Coadjuvant corticosteroid therapy in critically ill patients with severe influenza pneumonia was associated with increased intensive care unit (ICU) mortality, strongly suggesting that corticosteroids should not be used concomitantly in patients with influenza pneumonia, according to the results of a study published in Intensive Care Medicine.
Antiviral therapy is standard of care for the treatment of patients with influenza pneumonia, and intravenous corticosteroids are also often used in patients with acute respiratory failure or acute respiratory distress syndrome to reduce lung inflammation and ultimately improve patient outcomes. However, no clinical trial has assessed the risks and benefits of concomitant administration of corticosteroid and antiviral therapy.
Researchers conducted a secondary analysis of a prospective cohort of critically ill patients with influenza pneumonia admitted to 148 ICUs in Spain between June 2009 and April 2014. Patients who received concomitant corticosteroid therapy were compared with those who did not receive corticosteroids. The investigators used a propensity score (PS) matching analysis to reduce confounding factors. The primary outcome was ICU mortality.
The investigators enrolled 1846 patients with influenza pneumonia. A total of 604 (32.7%) patients received corticosteroids; methylprednisolone was the most frequently used corticosteroid (95.7%). Those receiving the corticosteroid got a median daily dose equivalent to 80 mg of methylprednisolone for a median duration of 7 days. Factors independently associated with corticosteroid use included asthma, chronic obstructive pulmonary disease, hematologic disease, and the use of mechanical ventilation.
The crude ICU mortality rate was higher in patients who received corticosteroid therapy (27.5%) than in those who did not (18.8%; P <.001), and after PS matching and Cox proportional hazards (hazard ratio 1.32; 95% CI, 1.08-1.70; P <.006) and competing risk analysis (subhazard ratio=1.37; 95% CI, 1.12-1.68; P <.001) the ICU mortality rate remained elevated in patients receiving corticosteroid therapy.
The homogeneous population of patients with influenza pneumonia limits extrapolation to other populations. The study is also limited by the failure to review the duration of viral shedding or the appearance of drug-resistant virus in any of the patients and the failure to record data on mechanical ventilation.
Nonetheless, the researchers contended that corticosteroids should not be used as coadjuvant therapy in patients with influenza pneumonia.
Moreno G, Rodriguez A, Reyes LF, et al. Corticosteroid treatment in critically ill patients with severe influenza pneumonia: a propensity score matching study. Intensive Care Med. 2018;44(9):1470-1482.