Transcript Hydrocortisone Infusion for Severe Community

Hydrocortisone Infusion for Severe Communityacquired Pneumonia
A Preliminary Randomized Study
Marco Confalonieri, Rosario Urbino, Alfredo Potena, Marco Piattella, Piercarlo
Parigi, Giacomo Puccio, Rossana Della Porta, Carbone Giorgio, Francesco
Blasi, Reba Umberger and G. Umberto Meduri
Ospedale di Trieste, Trieste; Ospedale Gradenigo-Torino; Ospedale Molinette
di Torino; Arcispedale S. Anna di Ferrara; Ospedale di Crema; Ospedale di
Paderno Dugnano-Milano; Institute of Respiratory Diseases, University of
Milan, Milan, Italy; and Memphis Lung Research Program, Memphis,
Tennessee
Correspondence and requests for reprints should be addressed to Dr. Marco
Confalonieri, Azienda Ospedaliero-Universitaria di Trieste, Strada di Fiume 447,
34100 Trieste, Italy. E-mail: [email protected]
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone Infusion for Severe Community-acquired Pneumonia
A Preliminary Randomized Study
• Objective: hydrocortisone administered early in
severe Community Acquired Pneumonia
attenuates pulmonary and systemic
inflammation and reduces sepsis related
complications and mortality
• Design: Prospective, placebo-controlled,
randomized, double-blind trial on two parallel
groups
• Setting: 6 hospitals in Italy from July 2000 to
March 2003
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone Infusion for Severe Community-acquired Pneumonia
Entry Criteria
• Patients with clinical and X-ray evidence of pneumonia
plus 2 minor or 1 major 1993 American Thoracic Society
criteria for severe pneumonia
– Minor criteria: (1) respiratory rate > 30 breaths at admission; (2)
PaO2/FiO2 < 250; (3) CXR showing bilateral or multilobar involvement;
(4) SBP < 90 mm Hg; or (5) DBP < 60 mm Hg.
– Major criteria: (1) mechanical ventilation; (2) increase in the size of
opacities on CXR of > 50% at 48 hours; (3) vasopressors > 4 hours; or
(4) serum creatinine >2 mg/dl.
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone Infusion for Severe Community-acquired Pneumonia
Exclusion Criteria
•
•
•
•
nosocomial pneumonia;
severe immunosuppression;
acute burn injury;
a preexisting medical condition with a life
expectancy less than 3 months;
• pregnancy;
• a major gastrointestinal bleed within 3 months of
the current hospitalization; or
• a condition requiring more than 0.5 mg/kg/day of
prednisone equivalent (i.e., acute asthma or
chronic obstructive pulmonary disease [COPD]).
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone Infusion for Severe Community-acquired
Pneumonia
Randomization
Placebo (n=23)
Primary end-points were improvement in
PaO2:FIO2 (PaO2:FIO2 > 300 or 100 increase
from study entry) and multiple organ dysfunction
syndrome (MODS) score by Study Day 8 and
development of delayed septic shock.
The secondary end-points were duration of
mechanical ventilation, length of ICU/RIU and
hospital stay, and survival to hospital discharge
and to 60 days
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone
200 mg IV load
followed by 10
mg/hr X 7 days
(n=23)
Results
Hydrocortisone treated patients had significant:
• improvement in PaO2:FIO2 (p = 0.002)
• improvement in CXR score (p < 0.0001),
• reduction in C-reactive protein levels (p = 0.01)
• reduction in MODS score (p = 0.003)
• reduction in delayed septic shock (p = 0.001).
• reduction in length of hospital stay (p = 0.03)
• reduction in mortality (p = 0.009).
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone
Placebo
p = 0.009
Placebo
Hydrocortisone
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Conclusion
• prolonged low-dose hydrocortisone
infusion hastens resolution of pneumonia
and prevents the development of sepsisrelated complications.
• a 7-day course of low-dose hydrocortisone
infusion was associated with a significant
reduction in duration of mechanical
ventilation, hospital length of stay, and
hospital mortality
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8
Hydrocortisone
Placebo
P=0.009
Center for Excellence in
Critical Care
Am J Respir Crit Care Med
2005;171:242-8