Corticosteroids for Pediatric Community-Acquired Pneumonia
Weiss AK, Hall M, Lee GE, Kronman MP, Sheffler-Collins S, Shah SS
Pediatrics.2011;127:e255-263
Community-acquired pneumonia (CAP) in children involves a notable inflammatory response. Although the inflammatory response is part of the host's effort to fight infection, it is unclear whether the net effect of this inflammatory response worsens the clinical course of CAP in children. In a similar vein, it is unclear whether administration of corticosteroids to reduce the inflammatory response will provide a net benefit in children with CAP. Weiss and coworkers conducted a retrospective cohort study using data obtained from 38 freestanding children's hospitals in the United States through the Pediatric Health Information System (PHIS). The data included both administrative and clinical care data, allowing the investigators to reconstruct a patient's hospitalization history and medical care. The children in the study were 1-18 years of age, diagnosed with CAP, and admitted to 1 of the PHIS hospitals during 2006 or 2007. Children were identified for inclusion on the basis of either a primary or secondary diagnosis of pneumonia. The investigators identified children in the CAP cohort who had asthma on the basis of asthma-related International Classification of Diseases, Ninth Revision (ICD-9) codes or receipt of bronchodilators on the first day of hospitalization. The investigators were also able to identify other measures of clinical care and disease severity including pleural effusions, fluid boluses, vasoactive infusions, blood products, intubation, or ventilation, and they accounted for disease severity in adjusted analyses.
The investigators were interested in 3 primary outcomes: hospital length of stay (LOS), readmission for CAP within 28 days of discharge, and a measure of cost. The variable of interest was whether the children had received oral or intravenous corticosteroids during the hospital stay. Because this study was not randomized, the investigators attempted to adjust, using propensity scores, for factors that might lead to an individual patient receiving steroids. The propensity scores accounted for the patient's age, sex, race, hospital, season of the year, and whether the patient was hospitalized for asthma in the 2 years prior to the index admission. The calculation of propensity scores also included measures of severity (listed above) and intensive care unit (ICU) admission.
A total of 20,703 children were included in the study, and 7234 (35%) had received corticosteroids. The majority of the children (63%) were 1-5 years of age; 23% were 6-11 years of age; and 14% were 12-18 years of age. Boys made up 48.9% of the sample. The racial distribution included 25% black, 62% white, 10% other, and 4% unknown (missing data). Approximately two thirds of the children were admitted during the viral respiratory season, and 13% had a previous asthma admission. Children who received systemic corticosteroids were twice as likely to have been previously admitted for asthma, were more likely to be black, and were more likely to be in the youngest age stratum. Approximately 20% of the children had received inhaled corticosteroids or leukotriene receptor antagonists prior to admission. Children who were admitted to the ICU were more likely to receive systemic corticosteroids (41%) compared with children who were not admitted to the ICU (34%). The median LOS was 3 days.
In multivariable analyses, children who received systemic corticosteroids during their hospitalization for CAP regardless of age had shorter hospital stays (hazard ratio, 1.24; 95% confidence interval, 1.18-1.30). Benefit was confined to those who had received bronchodilators at admission. In fact, there was a slight increase in LOS in children who did not receive bronchodilators but who did receive corticosteroids. Additionally, this group had higher odds of being readmitted within 28 days (odds ratio, 1.97).
In multivariable analyses, receipt of steroids did not appear to be associated with risk for hospital readmission. Receipt of corticosteroids was associated with lower costs by approximately $500. However, in the subgroup that did not receive bronchodilators but did receive corticosteroids, the cost was actually higher. The investigators concluded that in children with CAP receipt of corticosteroids was associated with a shorter hospital stay, and this benefit appeared most pronounced in children who had received bronchodilators at admission. The data also suggest that in children with CAP who did not receive bronchodilators, the use of systemic corticosteroids may be associated with a longer hospital stay and a higher risk for readmission.
This study tries to answer a question that residents and other trainees frequently raise when dealing with hospitalized children who have pneumonia. There is the concern that corticosteroids might suppress a child's immune response when he or she is trying to deal with CAP. However, given that children with asthma are more likely to develop pneumonia, many children with CAP have comorbid asthma. The data suggest that it is both safe and appropriate to administer systemic corticosteroids to treat wheezing or asthma in children hospitalized with CAP. However, it is harder to interpret the results related to children who did not receive bronchodilators. Weiss and coworkers commented that there are many reasons why the children who did not receive bronchodilators might have still received steroids. For example, this group may represent a more severely ill subset of patients. These questions will be best answered with randomized trials, but for now these data suggest that children with wheezing or asthma and CAP should receive corticosteroids.
Abstract
Adjunct Corticosteroids in Children Hospitalized With Community-Acquired Pneumonia
Weiss AK, Hall M, Lee GE, Kronman MP, Sheffler-Collins S, Shah SS
Pediatrics.2011;127:e255-263
Study Summary
Community-acquired pneumonia (CAP) in children involves a notable inflammatory response. Although the inflammatory response is part of the host's effort to fight infection, it is unclear whether the net effect of this inflammatory response worsens the clinical course of CAP in children. In a similar vein, it is unclear whether administration of corticosteroids to reduce the inflammatory response will provide a net benefit in children with CAP. Weiss and coworkers conducted a retrospective cohort study using data obtained from 38 freestanding children's hospitals in the United States through the Pediatric Health Information System (PHIS). The data included both administrative and clinical care data, allowing the investigators to reconstruct a patient's hospitalization history and medical care. The children in the study were 1-18 years of age, diagnosed with CAP, and admitted to 1 of the PHIS hospitals during 2006 or 2007. Children were identified for inclusion on the basis of either a primary or secondary diagnosis of pneumonia. The investigators identified children in the CAP cohort who had asthma on the basis of asthma-related International Classification of Diseases, Ninth Revision (ICD-9) codes or receipt of bronchodilators on the first day of hospitalization. The investigators were also able to identify other measures of clinical care and disease severity including pleural effusions, fluid boluses, vasoactive infusions, blood products, intubation, or ventilation, and they accounted for disease severity in adjusted analyses.
The investigators were interested in 3 primary outcomes: hospital length of stay (LOS), readmission for CAP within 28 days of discharge, and a measure of cost. The variable of interest was whether the children had received oral or intravenous corticosteroids during the hospital stay. Because this study was not randomized, the investigators attempted to adjust, using propensity scores, for factors that might lead to an individual patient receiving steroids. The propensity scores accounted for the patient's age, sex, race, hospital, season of the year, and whether the patient was hospitalized for asthma in the 2 years prior to the index admission. The calculation of propensity scores also included measures of severity (listed above) and intensive care unit (ICU) admission.
A total of 20,703 children were included in the study, and 7234 (35%) had received corticosteroids. The majority of the children (63%) were 1-5 years of age; 23% were 6-11 years of age; and 14% were 12-18 years of age. Boys made up 48.9% of the sample. The racial distribution included 25% black, 62% white, 10% other, and 4% unknown (missing data). Approximately two thirds of the children were admitted during the viral respiratory season, and 13% had a previous asthma admission. Children who received systemic corticosteroids were twice as likely to have been previously admitted for asthma, were more likely to be black, and were more likely to be in the youngest age stratum. Approximately 20% of the children had received inhaled corticosteroids or leukotriene receptor antagonists prior to admission. Children who were admitted to the ICU were more likely to receive systemic corticosteroids (41%) compared with children who were not admitted to the ICU (34%). The median LOS was 3 days.
In multivariable analyses, children who received systemic corticosteroids during their hospitalization for CAP regardless of age had shorter hospital stays (hazard ratio, 1.24; 95% confidence interval, 1.18-1.30). Benefit was confined to those who had received bronchodilators at admission. In fact, there was a slight increase in LOS in children who did not receive bronchodilators but who did receive corticosteroids. Additionally, this group had higher odds of being readmitted within 28 days (odds ratio, 1.97).
In multivariable analyses, receipt of steroids did not appear to be associated with risk for hospital readmission. Receipt of corticosteroids was associated with lower costs by approximately $500. However, in the subgroup that did not receive bronchodilators but did receive corticosteroids, the cost was actually higher. The investigators concluded that in children with CAP receipt of corticosteroids was associated with a shorter hospital stay, and this benefit appeared most pronounced in children who had received bronchodilators at admission. The data also suggest that in children with CAP who did not receive bronchodilators, the use of systemic corticosteroids may be associated with a longer hospital stay and a higher risk for readmission.
Viewpoint
This study tries to answer a question that residents and other trainees frequently raise when dealing with hospitalized children who have pneumonia. There is the concern that corticosteroids might suppress a child's immune response when he or she is trying to deal with CAP. However, given that children with asthma are more likely to develop pneumonia, many children with CAP have comorbid asthma. The data suggest that it is both safe and appropriate to administer systemic corticosteroids to treat wheezing or asthma in children hospitalized with CAP. However, it is harder to interpret the results related to children who did not receive bronchodilators. Weiss and coworkers commented that there are many reasons why the children who did not receive bronchodilators might have still received steroids. For example, this group may represent a more severely ill subset of patients. These questions will be best answered with randomized trials, but for now these data suggest that children with wheezing or asthma and CAP should receive corticosteroids.
Abstract
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