Monthly Archives: April 2023

Thanks to Jose for presenting this today! CAPE-COD (paper here)

• 800 patients with severe CAP randomized (excluded those who were on pressors, influenza, aspiration)
• Balanced baseline groups
• Hydrocortisone infusion 200mg/day, duration could be extended based on criteria + taper vs placebo with same protocol; median duration 5 days
• Fewer death by day 28 in those given hydrocortisone 6.2% vs 11.9%
• Fewer intubation by day 28 19.5% vs 27.7%
• More insulin in steroid group
• Especially helpful in women and age>65 by subgroup analysis
• strengths included fast onset to medication dosage ~15 hours, and high adherence to protocol, reasonable 21% VAP rate (compared to many studies with low rates)
• limitations: surprisingly low mortality, unstandardized microbiology (45% without identified pathogen)

Discussion points brought up included the variety of pathogens and heterogeneous groups and the syndrome of CAP, unclear exactly which subpopulation would be most benefitted (compared with COVID, where things were more clear and homogeneous), unusual population where a large number of patients had high CRP (based on a prior Spanish study that showed benefit in this population that took years to enroll a certain number of patients); steroids are a blunt instrument, choice of specific steroid (hydrocortisone vs dexametahsone). Of note – immediate meta-analysis incorporating this data – slight benefit?

Recent VA study showing no benefit (mostly men so maybe one explanation for the difference): https://link.springer.com/article/10.1007/s00134-022-06684-3

Of note – new guidelines for severe CAP including our very own Dr. Wunderink: https://link.springer.com/article/10.1007/s00134-023-07033-8

Future thoughts: designing trials better phenotyping to target specific pathways!