Predicting benefit from adjuvant therapy with corticosteroids in community-acquired pneumonia: a data-driven analysis of randomised trials.

Summary

This IPD meta-analysis of eight RCTs (n=3,224) found that adjunctive corticosteroids reduce 30-day mortality in hospitalized CAP (OR 0.72). Heterogeneity of treatment effect was explained by baseline CRP: patients with CRP >204 mg/L derived substantial benefit, whereas those with CRP ≤204 mg/L did not.

Key Findings

• Across eight RCTs (n=3,224), corticosteroids reduced 30-day all-cause mortality (OR 0.72, 95% CI 0.56–0.94).
• Effect-modelling identified baseline CRP as the key predictor of benefit; CRP >204 mg/L subgroup had a large mortality reduction (OR ~0.43) during external validation.
• No significant benefit was observed in patients with CRP ≤204 mg/L (OR ~0.98).

Clinical Implications

Consider adjunctive corticosteroids for hospitalized CAP patients with high baseline CRP (>204 mg/L), while avoiding routine use in low-CRP cases. Integrate CRP into CAP risk stratification and steroid decision-making.

Limitations

• Heterogeneity in corticosteroid regimens and trial populations
• Post hoc effect-modelling may be sensitive to unmeasured confounding across trials

Future Directions

Prospective trials implementing CRP-guided corticosteroid strategies and evaluating safety (e.g., hyperglycemia, secondary infections) are warranted; assess cost-effectiveness and integration into CAP care pathways.