebo group versus 7/23 (30%) in the hydrocortisone group (p value = 0.008), resulted in a selection that affected outcome. At day 8 the number of patients still on invasive mechanical ventilation was similar in both treatment groups, 15/16 (94%) in the placebo and 6/7 (84%) in the hydrocortisone group (p value = 0.5). Invasive mechanical ventilation in severe CAP is known to be associated with poor outcome (2), and a mortality > 30% (3). In this study, 50% of patients (8/16) who received invasive mechanical ventilation in the placebo group died during the observation period. Furthermore, these patients were more likely to have worsening chest radiographs, and ventilator-related complications, including ventilator-associated pneumonia and ARDS. Thus, the absence of deaths in the hydrocortisone group was unexpected and contradictory to what has been reported in the literature. This absence strongly reinforces the bias of the sample based on the severity of illness. Given the mitigating factors outlined above, the benefit of hydrocortisone infusion in patients with severe CAP should currently be viewed with caution, and further studies with adequate sample size should be performed to answer this intriguing question more appropriately.
a VERDICT—South Texas Veterans Health Care System FOOTNOTES Conflict of Interest Statement: M.I.R. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript; L.F.A. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript; E.M.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript; A.A. has been a consultant and on an Advisory Board for Altana, Elan, Chiron, Pfizer, Bayer, Aventis, Boehringer-Ingelheim, Ortho-MacNeil, and has received approximately $6,000 per year for the last 3 years and received $500 for speaking at the ACCP meeting at the Kinetic Concepts Inc. (KCI) sponsored symposia; he is an investigator in a KCI related protocol with a total grant amount of $50,000, and a Bayer related protocol with a total grant amount of $40,000, and a BART related protocol with a total grant amount of $80,000. REFERENCES
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
