In a double-blind, placebo-controlled trial, Sabine Meijvis and colleagues1 found clinical benefit of reduced length of hospital stay when dexamethasone was added to antibiotic treatment in immunocompetent patients with community-acquired pneumonia. However, of the 304 recruited cases, most had bacterial infections such as Streptococcus pneumoniae, and only seven (2·3%) were diagnosed as having influenza pneumonia (nine others [3·0%] had mixed influenza-bacterial infections, mostly S pneumoniae). As such, the results cannot be generalised to community-acquired pneumonia with viral causes.
Respiratory viruses are increasingly recognised as major causes of community-acquired pneumonia worldwide (up to about 20%),2 and influenza virus is the most important pathogen, causing excessive hospital admissions and deaths, particularly during the seasonal peaks and pandemics. Evidence suggests that corticosteroid use in influenza pneumonia cannot control excessive inflammation, but compromises the immune response, leading to longer viral shedding, secondary bacterial and fungal infections, and even increased mortality (webappendix).3, 4 Controlled studies are needed to address the use of corticosteroids in viral pneumonia and its safety. Notably, in viral pneumonia caused by the coronavirus that causes severe acute respiratory syndrome, increased viral load has been documented with corticosteroid treatment in a randomised trial.5
Given the differences in immunopathogenesis between viral and bacterial pneumonia, and the uncertainties in efficacy and safety,4 we recommend that corticosteroids should not be used routinely in known viral community-acquired pneumonia, especially influenza-related. In this regard, availability of rapid and reliable diagnostics for the causes of community-acquired pneumonia is important to guide antimicrobial treatments (targeted, susceptible antibacterials; or antivirals such as neuraminidase inhibitors), and the use of adjuvant corticosteroids.2, 4
Acknowledgments
We declare that we have no conflicts of interest.
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References
- 1.Meijvis SC, Hardeman H, Remmelts HH, et al. Dexamethasone and length of hospital stay in patients with community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial. Lancet. 2011;377:2023–2030. doi: 10.1016/S0140-6736(11)60607-7. [DOI] [PubMed] [Google Scholar]
- 2.Bartlett JG. Diagnostic tests for agents of community-acquired pneumonia. Clin Infect Dis. 2011;52(suppl 4):S296–S304. doi: 10.1093/cid/cir045. [DOI] [PubMed] [Google Scholar]
- 3.Brun-Buisson C, Richard JC, Mercat A, Thiébaut AC, Brochard L, for the REVA-SRLF A/H1N1v 2009 Registry Group Early corticosteroids in severe influenza A/H1N1 pneumonia and acute respiratory distress syndrome. Am J Respir Crit Care Med. 2011;183:1200–1206. doi: 10.1164/rccm.201101-0135OC. [DOI] [PubMed] [Google Scholar]
- 4.Lee N, Chan PK, Hui DS, et al. Viral loads and duration of viral shedding in adult patients hospitalized with influenza. J Infect Dis. 2009;200:492–500. doi: 10.1086/600383. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lee N, Chan KC, Hui DS, et al. Effects of early corticosteroid treatment on plasma SARS-associated coronavirus RNA concentrations in adult patients. J Clin Virol. 2004;31:304–309. doi: 10.1016/j.jcv.2004.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
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