Adjunct corticosteroids may benefit children admitted with community-acquired pneumonia who are wheezing

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Reference
• Copyright

Weiss AK, Hall M, Lee GE, Kronman MP, Sheffler-Collins S, Shah SS. Adjunct corticosteroids in children hospitalized with community-acquired pneumonia. Pediatrics 2011;127:e255-63.

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Question 

Among children hospitalized with community-acquired pneumonia (CAP), does the use of systemic corticosteroid therapy compared with standard care reduce length of stay and cost of care?

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Design 

Retrospective cohort study.

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Setting 

36 children's hospitals.

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Participants 

20 703 children aged 1 to 18 years (median age = 4 years) with CAP.

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Intervention 

Primary exposure was the use of adjunct systemic corticosteroids.

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Outcomes 

Length of stay (LOS), readmission, and total hospitalization cost.

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Main Results 

Adjunct corticosteroid therapy was administered to 7234 patients (35%). The median LOS was 3 days, and 245 patients (1.2%) required readmission. Systemic corticosteroid therapy was associated with shorter LOS overall (adjusted hazard ratio [HR]: 1.24 [95% CI, 1.18 -1.30]). Among children who received treatment with β-agonists, the LOS was shorter for children who had received corticosteroids compared with children who had not (adjusted HR: 1.36 [95% CI, 1.28 -1.45]). Among children who did not receive β-agonists, the LOS was longer for those who received corticosteroids compared with those who did not (adjusted HR: 0.85 [95% CI, 0.75-0.96]). Corticosteroids were associated with readmission of patients who did not receive concomitant β-agonist therapy (adjusted OR: 1.97 [95% CI, 1.09 -3.57]).

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Conclusions 

For children hospitalized with CAP, adjunct corticosteroids were associated with a shorter hospital LOS among patients who received concomitant β-agonist therapy. Among patients who did not receive this therapy, systemic corticosteroids were associated with a longer LOS and greater odds of re-admission. If β-agonist therapy is considered a proxy for wheezing, these findings suggest that among patients admitted to the hospital with a diagnosis of CAP, only those with acute wheezing benefit from adjunct systemic corticosteroid therapy.

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Commentary 

This study suggests that adjunct systemic corticosteroids may improve outcomes of “wheezing” in children with CAP. There are two limitations apparent in this retrospective study that suggest that there may be other unidentified variables that contributed to the success of systemic corticosteroids in these subjects. First, subjects were identified as having CAP based on ICD-9 codes, not with chest x-ray or clinical response to antibiotics. Thus, the pathogenesis of their disease is unknown (eg, viral vs bacterial, bronchiolitis vs pneumonia). Given the ages of the subjects and bacterial microbiology of CAP in these age groups, 62.5% of children ages 1-5 years were more likely to be infected with Streptococcus pneumoniae versus the 37.5% of children ≥ 6 years of age with Mycoplasma pneumoniae. It would be uncommon for patients with bacterial pneumonia due to S pneumoniae to respond to β-agonist therapy without underlying asthma. Yet, this group had improved outcomes with corticosteroid use. Second, the authors argue that β-agonist therapy, which was received by 53% of subjects in this study, is a proxy for the presence of wheezing. It seems unlikely that 53% of the children in this study had wheezing with the prevalence of asthma in children in the US being 9.6%.¹ Thus, the indication for systemic corticosteroid use in children with CAP has yet to be elucidated and is unlikely solely β-agonist use. This study has laid the groundwork for an exciting, randomized-controlled study to identify which children with CAP might benefit from concomitant systemic corticosteroids.

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Reference 

1. Akinbami LJ, Moorman JE, Lie X. Asthma Prevalence, Health Care Use, and Mortality: United States, 2005-2009. National Health Statistics Report, 2011.
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