Adjunctive Corticosteroid Therapy Research Articles

Pneumocystis pneumonia in intensive care: clinical spectrum, prophylaxis patterns, antibiotic treatment delay impact, and role of corticosteroids. A French multicentre prospective cohort study.

Severe Pneumocystis jirovecii pneumonia (PJP) requiring intensive care has been the subject of few prospective studies. It is unclear whether delayed curative antibiotic therapy may impact survival in these severe forms of PJP. The impact of corticosteroid therapy combined with antibiotics is also unclear. This multicentre, prospective observational study involving 49 adult intensive care units (ICUs) in France was designed to evaluate the severity, the clinical spectrum, and outcomes of patients with severe PJP, and to assess the association between delayed curative antibiotic treatment and adjunctive corticosteroid therapy with mortality. We included 158 patients with PJP from September 2020 to August 2022. Their main reason for admission was acute respiratory failure (n = 150, 94.9%). 12% of them received antibiotic prophylaxis for PJP before ICU admission. The ICU, hospital, and 6-month mortality were 31.6%, 35.4%, and 40.5%, respectively. Using time-to-event analysis with a propensity score-based inverse probability of treatment weighting, the initiation of curative antibiotic treatment after 96h of ICU admission was associated with faster occurrence of death [time ratio: 6.75; 95% confidence interval (95% CI): 1.48-30.82; P = 0.014]. The use of corticosteroids for PJP was associated with faster occurrence of death (time ratio: 2.48; 95% CI 1.01-6.08; P = 0.048). This study showed that few patients with PJP admitted to intensive care received prophylactic antibiotic therapy, that delay in curative antibiotic treatment was common and that both delay in curative antibiotic treatment and adjunctive corticosteroids for PJP were associated with accelerated mortality.

Adjunctive Systemic Corticosteroids for Pulmonary Exacerbations of Cystic Fibrosis.

Rationale: Pulmonary exacerbations (PEx) remain the most common cause of morbidity, recurrent hospitalization, and diminished survival in people with cystic fibrosis (PWCF) and are characterized by excess inflammation. Corticosteroids are potent, widely available antiinflammatory drugs. However, corticosteroid efficacy data from randomized controlled trials in PWCF are limited. Objectives: To determine whether adjunctive systemic corticosteroid therapy is associated with improved outcomes in acute CF PEx. Methods: We performed a secondary analysis of Standardized Treatment of Pulmonary Exacerbations 2 (STOP2), a large multicenter randomized controlled trial of antimicrobial treatment durations for adult PWCF presenting with PEx, that included the use of corticosteroids as a stratification criterion in its randomization protocol. Corticosteroid treatment effects were determined after propensity score matching for covariates including age, sex, baseline forced expiratory volume in 1 second (FEV1), genotype, and randomization arm. The primary outcome measure was the change in percentage predicted FEV1 (ppFEV1). Symptoms, time to next PEx, and the incidence of adverse events (AEs) and serious adverse events (SAEs) were assessed as secondary endpoints. Phenotypic factors associated with the clinical decision to prescribe steroids were also investigated. Results: Corticosteroids were prescribed for 168 of 982 PEx events in STOP2 (17%). Steroid prescription was associated with decreased baseline ppFEV1, increased age, and female sex. Cotreatment with corticosteroids was independent of treatment arm allocation and did not result in greater mean ppFEV1 response, longer median time to next PEx, or more substantial symptomatic improvement compared with propensity-matched PWCF receiving antibiotics alone. AEs were not increased in corticosteroid-treated PWCF. The total number of SAEs-but not the number of corticosteroid-related or PEx-related SAEs-was higher among patients receiving corticosteroids. Conclusions: Empiric, physician-directed treatment with systemic corticosteroids, although common, is not associated with improved clinical outcomes in PWCF receiving antibiotics for PEx. Clinical trial registered with www.clinicaltrials.gov (NCT02781610).

Efficacy and Safety of Corticosteroid Therapy for Community-Acquired Pneumonia: A Meta-Analysis and Meta-Regression of Randomized, Controlled Trials.

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality. In the present study, we aimed to assess the effect of corticosteroids on all-cause mortality in patients hospitalized with CAP. For this meta-analysis and meta-regression, we conducted a systematic search of trials that evaluated the effect of corticosteroid therapy in patients hospitalized with CAP through March 2023. We included randomized, controlled trials, comparing adjunctive corticosteroid therapy with the standard of care alone for treatment of patients hospitalized with CAP and reporting all-cause mortality. We excluded retrospective analyses, observational data, and trial protocols. The primary outcome was all-cause mortality within 30 days after hospital admission. The safety analysis included the frequency of adverse events and steroid-associated adverse events. The literature search identified 35 713 citations, of which 15 studies and 3367 patients were eligible for the final analysis. The all-cause mortality at 30 days was significantly lower in the corticosteroid group (104 of 1690, 6.15%) than in the control group (152 of 1677, 9.06%; risk ratio [RR], 0.67; 95% confidence interval [CI], .53 to .85; P = .001; I2 = 0%). In 9 studies (2549 patients) that reported the occurrence of adverse events, corticosteroid therapy was not associated with an increased risk of developing any adverse event compared with standard care (RR, 0.90; 95% CI, .65 to 1.24; P = .5; I2 = 88%). Adjunctive systemic corticosteroid therapy in patients hospitalized with CAP was associated with a reduction in all-cause mortality by day 30. The benefits were more pronounced in patients with severe pneumonia.

Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia.

To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.

An ayurvedic approach to a case of ulcerative keratitis (Savrana Shukra)

Ulcerative keratitis (UK) is one of the most prevalent ocular diseases characterized by partial or total loss of vision. While contact lens wear is the primary risk factor of the UK in the young, compromised ocular immunity is responsible for it in the old age group. Early diagnosis and treatment help to bring about better results. Antimicrobial therapy remains the mainstay of treatment in ulcerative keratitis, whereas adjunctive topical corticosteroid therapy remains a matter of debate. The UK signs and symptoms match that of Savrana Shukra mentioned in the Ayurvedic texts. We present the case of a 72-year-old male admitted for redness and blurred vision in the right eye, associated with ocular pain, tearing, and photophobia. We diagnosed the case as Savrana Shukra. He underwent Ayurvedic therapy in the form of internal medicines such as Amritotaram Kashaya, Manjistadi kashaya, Kaisora Guggulu and Pratimarsha Nasya with Anu tailam. He also underwent treatments such as Jalokavacharana, Netra Seka, Vidalaka and Anjana karma. After a month of treatment, the corneal ulcer healed completely and thinned down the scar on the cornea. His visual acuity improved from 6/60B to 6/6 in the affected eye. Ayurvedic treatment was effective in completely healing the corneal ulcer and controlling the active inflammation, thereby improving vision. However, more extensive studies with larger samples will yield more data to prove the potential of Ayurveda in such cases.

EXPLORING THE ROLE OF ADJUNCT CORTICOSTEROID THERAPY TO DECREASE COMMUNITY-ACQUIRED PNEUMONIA-RELATED COMPLICATIONS: A SYSTEMATIC REVIEW AND META-ANALYSIS

SESSION TITLE: Outcomes in Pneumonia and NTMSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/17/2022 12:15 pm - 1:15 pmPURPOSE: Adjunct corticosteroid therapy to patients with community-acquired pneumonia (CAP) remains controversial in clinical practice. We performed an updated systematic review and meta-analysis to assess the efficacy of corticosteroids in decreasing complications of CAP such as ARDS, empyema, shock, and pleural effusion.METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus for randomized controlled trials (RCT) from each database’s inception to February 2022. We estimated the summary risk ratios (RR) with their corresponding 95% confidence interval (CI) through random effects Mental-Haenszel model. Subgroup analyses were also conducted. I-squared statistics (I2) were used to evaluate heterogeneity. Publication bias was assessed with Begg’s tests.RESULTS: We included 11 RCTs containing 3,509 patients with CAP. Adjunctive corticosteroid therapy was associated with significant reduction in CAP-related complications (RR = 0.73, CI 0.55 – 0.97, p = 0.015, I2 = 56.9%). In subgroup analysis, patients who received higher dose of steroids (> 50 mg prednisone equivalents/day) had a more significant reduction in CAP-related complications (RR = 0.46, CI = 0.31 – 0.68, p = 0.001, I2 = 12.2%). No significant publication bias was observed with Begg’s test (p = 0.087).CONCLUSIONS: This meta-analysis indicates that adjunctive corticosteroids significantly reduce CAP-related complications.CLINICAL IMPLICATIONS: Adjunctive corticosteroid therapy is a plausible option to limit complications such as ARDS, empyema, shock, and pleural effusion in CAP patients with co-morbidities and who are at high risk for clinical deterioration.DISCLOSURES: No relevant relationships by Mubashir Ayaz AhmedNo relevant relationships by Shayet Hossain EshanNo relevant relationships by Sami HusseinNo relevant relationships by Mohammed HusseinNo relevant relationships by Jose Medina InojosaNo relevant relationships by Wasey Ali Yadullahi MirNo relevant relationships by Sudha MisraNo relevant relationships by Kamalnath Sankaran RajagopalanNo relevant relationships by Chenyu Sun SESSION TITLE: Outcomes in Pneumonia and NTM SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Adjunct corticosteroid therapy to patients with community-acquired pneumonia (CAP) remains controversial in clinical practice. We performed an updated systematic review and meta-analysis to assess the efficacy of corticosteroids in decreasing complications of CAP such as ARDS, empyema, shock, and pleural effusion. METHODS: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus for randomized controlled trials (RCT) from each database’s inception to February 2022. We estimated the summary risk ratios (RR) with their corresponding 95% confidence interval (CI) through random effects Mental-Haenszel model. Subgroup analyses were also conducted. I-squared statistics (I2) were used to evaluate heterogeneity. Publication bias was assessed with Begg’s tests. RESULTS: We included 11 RCTs containing 3,509 patients with CAP. Adjunctive corticosteroid therapy was associated with significant reduction in CAP-related complications (RR = 0.73, CI 0.55 – 0.97, p = 0.015, I2 = 56.9%). In subgroup analysis, patients who received higher dose of steroids (> 50 mg prednisone equivalents/day) had a more significant reduction in CAP-related complications (RR = 0.46, CI = 0.31 – 0.68, p = 0.001, I2 = 12.2%). No significant publication bias was observed with Begg’s test (p = 0.087). CONCLUSIONS: This meta-analysis indicates that adjunctive corticosteroids significantly reduce CAP-related complications. CLINICAL IMPLICATIONS: Adjunctive corticosteroid therapy is a plausible option to limit complications such as ARDS, empyema, shock, and pleural effusion in CAP patients with co-morbidities and who are at high risk for clinical deterioration. DISCLOSURES: No relevant relationships by Mubashir Ayaz Ahmed No relevant relationships by Shayet Hossain Eshan No relevant relationships by Sami Hussein No relevant relationships by Mohammed Hussein No relevant relationships by Jose Medina Inojosa No relevant relationships by Wasey Ali Yadullahi Mir No relevant relationships by Sudha Misra No relevant relationships by Kamalnath Sankaran Rajagopalan No relevant relationships by Chenyu Sun

Adjunctive corticosteroid therapy in patients with pulmonary tuberculosis.

SUMMARYOBJECTIVES:In tuberculosis treatment, corticosteroids are used as adjuvants, especially in meningeal/pericardial tuberculosis. In other forms of the disease, especially in severe tuberculosis requiring mechanical ventilation, its use is controversial. The aim of the present study is to assess whether the use of corticosteroids in the treatment of pulmonary tuberculosis patients in mechanical ventilation is associated with in-hospital mortality.METHODS:This is a retrospective cohort study. Tuberculosis patients >18 years requiring mechanical ventilation, admitted to the emergency department or intensive care unit, were included. Data on corticosteroid use and mortality were collected.RESULTS:In total, 467 patients were included in the analysis; 399 used corticosteroids and 68 were noncorticosteroid users. The mortality rate was higher among corticosteroid users (59.9%) than in noncorticosteroid users (41.2%) (p=0.010). The total dose of corticosteroid in prednisone equivalents was not different between survivors and nonsurvivors (median [interquartile range]: 80 mg [5–56.6 mg] vs. 80 mg [50–135 mg]; p=0.881).CONCLUSIONS:Tuberculosis patients in mechanical ventilation who used corticosteroids had a higher mortality rate than those who did not use corticosteroids. The role of corticosteroids in pulmonary tuberculosis, especially in critically ill patients, remains unclear and needs further evaluation in prospective studies.

Orbital Subperiosteal Abscess: The Role of Nonsurgical Management Among Adolescents and Adults

ABSTRACT Purpose To investigate the role of nonsurgical management in the treatment of orbital cellulitis complicated by subperiosteal abscess (SPA) in adolescent and adult populations. Methods A retrospective cohort study to assess the demographic, clinical, and outcome profiles of adolescent and adult patients with orbital SPA treated nonsurgically versus those who received surgical intervention. Primary outcome measures included hospitalization length and best-corrected visual acuity (BCVA) in the final evaluation. Results The study comprised 76 patients diagnosed with SPA in the setting of orbital cellulitis. Twelve were stratified into the nonsurgical cohort, while 64 represented the surgical group. Sinusitis was the most prevalent risk factor among both populations, and the rate did not differ significantly. SPA was located medially at a significantly higher rate in the nonsurgical cohort compared with the surgical. No patients in the nonsurgical population had a relative afferent pupillary defect (RAPD) on presentation. The proportion of patients who received adjunctive systemic corticosteroid therapy was comparable in both groups. Hospitalization length was significantly higher in the surgery cohort. BCVA in the final evaluation was favourable in both groups. Sinusitis subgroup analysis including eight nonsurgical patients produced overall consistent results. Conclusions Findings from the largest study of orbital cellulitis complicated by SPA to date demonstrate a role for nonsurgical management in adolescent and adult patients who present with a medial SPA and/or ophthalmic examination without an RAPD. Among these populations, visual prognosis is favourable whether management includes surgical debridement or not, and surgical intervention may not predict a shorter duration of hospitalization.

Can adjunctive corticosteroid therapy improve patient-centered outcomes following third molar surgery? A systematic review.

Background Third molar surgery is frequently associated with postoperative discomfort such as pain, edema and trismus. We aimed to evaluate the current evidence on the efficacy of adjunctive corticosteroid therapy in improving patient-centered outcomes following third molar surgery.Material and Methods This systematic review assessed and searched PubMed, Google scholar, Scopus, web of science, clinicaltrials.gov and Cochrane central for controlled trials, up to May 2021. The primary outcome measures were patient-centered outcomes such as quality of life following the use of adjunctive corticosteroid therapy in third molar removal. Only randomized controlled trials published in English language were included.Results A total of 355 studies were initially identified, and 12 studies were finally included. The results showed that both methylprednisolone and dexamethasone decreased postoperative side effects such as pain, trismus, and edema and consequently were improving patient reported outcomes. In this regard, none of the included papers reported any significant statistical difference between these two drugs (p > 0.05). The analysis regarding the route of administration for the corticosteroids showed that local and intravenous injection of dexamethasone had equivalent effects, and both methods showed better results as compared to simple oral administration.Conclusions Adjunctive use of corticosteroid drugs may improve patient-centered outcomes following third molar surgery. However, there is no significant difference between drugs and routs of administration. Comparing various administration routs, local submucosal injection of dexamethasone seems to be a straightforward, painless and cost-effective adjunctive therapy. Key words:Third molars, corticosteroids, patient-reported outcomes, health related quality of life.

Eyelid ptosis and muscle weakness in a child with Kawasaki disease: a case report

BackgroundKawasaki disease (KD) is an acute febrile vasculitis that often occurs in children under 5 years. Ptosis and muscle weakness associated with KD are rarely documented.Case presentationWe present a case of KD with eyelid ptosis and muscle weakness in a 3-year-old boy. At admission, grade IV and grade III muscle strength were recorded for upper and lower limbs, respectively. Diminished patellar tendon reflex was noted. Laboratory evaluation showed hypokalemia with the serum potassium concentration of 2.62 mmol/L. Intravenous immunoglobulin (IVIG) and aspirin were initiated immediately accompanied with methylprednisolone for adjunctive therapy. Potassium supplement was administered at the same time, which resulted in the correction of hypokalemia on the 2nd day of admission but no improvement in ptosis and muscle weakness. Neostigmine testing, lumber puncture, electromyography, and cerebral and full spine MRI were performed, which, however, did not find evidence for neural and muscle diseases. On the 5th day, the fever was resolved. On the 6th day, eyelid ptosis disappeared. And on the 14th day, the muscle strength and muscle tension returned to normal, patellar tendon reflex could be drawn out normally, and the boy regained full ambulatory ability.ConclusionsKD might affect the neural and muscular systems, and KD complicated with eyelid ptosis and muscle weakness is responsive to the standard anti-inflammatory treatment plus adjunctive corticosteroid therapy.

Epidemiology and Clinical Impact of Respiratory Coinfections at Diagnosis of Pneumocystis jirovecii Pneumonia.

The role of respiratory coinfections at diagnosis of Pneumocystis jirovecii pneumonia (PcP) on clinical impact has been underestimated. A retrospective observational study was conducted January 2011 to April 2019 to evaluate respiratory coinfections at diagnosis of PcP patients in 2 tertiary care hospitals. Coinfection was defined by identification of pathogens from P. jirovecii-positive samples. Of 7882 respiratory samples tested for P. jirovecii during the 8-year study, 328 patients with diagnosis of PcP were included. Mean age was 56.7 (SD 14.9) years, 193 (58.8%) were male, 74 (22.6%) had positive HIV serology, 125 (38.1%) had viral coinfection, 76 (23.2%) bacterial coinfection, and 90-day mortality was 25.3%. In the overall population, 90-day mortality was independently associated with solid tumor underlying disease (odds ratio [OR], 11.8; 95% confidence interval [CI], 1.90-78.0; P = .008), sepsis-related organ failure assessment score (SOFA) at admission (OR, 1.62; 95% CI, 1.34-2.05; P< .001), and cytomegalovirus (CMV) respiratory coinfection (OR, 3.44; 95% CI, 1.24-2.90; P = .02). Among HIV-negative patients, respiratory CMV coinfection was associated with worse prognosis, especially when treated with adjunctive corticosteroid therapy. Respiratory CMV coinfection at PcP diagnosis was independently associated with increased 90-day mortality, specifically in HIV-negative patients.

DELAYED DIAGNOSIS OF COCCIDIODES IMMITIS INFECTION WITH PULMONARY ABSCESS AND ARDS DIAGNOSED IN CHICAGO

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Coccidiodes immitis is a highly pathogenic fungus that is found in western and southern California's desert's regions. It frequently presents as a pneumonia that does not get better after anti-biotic therapy. With less than 5% of immunocompetent patient's progressing to have disseminated or severe infections (1). A disseminated Coccididiodes infection can be treated with liposomal amphotericin B, fluconazole, and steroids when there is Acute Respiratory Distress Syndrome (ARDS) (1,2). CASE PRESENTATION: In this case, a relatively healthy 80-year-old male with a past medical history of gastroesophageal reflux disease, hypertension, and hyperlipidemia who comes in shortness of breath, cough, and congestion. He had completed a course of azithromycin without resolution of symptoms. His initial chest x-ray showed a right upper lobe consolidation (Figure 1a). Bronchoscopy with transbronchial biopsies was performed which showed an acute organizing pneumonia (Figure 2). Despite antibiotic therapy and steroids, the patient did not have significant clinical improvement. So liposomal amphotericin B was started. An open lung biopsy was performed on day 14 as his chest X-ray was significantly worse with significant hypoxia (Figure 1b). Open lung biopsy showed a large abscess. A chest tube was placed. The abscess was irrigated with saline containing antibiotics. Pathology reported numerous coccidiodes spores (Figure 3). Antibiotics were discontinued. The patient's hospital course was complicated by a persistent air leak post lung biopsy and ARDS. Adjunctive steroids were added with improvement of his hypoxia. The patient was transitioned to a lower dose of steroids and to high dose fluconazole for long term treatment of his Coccidiodes infection. He was stable for placement of a tracheostomy and discharged to a long term acute care hospital (LTACH) for further care. His chest x-ray showed significant fibrosis (Figure 1c). DISCUSSION: When we re-examined the patient's history, he had a short trip to the southwestern United states for a total of 10 days with his family. This is the source of the patient's exposure. A thorough history may have helped, but urine Coccidiodes antigen testing was negative even after the open lung biopsy was performed. Despite clinical improvement, the patient passed 6 weeks after discharge to long term acute care hospital. CONCLUSIONS: Severe Coccoidiodes pulmonary infections can progress to ARDS. While, it is responsive to liposomal amphotericin B and steroids, it is still associated with a high morbidity and mortality (2). A high index of suspicion for a fungal infection should be maintained in patient's who have pneumonia refractory to antibiotic therapy. Speaking directly with the pathologist will also aide in the diagnosis of fungal infections non-endemic to the area especially like in this case (3). REFERENCE #1: Kirkland TN, Fierer J. Coccidioides immitis and posadasii; A review of their biology, genomics, pathogenesis, and host immunity. Virulence. 2018;9(1):1426-1435. doi:10.1080/21505594.2018.1509667 REFERENCE #2: Shibli M, Ghassibi J, Hajal R, O'Sullivan M. Adjunctive corticosteroids therapy in acute respiratory distress syndrome owing to disseminated coccidioidomycosis. Crit Care Med. 2002 Aug;30(8):1896-8. doi: 10.1097/00003246-200208000-00037. PMID: 12163812. REFERENCE #3: Pitcher JH, Zuckerman JB. Coccidioides Immitis Infection with Involvement of the Airway. Conn Med. 2016 Oct;80(9):539-541. PMID: 29772139 DISCLOSURES: No relevant relationships by Justin Ching, source=Web Response

Effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure: a cohort study

Background: Tuberculosis (TB) remains an important and evolving health problem worldwide. Acute respiratory failure, the most severe form of pulmonary tuberculosis, is associated with a high mortality rate. Adjunctive corticosteroid therapy has been reported as an effective treatment in extrapulmonary TB. The aim of this study was to investigate the effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure.&#x0D; Methods: This retrospective cohort study enrolled newly diagnosed pulmonary tuberculosis patients with acute respiratory failure who were admitted to Siriraj Hospital (Bangkok, Thailand) during January 2011 to December 2013. Patients that received corticosteroid as an adjunctive treatment for pulmonary TB were assigned to the steroid group. The control group consisted of patients that did not receive corticosteroid. Collected data included age, gender, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, sequential organ failure assessment (SOFA) scores, vital signs, PaO2/FiO2 ratio, chest X-ray abnormality pattern, and TB treatment strategies, including antituberculosis agents and adjunct corticosteroid treatment. The primary outcome was hospital mortality rate. The secondary outcomes were hospital length of stay and duration of mechanical ventilation.&#x0D; Results: Thirty-eight patients were included. There were 18 patients in the steroid group and 20 in the control group. No significant difference was observed between groups for age, gender, BMI, APACHE II score, vital signs, or PaO2/FiO2 ratio. Patients in the steroid group had a significantly higher mean SOFA score than controls (5.7±4.5 vs. 3.3±2.6, respectively; p=0.046). Almost all patients in this study (97.1%) had positive culture for M. tuberculosis from sputum. The mean corticosteroid dose was equivalent to hydrocortisone 329.7±146.0 mg/day. Patients in the steroid group had higher hospital mortality than control group patients, but the difference did not achieve statistical significance (66.7% vs. 45.0%, respectively; p=0.21). Adjunctive corticosteroid therapy did not significantly reduce hospital length of stay or duration of mechanical ventilation when compared between the steroid and control groups (12.0±13.3 vs. 14.6±19.3 days, respectively; p=0.636 and 7.2±10.6 vs. 8.0±8.3 days, respectively; p=0.801).&#x0D; Conclusion: Adjunctive corticosteroid therapy had no significant positive effect on outcomes in pulmonary tuberculosis patients with acute respiratory failure.

Effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure: a cohort study

Background: Tuberculosis (TB) remains an important and evolving health problem worldwide. Acute respiratory failure, the most severe form of pulmonary tuberculosis, is associated with a high mortality rate. Adjunctive corticosteroid therapy has been reported as an effective treatment in extrapulmonary TB. The aim of this study was to investigate the effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure. Methods: This retrospective cohort study enrolled newly diagnosed pulmonary tuberculosis patients with acute respiratory failure who were admitted to Siriraj Hospital (Bangkok, Thailand) during January 2011 to December 2013. Patients that received corticosteroid as an adjunctive treatment for pulmonary TB were assigned to the steroid group. The control group consisted of patients that did not receive corticosteroid. Collected data included age, gender, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, sequential organ failure assessment (SOFA) scores, vital signs, PaO2/FiO2 ratio, chest X-ray abnormality pattern, and TB treatment strategies, including antituberculosis agents and adjunct corticosteroid treatment. The primary outcome was hospital mortality rate. The secondary outcomes were hospital length of stay and duration of mechanical ventilation. Results: Thirty-eight patients were included. There were 18 patients in the steroid group and 20 in the control group. No significant difference was observed between groups for age, gender, BMI, APACHE II score, vital signs, or PaO2/FiO2 ratio. Patients in the steroid group had a significantly higher mean SOFA score than controls (5.7±4.5 vs. 3.3±2.6, respectively; p=0.046). Almost all patients in this study (97.1%) had positive culture for M. tuberculosis from sputum. The mean corticosteroid dose was equivalent to hydrocortisone 329.7±146.0 mg/day. Patients in the steroid group had higher hospital mortality than control group patients, but the difference did not achieve statistical significance (66.7% vs. 45.0%, respectively; p=0.21). Adjunctive corticosteroid therapy did not significantly reduce hospital length of stay or duration of mechanical ventilation when compared between the steroid and control groups (12.0±13.3 vs. 14.6±19.3 days, respectively; p=0.636 and 7.2±10.6 vs. 8.0±8.3 days, respectively; p=0.801). Conclusion: Adjunctive corticosteroid therapy had no significant positive effect on outcomes in pulmonary tuberculosis patients with acute respiratory failure.

Corticosteroids in the Management of Infectious Keratitis: A Concise Review

Microbial keratitis is devastating corneal morbidity with a variable spectrum of clinical manifestations depending on the infective etiology. Irrespective of the varied presentation delayed treatment can lead to severe visual impairment resulting from corneal ulceration, possible perforation, and subsequent scarring. Corticosteroids with a potent anti-inflammatory activity reduce host inflammation, thus minimizing resultant scarring while improving ocular symptoms. These potential effects of corticosteroids have been applied widely to treat various corneal diseases ranging from vernal keratoconjunctivitis to dry eye disease. However, antimicrobial therapy remains the mainstay of treatment in microbial keratitis, whereas the use of adjunctive topical corticosteroid therapy remains a matter of debate. Understandably, the use of topical corticosteroids is a double-edged sword with pros and cons in the treatment of microbial keratitis. Herein we review the rationale for and against the use and safety of topical corticosteroids in the treatment of infective keratitis. Important considerations, including type, dose, efficacy, the timing of initiation of corticosteroids, use of concomitant antimicrobial agents, and duration of corticosteroid therapy while prescribing corticosteroids for microbial keratitis, have been discussed. This review intends to provide new insights into the therapeutic utility of steroids as adjunctive treatment of corneal ulcer.

Effectiveness of adjunctive corticosteroid therapy in patients with severe COVID-19: A retrospective cohort study.

BACKGROUNDThe effectiveness of adjunctive corticosteroid use in patients with coronavirus disease 2019 (COVID-19) remains inconclusive.AIMTo investigate the effectiveness of adjunctive corticosteroid therapy in patients with severe COVID-19.METHODSWe conducted a retrospective analysis of the difference in several outcomes between patients with severe COVID-19 who received corticosteroid therapy (the corticosteroid group) and patients with severe COVID-19 who did not receive corticosteroid therapy (the non-corticosteroid group).RESULTSSeventy-five patients were included in this study. Of these, 47 patients were in the corticosteroid group and 28 patients were in the non-corticosteroid group. There were no differences between the two groups in the total length of hospital stay, the length of intensive care unit stay, high-flow oxygen days, non-invasive ventilator days, invasive ventilation days, and mortality rate. Total lesion volume ratio, consolidation volume ratio and ground-glass opacity volume ratio in the corticosteroid group decreased significantly on day 14, while those in the non-corticosteroid group did not show a significant decrease.CONCLUSIONOur results show that adjunctive corticosteroid use did not significantly improve clinical outcomes in severe COVID-19 patients, but might promote the absorption of pulmonary lesions. Larger multicenter randomized controlled studies may be needed to confirm this.

Prognostic impact of early adjunctive corticosteroid therapy in non-HIV oncology or haematology patients with Pneumocystis jirovecii pneumonia: A propensity score analysis.

PurposeWhile early adjunctive corticosteroid therapy (EACST) has been proven effective in HIV patients with Pneumocystis Jirovecii Pneumonia (PJP), data remains controversial concerning non-HIV oncology or haematology patients.MethodsThis retrospective study included cancer patients without HIV and with diagnosis of PJP admitted in a cancer referral centre, from January-1-2010 to March-31-2017. We compared 30-day and 1-year mortality rate, change in the respiratory item of the Sequential Organ Failure Assessment score(SOFA-resp worsening), use of tracheal intubation between day-1 and day-5 of anti-pneumocystis therapy and occurrence of coinfections between patients with EACST and those with no or late corticosteroid therapy, using an inverse probability weighting propensity score-based (IPW) analysis.Results133 non-HIV oncology or haematology PJP patients were included (EACST n = 58, others n = 75). The main underlying conditions were haematological malignancies (n = 107, 80,5%), solid tumour (n = 27, 20,3%) and allogeneic stem cell transplantation (n = 17, 12,8%). Overall 30-day and 1-year mortality rate was 24,1% and 56,4%, respectively. IPW analysis found no difference on 30-day (HR = 1.45, 95% CI [0.7–3.04], p = 0.321) and 1-year (HR = 1.25, CI 95% [0.75–2.09], p = 0.39) mortality rate between groups.ConclusionNo difference in SOFA-resp worsening, tracheal intubation and coinfections was found between groups. Combination of EACST with anti-pneumocystis therapy in non-HIV onco-haematology PJP-patients was not associated with clinical improvement.

Corticosteroids in Community-Acquired Pneumonia: A Review of Current Literature.

Objective: To review the evidence and recommendations for the use of adjunctive corticosteroid therapy in community-acquired pneumonia (CAP). Data Sources: A literature search was conducted using PubMed (1993 to November 2020) using the search terms corticosteroids AND community-acquired pneumonia. Study Selection and Data Extraction: Pertinent randomized controlled trials, systematic reviews, and meta-analyses assessing the efficacy and safety of adjunctive corticosteroids in patients with pneumonia were evaluated for inclusion. Data Synthesis: Studies suggest that corticosteroids reduce time to clinical stability and length of hospital stay, but data regarding other important clinical outcomes, such as mortality, are limited. The greatest margin of benefit appears to be in patients with severe CAP. Evidence consistently demonstrates hyperglycemia as the most common adverse effect of corticosteroid therapy in CAP. Safety concerns regarding the potential impact of corticosteroids on the rate of CAP-related rehospitalizations require further investigation. Relevance to Patient Care and Clinical Practice: This review summarizes literature evaluating the efficacy and safety of adjunctive corticosteroids in patients with CAP. It also includes a discussion on current guideline recommendations, patient selection, corticosteroid regimens, adverse effect considerations, limitations, and future directions in this area of research. Conclusions: Studies reviewed suggest that corticosteroids are relatively beneficial and safe in patients with CAP, with the greatest benefit in severe CAP. Currently, the routine use of corticosteroids is not recommended by clinical practice guidelines with the exception of CAP and refractory septic shock. Further research is needed to better define the ideal role of corticosteroids in CAP.

Primary adjunctive corticosteroid therapy is associated with improved outcomes for patients with Kawasaki disease with coronary artery aneurysms at diagnosis

ObjectivePatients with Kawasaki disease (KD) with coronary artery enlargement at diagnosis are at the highest risk for persistent coronary artery aneurysms (CAAs) and may benefit from primary adjunctive anti-inflammatory therapy...

Thalidomide and Phosphodiesterase 4 Inhibitors as Host Directed Therapeutics for Tuberculous Meningitis: Insights From the Rabbit Model.

Tuberculous meningitis (TBM) is the most devastating form of extrapulmonary Mycobacterium tuberculosis infection in humans. Severe inflammation and extensive tissue damage drive the morbidity and mortality of this manifestation of tuberculosis (TB). Antibiotic treatment is ineffective at curing TBM due to variable and incomplete drug penetration across the blood-brain barrier (BBB) and blood-cerebrospinal fluid (CSF) barriers. Adjunctive corticosteroid therapy, used to dampen the inflammation, and the pathologic manifestation of TBM, improves overall survival but does not entirely prevent the morbidity of the disease and has significant toxicities, including immune-suppression. The rabbit has served as a fit for purpose experimental model of human TBM since the early 1900s due to the similarity in the developmental processes of the brain, including neuronal development, myelination, and microglial functions between humans and rabbits. Consistent with the observations made in humans, proinflammatory cytokines, including TNF-α, play a critical role in the pathogenesis of TBM in rabbits focusing the attention on the utility of TNF-α inhibitors in treating the disease. Thalidomide, an inhibitor of monocyte-derived TNF-α, was evaluated in the rabbit model of TBM and shown to improve survival and reduce inflammation of the brain and the meninges. Clinical studies in humans have also shown a beneficial response to thalidomide. However, the teratogenicity and T-cell activation function of the drug limit the use of thalidomide in the clinic. Thus, new drugs with more selective anti-inflammatory properties and a better safety profile are being developed. Some of these candidate drugs, such as phosphodiesterase-4 inhibitors, have been shown to reduce the morbidity and increase the survival of rabbits with TBM. Future studies are needed to assess the beneficial effects of these drugs for their potential to improve the current treatment strategy for TBM in humans.