1/In this RCT, continuous IV hydrocortisone significantly lowered the risk of death in patients with severe CAP compared to placebo. Welcome to our weekly #OMTweetorial. #MedTwitter #MedEd #EBM #JournalClub

2/In this pre-COVID government-funded trial in @NEJM, Pierre-François Dequin et al assessed whether a continuous hydrocortisone infusion reduced mortality in patients with severe CAP.

3/Design: RCT of 800 adults admitted to ICUs in France with severe CAP. Randomized 1:1 to placebo or a 4-d continuous infusion of hydrocortisone 200 mg IV daily followed by an 8–14 d taper. All pts received abx and standard supportive care. Primary outcome: death by day 28.

4/Secondary outcomes included: death within 90 days, intubation, vasopressor therapy. Safety criteria included: secondary infection, GI bleed, daily insulin administration by day 7.

5/ Results? Hydrocortisone compared to placebo: Death (day 28): 6.2% vs. 11.9% (-5.6%; 95% CI, -9.6 to -1.7). Death (day 90): 9.3% vs. 14.7% (-5.4%; -9.9 to -0.8). Intubation: 18.0% vs. 29.5% (HR, 0.59; 0.40 to 0.86). Vasopressors: 15.3% vs. 25.0% (0.59; 0.43 to 0.82)

6/Safety outcomes: Similar rates of ICU-acquired infections and GI bleeding. Higher daily insulin requirements with hydrocortisone than with placebo.

7/ Limitations? Exclusion of individuals with septic shock. Adverse neuromuscular and neuropsychiatric effects were not reported. Bolus dosing of hydrocortisone was not tested. A small number of immunocompromised participants limits generalizability to this

8/ Is this evidence enough to change your practice for critically ill patients with severe CAP? Let us know in the thread!