ImportanceSevere pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%.ObservationsCorticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections.Conclusions and RelevanceTreatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.

中文翻译：

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低剂量皮质类固醇治疗患有严重肺部感染的危重成人


重要性严重肺部感染，包括 COVID-19、社区获得性肺炎、流感和肺孢子虫肺炎，是全世界成年人死亡的主要原因。危重患者的肺部感染可能会导致败血性休克、急性呼吸窘迫综合征或两者兼有，这与 30% 至 50% 的死亡率相关。观察结果皮质类固醇可减轻对感染的免疫反应，并改善几种重症患者的预后肺部感染。低剂量皮质类固醇，定义为每天小于或等于 400 毫克氢化可的松当量，可以降低重症 COVID-19、社区获得性肺炎和肺孢子虫肺炎患者的死亡率。一项对 6425 名需要补充氧气或无创或有创机械通气的住院患者进行的随机临床试验表明，每天 6 毫克地塞米松，连续 10 天可降低 28 天死亡率（23% vs 26%）。一项荟萃分析纳入了 1689 名在重症监护病房接受治疗的严重细菌性社区获得性肺炎患者的 7 项随机临床试验，报告显示，氢化可的松当量每日小于或等于 400 毫克，持续 8 天或更短时间与较低的 30 天生存率相关。与安慰剂相比死亡率（10% vs 16%）。在一项对 6 项随机临床试验的荟萃分析中，对于 HIV 和中重度肺孢子虫肺炎患者，与安慰剂相比，低剂量皮质类固醇与较低的死亡率相关（13% vs 25%）。 在一项低剂量类固醇治疗败血性休克试验的预定义亚组分析中，社区获得性肺炎患者随机接受为期 7 天的静脉注射氢化可的松（每 6 小时 50 毫克）和氟氢可的松（每天 50 微克），与安慰剂组相比，死亡率降低。 39% 与 51%）。根据对纳入 1091 名患者的 8 项研究进行的荟萃分析，对于由各种疾病引起的急性呼吸窘迫综合征患者，低剂量皮质类固醇与院内死亡率降低相关（34% vs 45%）。低剂量皮质类固醇的不良反应可能包括高血糖、胃肠道出血、神经精神疾病、肌肉无力、高钠血症和继发感染。结论和相关性低剂量皮质类固醇治疗与严重 COVID-19 感染、重症社区患者的死亡率降低相关- 获得性细菌性肺炎和中度至重度肺孢子菌肺炎（针对艾滋病毒患者）。低剂量皮质类固醇也可能有益于患有感染性休克、急性呼吸窘迫综合征或两者兼而有之的呼吸道感染危重患者。