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The most widely accepted definition for sCAP is the recent severe consensus guideline on managing sCAP in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Multiple efforts have been made to search for effective modulation of the immune response in CAP&#44; focused almost exclusively on anti-inflammatory therapies&#46; Corticosteroids have been evaluated in numerous studies as a potential treatment option in patients with sCAP without reaching a conclusive recommendation on their use based on poor certainty because of both statistical and clinical heterogeneity&#44; lack of optimal dosing and persistent problems with the imprecision of pooled estimations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recommendations for managing sCAP are usually included as a subsection in general CAP management guidelines&#59; 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Saleem et al&#46; published a systematic review and metaanalysis in Chest<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> evaluating the effectiveness of corticosteroids for CAP of bacterial origin among adult hospitalized patients&#44; including very recently published data&#44; such as ESCAPe-RCT&#46; All-cause mortality was selected as the primary outcome&#46; Investigators included sixteen trials that involved 3842 patients who were randomized to receive either corticosteroids or placebo&#46; Seven studies included patients with sCAP&#46; The therapy duration and specific corticosteroid administered were different between trials&#46; No association was found between corticosteroid use and mortality&#44; ICU admission and incidence of adverse events&#44; even when the effect of a higher either average daily dose or cumulative dose was considered&#46; However&#44; the authors reported that adjuvant corticosteroids are associated with reducing the need for mechanical ventilation &#40;MV&#41;&#46; It is interesting&#44; because it makes us question whether patients with more severe diseases could experience some benefit&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Shortly after that&#44; another multicenter&#44; double-blind&#44; placebo control&#44; CAPE COD trial&#44; with favourable results on the use of corticosteroids in the treatment of severe community-acquired pneumonia&#44; was published by Dequin et al&#46; in the New England Journal of Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> They included 800 patients with sCAP admitted to the intensive care unit &#40;ICU&#41; who received intravenous hydrocortisone &#40;200<span class="elsevierStyleHsp" style=""></span>mg daily for 4 or 8 days as determined by clinical improvement&#44; tapering for 8&#8211;14 days&#41; or a placebo &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The primary outcome was death at 28 days&#46; There was a significant decrease in mortality &#40;the primary outcome&#41;&#44; with 6&#46;2&#37; of the hydrocortisone group and 11&#46;9&#37; of the placebo group dead at 28 days &#40;ARR 5&#46;6&#37;&#44; 95&#37; CI &#8722;9&#46;6 to &#8722;1&#46;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; Steroids were most beneficial among patients with a C-reactive protein &#40;CRP&#41; level &#62;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#46; This is another very high-quality study&#44; with excellent methodology as the ESCAPe trial&#44; but also with the problem of being stopped without hitting the desired sample size&#44; and the mortality was lower than expected&#44; which adds some uncertainty&#46; This trial analyzed a selected group of patients with well-defined pneumonia and clear markers of severity&#46; They excluded septic shock&#44; aspiration pneumonia&#44; influenza&#44; post-obstructive pneumonia&#44; and cystic fibrosis&#44; among a much longer list&#46; This makes us question whether this population represents the patients admitted to our intensive care units&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pitre and coworkers recently published an updated systematic review and pairwise and dose-response meta-analysis of RCTs&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> examining the role of corticosteroids in patients hospitalized with bacterial CAP&#44; including dose and duration of therapy&#46; Eighteen studies&#44; included ESCAPe and CAPE COD trials and 4661 patients&#46; The authors reported that corticosteroids probably reduce mortality in more sCAP &#40;RR 0&#46;62 &#91;95&#37; CI 0&#46;45&#8211;0&#46;85&#93;&#59; moderate certainty&#41; with possibly no effect in less sCAP &#40;RR 1&#46;08 &#91;95&#37; CI 0&#46;83&#8211;1&#46;42&#93;&#59; low certainty&#41; and probably reduce risk of requiring invasive MV and ICU admission&#46; This study provides essential contributions evaluated for subgroup effect based on the severity of CAP&#46; This subgroup analysis demonstrates that corticosteroids&#39; impact on mortality is limited to those with severe disease&#44; which aligns with previous studies&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Very recently Wu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> published a systematic review evaluating the efficacy and safety of adjunctive corticosteroids in the treatment of sCAP&#46; A total of seven RCTs including ESCAPe and CAPE COD trials involving 1689 patients&#44; were included&#46; Likewise&#44; in the meta-analysis previously described&#44; corticosteroids&#39; dose&#44; regimen&#44; and treatment duration varied among the include RCTs&#46; The primary outcome was the 30-day all-cause mortality&#59; the authors informed that the overall study group had a lower mortality rate at day 30 than the control group &#40;RR 0&#46;61 95&#37; CI 0&#46;44&#8211;0&#46;85&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Compared with the control group&#44; the study group had a lower risk of the requirement of MV &#40;RR 0&#46;57&#59; 95&#37; CI 0&#46;45 to 0&#46;73&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; shorter ICU stay &#40;MD &#8722;0&#46;8&#59; 95&#37; CI &#8722;1&#46;4 to &#8722;0&#46;1&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; and hospital stay &#40;MD &#8722;1&#46;1&#59; 95&#37; CI &#8722;2&#46;0 to &#8722; 0&#46;1&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; However&#44; in the subgroup analyses&#44; the differences remained statistically significant only between specific patients subgroups such as &#8804; 60 years&#44; with ICU admission&#44; without septic shock on enrollment&#44; use of hydrocortisone and corticosteroid therapy duration of &#8804;8 days and without corticosteroids tapering&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the above-mentioned studies<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;10</span></a> observed no significant differences between the study and control groups in terms of gastrointestinal bleeding&#44; nosocomial infection and acute kidney injury&#59; glucose levels should be closely monitored due to the high risk of hyperglycemia in the study group&#46; However&#44; none studied the long-term effects of corticosteroid use such as myopathy&#44; polyneuropathy and delirium&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">With these results&#44; the obvious question is&#58; should we administer corticosteroids to all patients with sCAP&#63;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most likely answer to this question is no&#44; as there is not enough evidence to change clinical practice as recommended by the guidelines&#46; We should continue administering corticosteroids&#44; preferably hydrocortisone&#44; in those with sCAP with septic shock&#44; as recommended in the recent guidelines&#46; We should extend its use to patients without septic shock but with a high inflammatory profile sCAP determined by a CRP level &#62;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#46; Such treatment should be administered early&#44; within 24<span class="elsevierStyleHsp" style=""></span>h of diagnosis of sCAP&#46;</p></span>"
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    "fechaRecibido" => "2023-06-18"
    "fechaAceptado" => "2023-08-16"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Reference</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Country</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Design</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; of patients</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Intervention</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Inclusion time since diagnosis</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Male &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">ICU &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">MV &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Severity</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">CRP &#40;mg&#47;L&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Control Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Steroid Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Meduri 2022 &#40;ESCAPe&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM RCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">297&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MP 40 mg IV bolus&#44; then 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day for 7 days&#44; then taper for 20 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&#8211;96<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe &#40;PSI score IV&#8211;V &#62; 50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dequin 2023 &#40;CAPE COD&#41;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM RCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">395&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HCT 200<span class="elsevierStyleHsp" style=""></span>mg IV daily for 4&#8211;8 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe &#40;PSI score IV&#8211;V &#62; 50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">250&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46; Confalonieri"
                            1 => "G&#46;U&#46; Meduri"
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                        ]
                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                          "etal" => true
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                            0 => "R&#46;A&#46; Siemieniuk"
                            1 => "M&#46;O&#46; Meade"
                            2 => "P&#46; Alonso-Coello"
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                      "Revista" => array:7 [
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            3 => array:3 [
              "identificador" => "bib0020"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Metlay"
                            1 => "G&#46;W&#46; Waterer"
                            2 => "A&#46;C&#46; Long"
                            3 => "A&#46; Anzueto"
                            4 => "J&#46; Brozek"
                            5 => "K&#46; Crothers"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2019"
                        "volumen" => "200"
                        "numero" => "7"
                        "paginaInicial" => "e45"
                        "paginaFinal" => "e67"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "South African guideline for the management of pneumonia in adults"
                      "autores" => array:1 [
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Point of view
Should we use corticosteroids in patients with severe community-acquired pneumonia admitted to the Intensive Care Unit?
¿Debemos emplear corticoides en el paciente con neumonía comunitaria grave que ingresa en UCI?
Maria Luisa Cantón-Bulnesa,
Autor para correspondencia
luisabulnes@hotmail.com

Corresponding author.
, Ignacio Martín-Loechesb,c,d,e
a Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
b Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland
c Trinity College Dublin, Dublin, Ireland
d CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
e Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
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    "titulo" => "Should we use corticosteroids in patients with severe community-acquired pneumonia admitted to the Intensive Care Unit&#63;"
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        "autoresLista" => "Maria Luisa Cant&#243;n-Bulnes, Ignacio Mart&#237;n-Loeches"
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            "nombre" => "Maria Luisa"
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            "entidad" => "Intensive Care Clinical Unit&#44; Hospital Universitario Virgen Macarena&#44; Seville&#44; Spain"
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            "entidad" => "Department of Intensive Care Medicine&#44; Multidisciplinary Intensive Care Research Organisation &#40;MICRO&#41;&#44; St James&#39;s Hospital&#44; Dublin&#44; Ireland"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "&#191;Debemos emplear corticoides en el paciente con neumon&#237;a comunitaria grave que ingresa en UCI&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Whether steroid causes&#44; a mortality benefit in the severe community-acquired pneumonia &#40;sCAP&#41; remains debatable&#46; Irrespective of the microorganism&#44; lower respiratory tract infection is often associated with a profound host response leading to altered alveolar-capillary membrane permeability&#44; triggering complex systemic and pulmonary inflammatory&#47;immune responses&#46; The host&#39;s inability to fully down-regulate systemic inflammation can lead to severe complications due to direct tissue injury and constitute one of the demonstrated causes of increased mortality in sCAP&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite medical breakthroughs&#44; sCAP remains a highly prevalent disease associated with significant morbidity and mortality&#46; The most widely accepted definition for sCAP is the recent severe consensus guideline on managing sCAP in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Multiple efforts have been made to search for effective modulation of the immune response in CAP&#44; focused almost exclusively on anti-inflammatory therapies&#46; Corticosteroids have been evaluated in numerous studies as a potential treatment option in patients with sCAP without reaching a conclusive recommendation on their use based on poor certainty because of both statistical and clinical heterogeneity&#44; lack of optimal dosing and persistent problems with the imprecision of pooled estimations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recommendations for managing sCAP are usually included as a subsection in general CAP management guidelines&#59; many recommend against the routine use of corticosteroids in patients with CAP&#44; except in cases of refractory septic shock&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; it has recently published a guideline which provides recommendations on sCAP&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Based on the results of the meta-analysis performed for the guidelines&#44; the authors recommend using corticosteroids in sCAP patients with septic shock except in severe acute respiratory syndrome &#40;SARS&#41;&#44; middle east respiratory syndrome &#40;MERS&#41; and influenza pneumonia&#46; It&#39;s&#44; therefore&#44; not surprising that&#44; given the heterogeneity of guidelines&#44; clinical practice regarding corticosteroids for sCAP remains highly variable&#46; In this context&#44; Meduri and colleagues published the ESCAPe RCT&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which included 584 patients with sCAP &#40;ATS&#47;IDSA criteria&#41; who were within 72&#8722;96<span class="elsevierStyleHsp" style=""></span>h of hospital presentation and was a double-blind placebo-controlled study evaluating low-dose methylprednisolone for 21 days &#40;40<span class="elsevierStyleHsp" style=""></span>mg methylprednisolone for seven days&#44; 20<span class="elsevierStyleHsp" style=""></span>mg for seven days&#44; 12<span class="elsevierStyleHsp" style=""></span>mg for seven days&#41; in critically ill patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The primary endpoint was 60 days mortality&#59; no significant differences &#40;16&#37; vs 18&#37;&#59; adjusted OR 0&#46;9&#44; 95&#37; CI 0&#46;57&#8211;1&#46;4&#41; were found&#46; However&#44; it is important to stress that the study was stopped early due to low recruitment&#46; Despite a hypothesis that corticosteroids would benefit this population&#44; no effect was found&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">More recently&#44; Saleem et al&#46; published a systematic review and metaanalysis in Chest<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> evaluating the effectiveness of corticosteroids for CAP of bacterial origin among adult hospitalized patients&#44; including very recently published data&#44; such as ESCAPe-RCT&#46; All-cause mortality was selected as the primary outcome&#46; Investigators included sixteen trials that involved 3842 patients who were randomized to receive either corticosteroids or placebo&#46; Seven studies included patients with sCAP&#46; The therapy duration and specific corticosteroid administered were different between trials&#46; No association was found between corticosteroid use and mortality&#44; ICU admission and incidence of adverse events&#44; even when the effect of a higher either average daily dose or cumulative dose was considered&#46; However&#44; the authors reported that adjuvant corticosteroids are associated with reducing the need for mechanical ventilation &#40;MV&#41;&#46; It is interesting&#44; because it makes us question whether patients with more severe diseases could experience some benefit&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Shortly after that&#44; another multicenter&#44; double-blind&#44; placebo control&#44; CAPE COD trial&#44; with favourable results on the use of corticosteroids in the treatment of severe community-acquired pneumonia&#44; was published by Dequin et al&#46; in the New England Journal of Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> They included 800 patients with sCAP admitted to the intensive care unit &#40;ICU&#41; who received intravenous hydrocortisone &#40;200<span class="elsevierStyleHsp" style=""></span>mg daily for 4 or 8 days as determined by clinical improvement&#44; tapering for 8&#8211;14 days&#41; or a placebo &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The primary outcome was death at 28 days&#46; There was a significant decrease in mortality &#40;the primary outcome&#41;&#44; with 6&#46;2&#37; of the hydrocortisone group and 11&#46;9&#37; of the placebo group dead at 28 days &#40;ARR 5&#46;6&#37;&#44; 95&#37; CI &#8722;9&#46;6 to &#8722;1&#46;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; Steroids were most beneficial among patients with a C-reactive protein &#40;CRP&#41; level &#62;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#46; This is another very high-quality study&#44; with excellent methodology as the ESCAPe trial&#44; but also with the problem of being stopped without hitting the desired sample size&#44; and the mortality was lower than expected&#44; which adds some uncertainty&#46; This trial analyzed a selected group of patients with well-defined pneumonia and clear markers of severity&#46; They excluded septic shock&#44; aspiration pneumonia&#44; influenza&#44; post-obstructive pneumonia&#44; and cystic fibrosis&#44; among a much longer list&#46; This makes us question whether this population represents the patients admitted to our intensive care units&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pitre and coworkers recently published an updated systematic review and pairwise and dose-response meta-analysis of RCTs&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> examining the role of corticosteroids in patients hospitalized with bacterial CAP&#44; including dose and duration of therapy&#46; Eighteen studies&#44; included ESCAPe and CAPE COD trials and 4661 patients&#46; The authors reported that corticosteroids probably reduce mortality in more sCAP &#40;RR 0&#46;62 &#91;95&#37; CI 0&#46;45&#8211;0&#46;85&#93;&#59; moderate certainty&#41; with possibly no effect in less sCAP &#40;RR 1&#46;08 &#91;95&#37; CI 0&#46;83&#8211;1&#46;42&#93;&#59; low certainty&#41; and probably reduce risk of requiring invasive MV and ICU admission&#46; This study provides essential contributions evaluated for subgroup effect based on the severity of CAP&#46; This subgroup analysis demonstrates that corticosteroids&#39; impact on mortality is limited to those with severe disease&#44; which aligns with previous studies&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Very recently Wu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> published a systematic review evaluating the efficacy and safety of adjunctive corticosteroids in the treatment of sCAP&#46; A total of seven RCTs including ESCAPe and CAPE COD trials involving 1689 patients&#44; were included&#46; Likewise&#44; in the meta-analysis previously described&#44; corticosteroids&#39; dose&#44; regimen&#44; and treatment duration varied among the include RCTs&#46; The primary outcome was the 30-day all-cause mortality&#59; the authors informed that the overall study group had a lower mortality rate at day 30 than the control group &#40;RR 0&#46;61 95&#37; CI 0&#46;44&#8211;0&#46;85&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Compared with the control group&#44; the study group had a lower risk of the requirement of MV &#40;RR 0&#46;57&#59; 95&#37; CI 0&#46;45 to 0&#46;73&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; shorter ICU stay &#40;MD &#8722;0&#46;8&#59; 95&#37; CI &#8722;1&#46;4 to &#8722;0&#46;1&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#44; and hospital stay &#40;MD &#8722;1&#46;1&#59; 95&#37; CI &#8722;2&#46;0 to &#8722; 0&#46;1&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; However&#44; in the subgroup analyses&#44; the differences remained statistically significant only between specific patients subgroups such as &#8804; 60 years&#44; with ICU admission&#44; without septic shock on enrollment&#44; use of hydrocortisone and corticosteroid therapy duration of &#8804;8 days and without corticosteroids tapering&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All the above-mentioned studies<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;10</span></a> observed no significant differences between the study and control groups in terms of gastrointestinal bleeding&#44; nosocomial infection and acute kidney injury&#59; glucose levels should be closely monitored due to the high risk of hyperglycemia in the study group&#46; However&#44; none studied the long-term effects of corticosteroid use such as myopathy&#44; polyneuropathy and delirium&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">With these results&#44; the obvious question is&#58; should we administer corticosteroids to all patients with sCAP&#63;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The most likely answer to this question is no&#44; as there is not enough evidence to change clinical practice as recommended by the guidelines&#46; We should continue administering corticosteroids&#44; preferably hydrocortisone&#44; in those with sCAP with septic shock&#44; as recommended in the recent guidelines&#46; We should extend its use to patients without septic shock but with a high inflammatory profile sCAP determined by a CRP level &#62;15<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;&#62;150<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#46; Such treatment should be administered early&#44; within 24<span class="elsevierStyleHsp" style=""></span>h of diagnosis of sCAP&#46;</p></span>"
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    "fechaRecibido" => "2023-06-18"
    "fechaAceptado" => "2023-08-16"
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                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Reference</th><th class="td" title="\n
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                  \t\t\t\t  " rowspan="2" align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">MV &#40;&#37;&#41;</th><th class="td" title="\n
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                  \t\t\t\t">Meduri 2022 &#40;ESCAPe&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">USA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">DM RCT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">287&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">297&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">MP 40 mg IV bolus&#44; then 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day for 7 days&#44; then taper for 20 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">72&#8211;96<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Severe &#40;PSI score IV&#8211;V &#62; 50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dequin 2023 &#40;CAPE COD&#41;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">France&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">DM RCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">395&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">HCT 200<span class="elsevierStyleHsp" style=""></span>mg IV daily for 4&#8211;8 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Severe &#40;PSI score IV&#8211;V &#62; 50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">250&nbsp;\t\t\t\t\t\t\n
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