Discussion
pneumonitis, pneumonia, bacterial infection, bacteremia, insulin dependence, COPD, diabetes
PNEUMONITIS, RECURRENCE, PNEUMONIA, BACTERIAL INFECTION, ADVERSE EVENTS, RECURRENT PNEUMONIA, HYPERGLYCEMIA, COPD, SECONDARY, ADVERSE EFFECTS, SECONDARY INFECTION, COMMUNITY-ACQUIRED PNEUMONIA, DIABETES
In this 180-day analysis of a large randomized controlled trial in patients hospitalized with CAP, we found similar risks for mortality and most other secondary endpoints, but higher incidences of secondary infections, recurrent pneumonias and new insulin dependence in patients randomized to the active corticosteroid group.While corticosteroids have shown beneficial effects at short term in the population of patients with CAP including shorter time to stabilization and lower mortality [There is limited availability of evidence on outcome after CAP beyond day 30 [Whereas the absolute number of new insulin dependence at day 180 was low, it was significantly higher in the prednisone group. Various individual risk factors for the development of corticosteroid-induced diabetes have been identified [We performed subgroup analyses with the aim to identify specific subgroups which would be more susceptible to adverse events, but we could not assert any effect modification by median age, initial median CRP, previous history of COPD, or severity of community-acquired pneumonia. We did find that patients without bacteremia and without proof of bacterial infection had a higher incidence of recurrence of pneumonia when receiving corticosteroids, but there was no effect modification by viral etiology of pneumonia. One might speculate that this could be a subset of patients which did, in fact, not have infectious pneumonia but rather a pneumonitis, which was overseen as generally considered uncommon in the pre-COVID-19-era.In another subanalysis with 30-day data, a phenotype with high cytokines benefited most from adjunct corticosteroids, as published elsewhere [The meta-analysis by Stern et al. showed a mortality benefit only in patients with severe CAP [In our trial, secondary infections during hospital stay and at 30 days were not increased in the prednisone group. The reduction in length of stay at day 30 may have outbalanced the increased risk for secondary infections conferred by the corticosteroids.In summary, when considering adjunct corticosteroids for CAP, it is necessary to weigh the anticipated benefits like faster time to clinical stability, shorter length of stay and shorter duration of intravenous antibiotic treatment against potential adverse effects like in-hospital hyperglycemia, secondary infections beyond day 30 and recurrence of CAP beyond day 30.