Steroids in acute respiratory distress syndrome: A panacea or still a puzzle?

Table 4 Comparison of major studies of steroids in community-acquired pneumonia

Ref.	Country, number of participating sites	Number of patients	Type of patient population	Severity of CAP	Intervention group	Control group	Primary outcome	Remarks
Confalonieri et al[25], 2005	Italy, 6	46	Adults with severe CAP according to 1993 ATS severity criteria	Severe	IV hydrocortisone 200 mg bolus followed by IV infusion of 10 mg/hr for 7 d	Placebo	Improvement in P/F ratio and MODS score by study day 8 and reduction in delayed septic shock	Small sample size
Snijders et al[26], 2010	Netherlands, 1	204	Adults hospitalized with CAP	Any severity	IV or oral Prednisolone 40 mg for 7 d	Placebo	Clinical cure at day 7	Large number of non-severe CAP patients
Meijvis et al[27], 2011	Netherlands, 2	302	Adults with CAP without need of intensive care	Any severity	IV dexamethasone 5 mg daily for 4 d	Placebo	Length of hospital stay	ICU patient excluded
Fernandez-Serrano et al[28], 2011	Spain, 1	52	Adults up to age 75 with severe CAP according to extent of consolidation and P/F ratio	Severe	IV methylprednisolone 500 mg bolus followed by tapering infusion over 9 d	Placebo	Need for mechanical ventilation	Small sample size
Blum et al[29], 2015	Switzerland, 7	785	Adults hospitalized with CAP	Any severity	Oral prednisolone 50 mg for 7 d	Placebo	Time to clinical stability	Good sample size, primary end-point not clinically relevant
Torres et al[30], 2015	Spain, 3	120	Adults with severe CAP according to ATS or PSI criteria and CRP > 150 mg/L	Severe	IV methylprednisolone 0.5 mg/kg twice daily for 5 d	Placebo	Rate of treatment failure (composite of early and late treatment failure)	Inclusion of CRP in inclusion criteria limits generalizability of results
Meduri et al[21], 2022	United States, 42	584	Adults with severe CAP according to modified ATS/IDSA criteria with admission to intensive or intermediate care	Severe	IV methylprednisolone 40 mg/d (days 1-7), 20 mg/d (days 8-14), 12 mg/day (days 15-17), 4 mg/d (days 18-20)	Placebo	All-cause mortality at 60 d	Underpowered, delayed initiation of steroids may have masked differences between treatment groups
Dequin et al[31], 2023	France, 31	800	Adults with severe CAP in ICU	Severe	IV hydrocortisone 200 mg/d for 8 or 14 d based on improvement in patient’s condition	Placebo	All-cause mortality at 28 d	Largest RCT till date; stopped early (underpowered)

ATS: American thoracic society; PSI: Pneumonia severity index; CRP: C-reactive protein; IDSA: Infectious Diseases Society of America; CAP: Community-acquired pneumonia; ICU: Intensive care unit; RCT: Randomised controlled trial.