Corticosteroids in septic shock secondary to community acquired pneumonia: clarity mixed with uncertainty

Lower respiratory infections were responsible for nearly 2·4 million deaths worldwide in 2016. 1 Troeger C Blacker B Khalil IA et al. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018; 18: 1191-1210 Summary Full Text Full Text PDF PubMed Scopus (1004) Google Scholar The morbidity and mortality from community acquired pneumonia (CAP) result from the profound inflammatory response associated with the illness and patients can go on to develop serious life-threatening complications such as septic shock and acute respiratory distress syndrome (ARDS). Adjunctive corticosteroids could be beneficial in patients with CAP, although the evidence is by no means conclusive. 2 Dequin PF Meziani F Quenot JP et al. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023; 388: 1931-1941 Crossref PubMed Scopus (85) Google Scholar , 3 Torres A Sibila O Ferrer M et al. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: a randomized clinical trial. JAMA. 2015; 313: 677-686 Crossref PubMed Scopus (420) Google Scholar , 4 Meduri GU Shih MC Bridges L et al. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med. 2022; 48: 1009-1023 Crossref PubMed Scopus (57) Google Scholar Whether the presence of concomitant septic shock with CAP influences the treatment effect of corticosteroids is unknown. Hydrocortisone plus fludrocortisone for community acquired pneumonia-related septic shock: a subgroup analysis of the APROCCHSS phase 3 randomised trialIn a pre-specified subgroup analysis of the APROCCHSS trial of patients with CAP and septic shock, hydrocortisone plus fludrocortisone reduced mortality as compared with placebo. Although a large proportion of patients with CAP also met criteria for ARDS, the subgroup analysis was underpowered to fully discriminate between ARDS and CAP modifying effects on mortality reduction with corticosteroids. There was no evidence of a significant treatment effect of corticosteroids in the non-CAP subgroup. Full-Text PDF