Efficacy And Safety Of Glucocorticoids In The Treatment Of Sever Community-acquired Pneumonia:A Meta-analysis

Background:Severe community-acquired pneumonia(SCAP)is a common acute and infectious disease in clinical respiratory medicine.With population aging,pathogen variation,antibiotic resistance,and low immune function,SCAP still ranks first in infectious diseases due to its high morbidity and mortality,and it has become one of the world's top 10 death killers that threaten human life and health.With acute onset and rapid progress,the traditional treatment method of SCAP is to give adequate and effective antibiotic treatment.If necessary,it can be supplemented with mechanical ventilation,nutritional support,liquid perfusion or other treatment methods.Although the rapid development of antibiotics and adjuvant therapy,the survival benefits of traditional therapy are quite limited,and antibiotic therapy can not completely reduce the mortality of SCAP patients.Therefore based on the pathogenesis of pneumonia,the clinician found that the essential point related to the outcome of SCAP is the imbalance of inflammatory mediators.While glucocorticoid possess powerful ono-specific anti-inflammatory effect which attractes many doctors' attention.As an auxiliary treatment,glucocorticoid can relieve fever and acute inflammatory exudation,improve the gas exchange,resist shock,inhibite inflammatory cytokines,regulate immune function,and so on.It has been several years since glucocorticoid applys to SCAP.A number of related randomized controlled trials have been designed to study of the curative effect and prognosis of glucocorticoid in the treatment of SCAP at both home and abroad.Even though the results have not been consistent,many trials indicate that glucocorticoid is associated with the improvement of patient's clinical symptoms as well as reduce mortality.However,due to side effects of hormones,it also increases the risk of secondary infection,resulting in a poor prognosis.At present,except in pneumocystis carinii,there is no consistent conclusion in the treatment of SCAP or accompanied by ARDS and septic shock about the efficacy,safety and therapeutic dose.Therefore,this paper presents a meta-analysis of the randomized controlled trials using SCAP glucocorticoids.Objectives:The aim of the study is to evaluate the efficacy and safety of glucocorticoid in the treatment of severe community acquired pneumonia via meta analysis.Methods:Several databases including Chinese and English database such as PubMed,EMBASE,Cochrane Library,EBASO,Medline,Google Scholar,Science Dicet,CBM,CNKI and so on were searched for related studies published in English or Chinese up to January,2018.Randomized controlled trials(RCTs)of corticosteroids in hospitalized adults with severe CAP were included.The inclusion and exclusion criteria were used to screen the literature which fulfill the requirement.In addition,we brought the Jadad scale into play to evaluate the quality of the inclusion literature,and extracte data by means of the Cochrane system evaluation manual.Meta-analysis was performed by a random-effect model with RevMan 5.3 software.Results:We included 10 RCTs enrolling 665 severe CAP patients.Compared with conventional treatment,adjunctive corticosteroids significantly reduced all-cause mortality(OR=0.38,95%CI:0.22-0.65,Z=3.46,P=0.005(<0.05)),In subgroup analysis by duration of corticosteroids,we found that prolonged and medium corticosteroids therapy significantly reduced all-cause mortality(OR=0.44,95%CI:0.24-0.82,Z=2.58,P=0.01),(RR=0.35,95%CI:0.36-0.76,Z=2.66,P=0.008).C-reactive protein after three days' therapy significantly reduced(MD=-59.58mg/l,95%CI:-88.1~-33.04,P<0.0001)the risk of septic shock(OR=0.19,95%CI0.10-0.36,P<0.0001)and need for mechanical ventilation(OR = 0.33,95 % CI:0.21~0.52,P<0.00001).Adjunctive corticosteroids exactly had no influence in gastrointestinal hemorrhage(OR=0.80,95%CI:0.23-2.83,P=0.73)and super infection(OR=2.62,95%CI:0.92-7.48,P=0.07).Conclusion:1?Compared with conventional treatment,our results suggested that adjunctive corticosteroids therapy decreased all-cause mortality in patients with severe CAP,and prolonged(5-9 days),medium corticosteroids treatment was more beneficial for severe CAP.2?The study indicated that corticosteroids treatment was safe.The use of whole-body corticosteroids is not associated with the risk of super infection and upper gastrointestinal bleeding in the patients with severe community acquired pneumonia and reduced the risk of septic shock and the need for mechanical ventilation.