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To use or not to use corticosteroids for pneumonia? A clinician's perspective.

Struttura Complessa Pneumologia, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Trieste, Ospedale di Cattinara, Trieste, Italy.
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo 06/2012; 77(2):94-101.
Source: PubMed

ABSTRACT The use of corticosteroids in the management of pneumonia is still a controversial issue. The physicians in daily clinical practice often use corticosteroids in patients with pneumonia for different reasons all over the world. As an example of real life is the frequent use of corticosteroids to treat patients with pneumonia due to H1N1 pandemic influenza in spite of WHO' statements that clearly discouraged this therapy. In fact, the literature up to august 2012 reported a total of 6,650 patients with pneumonia due to H1N1 virus infection (of whom 2,515 were ICU patients): corticosteroids were used with various dose regimen in 2404 patients (37.8%). The attitude of international guidelines on pneumonia in using steroids do not help the clinician to clearly choice when and how to treat pneumonia with steroids. However, stress doses of corticosteroids are suggested by some major guidelines on community-acquired pneumonia in case of severe episodes with sepsis. To date, there are 10 randomised controlled trials assessing the effectiveness of corticosteroids for community-acquired pneumonia globally involving 1090 participants. Most of the trials adopted stress doses of glucorticoids for 4-7 days. The evidence from these trials taken separately is weak due to limitations of the studies themselves, but a Cochrane review and a systematic review found benefit using prolonged low doses of glucocorticoids in severe community-acquired pneumonia. Moreover, such a strategy decreases vasopressor dependency and appears to be safe. Nevertheless, larger trials with more patients and clinically important end-points were claimed to provide robust evidence. Finally, infection surveillance is critical in patients treated with corticosteroids, and to prevent the rebound phenomenon, the drug should be weaned slowly.

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    • "Although confusion, co-infection and gastrointestinal side effects were reported in association with glucocorticoid treatment, the incidence was not significantly higher in the steroid group [16]. While some authors advise five days of glucocorticoid treatment in critically ill patients without tapering [49-51], others recommend tapering of glucocorticoids to avoid a rebound of inflammatory markers with consecutive rebound pneumonia [37,45,46,52]. However, it has been shown that glucocorticoids given > seven days lead to a worse clinical course measured by length of stay, clinical stability and mechanical ventilation, and more systemic complications when looking at shock and cardiac arrhythmia [53]. "
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    • "Furthermore, corticosteroid therapy in patients with pandemic (H1N1) 2009 virus infection was shown to be associated with higher mortality than that without steroid treatment [52], suggesting that corticosteroid therapy might be hazardous as shown in mice infected with H5N1 highly pathogenic avian influenza virus [53]. These results suggest that anti-inflammatory drugs broadly used in humans do not necessarily suppress inflammation and the cytokine storm (hypercytokinemia) [54]. Therefore, development of other types of anti-hypercytokinemia treatment rather than anti-inflammatory drugs is required for immunocompromised patients with influenza virus infection and for patients with highly pathogenic avian influenza virus infection [55,56]. "
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