ADJUVANT corticosteroid therapy reduces 30-day mortality in hospitalised patients with community-acquired pneumonia, but its benefits depend on baseline inflammation levels, according to a new meta-analysis of randomised controlled trials.
This individual patient data meta-analysis included eight randomised controlled trials published before July 2024, comparing corticosteroids with placebo in 3224 hospitalised patients. The primary endpoint was 30-day all-cause mortality, analysed using the intention-to-treat principle. Patients were classified as having less severe or severe pneumonia based on the pneumonia severity index and further stratified by a corticosteroid-effect model trained on six trials and validated on two. This model used C-reactive protein (CRP) to identify patients likely to benefit from corticosteroid therapy.
Overall, 7.6% of patients died within 30 days, with mortality lower in the corticosteroid group (6.6%) than in the placebo group (8.7%) (odds ratio [OR] 0.72, 95% CI 0.56–0.94; p=0.017). The corticosteroid-effect model, validated in the two most recent trials, confirmed significant heterogeneity of treatment effect. Among patients predicted to benefit (CRP >204 mg/L, n=630), mortality was significantly lower with corticosteroids (6.1%) compared to placebo (13.0%) (OR 0.43, 95% CI 0.25–0.76; pinteraction=0.026). In contrast, patients with lower CRP (≤204 mg/L, n=725) showed no significant benefit (OR 0.98, 95% CI 0.63–1.50). No treatment interaction was found between less severe and severe pneumonia subgroups. However, corticosteroids increased the risk of hyperglycaemia (24.8% vs 12.8%; OR 2.50, 95% CI 1.63–3.83; p<0.0001) and hospital readmission (7.0% vs 3.7%; OR 1.95, 95% CI 1.24–3.07; p=0.0038).
These findings highlight the importance of CRP-driven patient selection for corticosteroid therapy in pneumonia, balancing mortality benefits against increased metabolic and hospitalisation risks.
Ada Enesco, EMJ
Reference
Smit JM et al. Predicting benefit from adjuvant therapy with corticosteroids in community-acquired pneumonia: a data-driven analysis of randomised trials. Lancet Respir Med. 2025;13(3):221-233.
