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A Nursing Approach to the Efficacy of Corticosteroids in Community Acquired Pneumonia Treatment

Submitted by Adiel B. Sadik & Stephanie A. Varela Ph.D

Tags: critical care morbidity mortality nursing nursing community

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Author Note

We have no known conflict of interest to disclose.

This research did not receive any grant from funding agencies in any sector. Correspondence concerning this article should be addressed to Adiel Sadik

Abstract

This study aims to describe the use of corticosteroid therapy in treating community-acquired pneumonia (CAP), determine differences in morbidity and mortality between groups receiving corticosteroids and groups receiving standard care, and examine relationships among clinical outcomes. This literature review will explain and determine the effect of corticosteroids on patient recovery and assess the efficacy and safety of corticosteroids in CAP treatment.

Keywords: nursing, community-acquired pneumonia, corticosteroid, critical care, morbidity, mortality, hyperglycemia

The Efficacy of Corticosteroids in Community-Acquired Pneumonia Treatment

Community-acquired pneumonia (CAP) has plagued patients and hospitals by accounting for 4.5 million hospital and emergency room visits. It is also the most common infectious source of death annually in the United States (Ramirez, 2024). Standard treatment includes bronchodilators, antibiotics, and supportive care. Yet, the role of corticosteroids in improving recovery and lung function remains debated due to potential risks and impacts on patient recovery and outcomes.

Evaluating the efficacy of corticosteroid treatment is significant to nursing because it improves clinical decision-making and outcomes for patients with community-acquired pneumonia. This literature review aims to evaluate the effect of corticosteroids on blood glucose and mortality in adults with pneumonia by comparing those receiving corticosteroids with those receiving standard care without them. The results will guide nursing practice and treatment decisions for pneumonia patients.

Pneumonia Classification

Pneumonia is a larger categorical illness classified based on the mechanism of acquisition. Julio Ramirez (2024) wrote a peer-reviewed overview of CAP in adults in the UpToDate medical database, where he described nosocomial pneumonia as an acute infection of the parenchyma in the lungs acquired in hospitals, specifically called Hospital-acquired pneumonia (HAP) when it developed within forty-eight hours of hospital admission or Ventilator-associated pneumonia (VAP) if developed within forty-eight hours of endotracheal intubation. Healthcare-associated pneumonia (HCAP) refers to pneumonia acquired in any healthcare facility or after a recent hospitalization. However, the term HCAP is no longer commonly used because it was considered too broad, leading to inappropriately broad antibiotic use and poor outcomes.

This literature review focuses on Community-acquired pneumonia (CAP), an acute infection of the pulmonary parenchyma acquired within the context of the community, outside of the hospital setting (Ramirez, 2024). There are three categories of pneumonia: mild pneumonia, moderate pneumonia, and severe pneumonia (Seeger & Rhode, 2023).

Incidence and Epidemiology

Understanding the heavy burden that CAP places on the community and resources is critical to understanding the resources for prevention and management. CAP is an aggressive disease process and is considered one of the most common and morbid conditions encountered in medical practice. CAP is accountable for around 4.5 million outpatient and emergency room visits in the United States annually, making it the second most common cause of hospitalization and the most common infectious killer (Ramirez, 2024). A two-year study out of Louisville, Ohio, examines the incidence and mortality of adults hospitalized with pneumonia. Louisville is a city with a recorded population of 587,499 adults at the time. According to the study, 649 adults per 100,000 are hospitalized with CAP, corresponding to 1,591,825 cases across the United States annually. CAP is concentrated in low-income areas with a dense African American population. Of those hospitalized in Louisville, there was a 6.5% mortality rate. The mortality rates in Louisville of 30 days, 6 months, and 1 year were 13.0%, 23.4%, and 30.6%; respectively, equating to 102,821 annual deaths in the United States (Ramirez et al., 2017). The burden placed on the United States by CAP is significant, with over 1.5 million adult individuals needing hospitalizations yearly, and approximately one-third of the patients hospitalized with CAP dying within one year, or 9% needing to be re-hospitalized due to a recurrent episode in the same year (Ramirez et al., 2017; Ramirez, 2024).

Risk Factors and Predispositions

Several risk factors compound the risk of developing CAP. According to a New England Journal of Medicine study, age is a significant risk factor for CAP, with incidence rates increasing among adults over 65. Adults aged 65 - 79 had an annual incidence of 63.0 cases per 10,000 people. However, for those over 80 years, the rate sharply increases to 164.3 cases per 10,000, almost three times higher than adults in the younger group. Data continues to show that age increases the incidence of CAP and is associated with a higher mortality rate (Jain et al., 2015).

Ramirez (2024) further explains the risk factors and predispositions for CAP. Chronic comorbidities, especially chronic obstructive pulmonary disease (COPD), place an individual at a higher risk of obtaining CAP and requiring hospitalization. The incidence of patients with COPD is 5,832 per 100,000 in the United States annually. Other comorbidities that increase the risk for CAP are bronchiectasis, asthma, congestive heart failure, stroke, diabetic mellitus, malnutrition, and immunocompromising conditions or medications. Secondly, viral respiratory tract infections can lead to primary viral pneumonia, predisposing the patient to develop secondary bacterial pneumonia.

Any conditions that impair airway protection raise the risk of developing CAP. Examples include conditions that increase the risk for microaspiration of stomach contents, upper airway secretions, or changes in consciousness, such as stroke, seizure, anesthesia, dysphagia, drug use, and alcohol abuse. Modifiable risk factors for CAP include smoking, opioid use, and excessive alcohol intake, defined as 80 grams a day (Ramirez, 2024).

Other lifestyle factors that increase the risk of CAP include residing in population-dense living conditions (such as prisons and homeless shelters), low-income settings, or an area exposed to environmental toxins like solvents, paints, and gasoline (Ramirez, 2024).

Microbial Etiology

Although Streptococcus pneumoniae and other respiratory viruses are the most commonly seen pathogens in CAP patients, over 60% of cases show that no specific pathogen can be detected despite extensive microbiologic evaluation (Jain et al., 2015). Ramirez explains that commonly identified pathogens can be grouped by either being typical bacteria, atypical bacteria, or viral. Typical bacteria include S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Group A streptococci, Aerobic gram-negative bacteria (e.g., Enterobacteriaceae such as Klebsiella spp or Escherichia coli), Microaerophilic bacteria and anaerobes are seen in cases that are associated with aspiration. Atypical bacteria refer to the resistance of these organisms towards beta-lactams, unable to be viewed on a Gram stain or cultured traditionally. Lastly, respiratory viruses include influenza A and B viruses, severe acute respiratory syndrome coronavirus 2, other coronaviruses, rhinoviruses, parainfluenza viruses, adenoviruses, respiratory syncytial virus, human metapneumovirus, and human bocaviruses (Ramirez, 2024).

Pathophysiological Mechanisms

The transmission of pneumonia is primarily droplets through inhalation. The pathogen colonizes the nasopharynx and continues toward the lung alveoli through microaspiration. The pathogen competes with the resident microbes for resources and time to replicate. Infection officially occurs when the population of the virus or bacteria is large enough or the host immune system is compromised (Ramirez, 2024). Respiratory microbes can change the host's immune response towards the infecting pathogen. In cases like these, a changed alveolar microbiome, known as alveolar dysbiosis, may predispose an individual to develop pneumonia. The pathogen replication, the production of enough virulence factors, and the host immune system's reaction can lead to inflammation and lung parenchyma damage, resulting in pneumonia (Ramirez, 2024). Exogenous insults, such as viral infection or smoke exposure, can change the alveolar microbiome's typical composition and trigger an overgrowth of microbes. There have also been incidences where CAP forms from uncontrolled microbe replication of microbes that usually reside in the alveoli. In all instances, the response of the host's immune defenses is vital when determining the potential severity of CAP (Ramirez, 2024). Sometimes, a smaller inflammatory response within the lung may be enough to control the infection. However, if it is not controlled fast enough, the host's immune system triggers a systemic response to control the infection and prevent complications, such as bacteremia and septic shock, potentially worsening outcomes (Ramirez, 2024).

Clinical Manifestations

Pneumonia presents two primary categories of symptoms, originating from the pulmonary and systemic systems. Ramirez (2024) further discusses how common signs of pulmonary symptoms associated with CAP include cough (regardless of sputum production), dyspnea, and pleuritic chest pain. Other pulmonary signs and symptoms that can be seen are from the collection of white blood cells (WBCs), fluids, and proteins in the alveolar space. The irregular presence of WBCs, fluids, and proteins in the alveolar space impairs alveolar gas exchange, resulting in poor gas exchange and hypoxemia. Upon physical examination, tachypnea, labored breathing, adventitious breath sounds, tactile fremitus, egophony, and dullness on percussion can be seen. WBC and fluid accumulation within the alveolar space can be visualized on a chest radiograph as pulmonary opacities. However, in immunocompromised patients, pulmonary infiltrates may not be visible on chest radiographs. In such cases, computed tomographies are recommended to better visualize the pulmonary infiltrates (Ramirez, 2024).

Besides pulmonary signs and symptoms, a typical CAP patient presents with systemic signs of distress, frequently seen as an oral temperature elevated to at least 37.8 C. Other systemic signs may include chills, fatigue, malaise, chest pain, and weight loss. The systemic inflammatory response can also lead to symptoms like tachycardia and leukopenia. In such cases, inflammatory markers like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) will likely increase. Procalcitonin may also rise but is closely linked to bacterial infections (Ramirez, 2024). Additionally, pneumonia is the leading cause of sepsis, therefore initial presentation may include the symptoms commonly observed in septic patients. These symptoms include hypotension, altered mental status, and other signs of organ dysfunction, such as renal dysfunction, liver dysfunction, and thrombocytopenia (Annane et al., 2018). 

It is worth noting that typical signs and symptoms of pneumonia may be subtle or absent in patients with advanced age or who are immunocompromised. For example, an older patient may appear with altered mental status but will lack a typical fever or leukocytosis (Waterer et al., 2006).

Differential diagnoses that should be considered when evaluating for the possibility of pneumonia include acute exacerbation of bronchiectasis, aspiration or chemical pneumonitis, atelectasis, collagen vascular diseases, congestive heart failure with pulmonary edema, drug reactions, interstitial lung diseases, lung cancer, pulmonary embolism, pulmonary hemorrhage, and vasculitis (Ramirez, 2024).

Severity Assessment

Ramirez classifies the three levels of severity regarding CAP patients, each corresponding to three levels of care, treatment, and outcomes. The Pneumonia Severity Index (PSI) and CURB-65 are the most frequently used tools to measure severity. UpToDate states that they consider the PSI more accurate than the CURB-65 score. However, CURB-65 is preferred by many providers because it is more straightforward and easier to use (Ramirez, 2024). CURB-65 measures confusion, BUN score over 19 mg/dL, respiratory rate over 30 breaths per minute, systolic blood pressure under 90 mmHg or Diastolic Blood Pressure under 60 mmHg, and age over 65 years. For each one of those categories that a patient presents with, a point adds to their overall score (Macfarlane & Patel, n.d.).

Mild pneumonia consists of a fever, cough, and shortness of breath. In mild pneumonia, patients are otherwise healthy and present with vital signs within normal ranges. They have no other concerns and no slight risk factors for complications. Patients with mild pneumonia can be seen in ambulatory settings for health-related visits. Patients presenting with mild CAP typically have PSI scores of I to II and CURB-65 scores of 0 if under the age of 65 or a CURB-65 score of 1 if older than 65 to account for the added age point (Ramirez, 2024).

Moderate pneumonia requires hospital admission, often due to peripheral oxygen saturation dropping below 92% on room air or signs of dyspnea. The corresponding PSI score is III or higher, and CURB-65 scores > 1 (or CURB-65 score > 2 if the age is over 65 years) (Ramirez, 2024). Patients who show early signs of sepsis or have a rapidly progressive disease may also require hospitalization to monitor the response to treatment on a higher level of care. Additional factors should be assessed when deciding if a patient needs hospital admission. In particular, hospital admission may be necessary when a patient cannot take oral medications, has cognitive or functional impairments, or has social challenges that could affect adherence to medication or access to timely care. Examples of these challenges include substance abuse, homelessness, or living a long distance from a medical facility (Ramirez, 2024).

Severe pneumonia is characterized by sepsis and respiratory distress due to the immune system's inefficient response to control the infection. Patients with severe CAP may experience respiratory failure and require mechanical ventilation or progress into sepsis, requiring vasopressor support to maintain adequate blood pressure and circulation. Such patients should be admitted to the intensive care unit (ICU) for a higher level of care (Ramirez, 2024). Medical providers and staff need to pay close attention to whether patients with severe CAP progressed to sepsis before the development of organ failure. Prompt ICU admission and appropriate antibiotic administration significantly improve outcomes (Ramirez, 2024).

Nursing Interventions and Care Protocols

Effective nursing interventions are critical to improve outcomes for patients with CAP. The 11th edition of Adult Medical Surgical Nursing, written by Holman et al. (2019/2022), recommends nursing care guidelines for pneumonia patients. Nursing priorities for a patient with moderate or severe CAP include assessing and monitoring oxygenation status and other vital signs, encouraging deep breathing and coughing exercises if the patient is awake, suctioning secretions as needed, positioning support, oral hygiene, managing pain, and closely monitoring for complications such as respiratory distress and sepsis. Nursing care involves positioning the patient to maximize ventilation at high-fowlers unless contraindicated. If the patient is awake, the nurse should encourage coughing and deep breathing with an incentive spirometer to prevent alveolar collapse, reassure the patient who is experiencing dyspnea or respiratory distress, determine the patient's physical limitations and structure-activity to include rest periods (Holman et al., 2019/2022, p. 129). Frequent turning and repositioning are essential for loosening secretions, preventing bedsores, and maintaining skin integrity. Oral hygiene protocol is heavily emphasized in critical patients with CAP. Before the nurse gives oral hygiene, they should ensure that the head of the bead is between 30 and 40 degrees to prevent micro-aspirations. The nurse should proceed to clean the teeth, tongue, and palate with a 0.12% chlorhexidine solution two to three times a day to reduce biofilm growth and gingival inflammation (Almeida et al., 2024). While the nurse provides oral care, they should monitor for skin breakdown around the nose and mouth from the oxygen device.

Holman et al. (2019/2022) continues by elaborating on the nursing care regarding the frequently given antibiotics, bronchodilators, and anti-inflammatories. The nurse should be aware of the drug, side effects, adverse effects, contraindications, potential interactions, and appropriate nursing actions. Monitoring for frequent liquid stools is essential to detect possible Clostridium difficile infections when a patient is taking antibiotics. Kidney function should also be monitored, especially for older adults taking penicillin or cephalosporins. Regarding bronchodilators, blood medication levels should be checked for toxicity in patients taking theophylline. Adverse effects of toxicity include tachycardia, nausea, and diarrhea. Patients prescribed albuterol require observation for possible tremors and tachycardia in patients on albuterol, while those using ipratropium should be monitored for headaches, blurred vision, and palpitations (p. 129).

Additionally, the nurse should help coordinate interprofessional care. Respiratory therapy should be consulted for inhalers, breathing treatments, physiotherapy, suctioning, and help with managing the airway (Holman et al., 2019/2022, p. 129). The additional work of breathing that CAP patients may experience increases calorie expenditure. Proper nutrition is necessary to prevent secondary infections in the respiratory system. Nutritional services should be consulted for weight loss/gain related to medications or pneumonia and to guide fluid replenishment to hydrate and help thin secretions unless contraindicated by another condition (Holman et al., 2019/2022, p. 129). Physical therapy should be consulted to assist in increasing activity levels if the patient experiences prolonged weakness due to an extended hospital stay or by the condition itself (Holman et al., 2019/2022, p. 129).

Corticosteroid Therapy

Corticosteroids, often called steroids or glucocorticoids, are a drug class of synthetic analogs of steroid hormones that are produced in the adrenal cortex (Rhen & Cidlowski, 2005). Corticosteroids play a crucial role in various physiological processes in the human body. They are necessary for several physiological processes and are essential in treating many inflammatory, allergic, immunologic, and malignant disorders. Corticosteroids help modulate stress responses, immune reactions, inflammation regulation, carbohydrate and protein metabolism, and influence blood electrolyte levels and behavior (Rhen & Cidlowski, 2005).

Commonly synthetic derivatives of natural glucocorticoids include generic prednisone, prednisolone, methylprednisolone, betamethasone, dexamethasone, triamcinolone, and hydrocortisone. Corticosteroids can be administered to the patient by inhalation, orally, or intravenously in a variety of clinical settings (Rhen & Cidlowski, 2005).

In Western medicine, corticosteroids have been utilized to treat various infections, including meningitis, tuberculosis, pneumocystis pneumonia, septic shock, and bacterial pneumonia (Saleem et al., 2023). While corticosteroids can be helpful in treatments regarding patient and health outcomes, they frequently are accompanied by clinically adverse side effects. Most side effects related to corticosteroid therapy depend on the dose and duration, widely differentiating based on individual patient factors (Sch cke et al., 2002). Prolonged high-dose corticosteroid use can lead to issues such as obesity with particular fat distribution patterns such as face swelling, immune suppression, delayed wound healing, growth delays in children,hirsutism, diabetes, depressive disorders, Cushing's syndrome, and osteoporosis (Oray et al., 2016). Although long-term use can result in several severe side effects, short-term use of corticosteroids is associated with mild side effects. Hyperglycemia and hypertension may be seen with short-term use of corticosteroid therapy (Steroids Side Effects / Systemic Corticosteroid Therapy Adverse Effects, 2024). The most common psychiatric side effects with short-term use include euphoria and hypomania, which typically resolve upon discontinuation (Warrington & Bostwick, 2006).

Before initiation of corticosteroid therapy, it is vital to consider the possible adverse effects. Hyperglycemia is a common complication of corticosteroid treatment, yet is linked to worse outcomes in critically ill patients (Rushakoff, 2019). However, hyperglycemia has not been proven to increase mortality rates directly (Krinsley, 2003). Another adverse effect of corticosteroid therapy is the potential for fluid retention, which can progress into pulmonary congestion, potentially worsening the severity of CAP. In high doses of corticosteroid therapy, there is an immediate risk of infection by inhibiting phagocytic cell function. However, most clinical trials in this literature review focus on low-dose corticosteroids administered for short periods in pneumonia patients, so they present minimal risk of infection or worsening existing infections (Stern et al., 2017). Nursing interventions surrounding corticosteroid therapy include monitoring for decreased immunity function, hyperglycemia, fluid retention, weight gain, and aphthous lesions (Holman et al., 2019/2022, p. 129).

Variable Analysis

This literature review analyzes multiple variables to assess corticosteroid therapy's efficacy in treating community-acquired pneumonia (CAP) in regards to blood glucose management and mortality outcomes. The independent variable is the administration of corticosteroids and the respective dose and duration. Dependent variables include clinical outcomes such as treatment failure rates, mortality, and length of hospital stay. In this review, the studies mentioned compare various doses, durations of therapy, and combinations of corticosteroids with the standard antibiotic treatments in their respective areas.

Blood Glucose Management

Chen et al. (2019) assessed the impact of short-term and low-dose systemic corticosteroid treatment on the clinical outcomes of patients with severe community-acquired pneumonia (SCAP) in China. They conducted a multi-center retrospective study from 2013-2015 in five teaching hospitals from Beijing, Shandong, and Yunnan Provinces in China. The 132 patients in the corticosteroid group were prescribed methylprednisolone 0.6 +\- 0.1 mg/kg/day. Although the patients in the corticosteroid group were younger and had fewer comorbidities, such as cardiovascular and cerebrovascular diseases, they had higher rates of COPD, asthma, and chronic liver disease. However, the patients in the corticosteroid-treated group experienced worse complications, including noninvasive ventilation and late-stage hyperglycemia. More people experienced hyperglycemia requiring insulin treatment in the corticosteroid group compared to the non-corticosteroid group. Specifically, 37.5% of patients in the corticosteroid groups experienced late-stage hyperglycemia necessitating insulin therapy. However, only 2.8% of patients in the non-corticosteroid group faced the same issue. After adjusting for gender, age, and comorbidities, patients who were taking corticosteroids were 4.74 times as likely to develop hyperglycemia that necessitates insulin. This marks a drastic difference in the blood glucose levels of both groups (Chen et al., 2019). Contrasting Chen et al.'s study, in 2016, Popovic et al. conducted a large randomized study to address corticosteroid therapy's efficacy for diabetic patients with CAP. In their trial, they deemed that adjunct prednisone in CAP patients with diabetes or hyperglycemia on admission still showed benefits despite the hyperglycemic levels. They found no adverse effect on outcomes when utilizing prednisone therapy (Popovic et al., 2016).

The nurse and the healthcare team work collaboratively in inpatient settings to best treat discomfort and prevent complications. For a CAP patient enduring corticosteroid therapy, it would be best practice for the nurse to monitor blood sugars routinely. Utilizing a sliding scale for insulin dosage, the nurse can adjust the dosage that would best lower blood sugars without risking hypoglycemia, defined as blood glucose levels under 70 mg/dL (Rushakoff, 2019). The nurse should advocate for diabetic CAP patients to have blood sugar checks even more frequently, four times a day, one before each meal and another before they sleep for the night.

When administering insulin to CAP patients with elevated blood sugars, it is best practice for the nurse to ensure that there are treatments for hypoglycemia on file before administering insulin due to the possibility of hypoglycemia. If a hypoglycemic adult patient is conscious and can drink liquids and chew solids effectively, the nurse should provide over 15 grams of fruit juice or crackers. Infants and toddlers may need less than 15 grams of carbohydrates to see a positive effect in blood glucose levels. The nurse should re-check the blood glucose fifteen minutes after the intervention. If the blood glucose remains under 70 mg/dL, the nurse should repeat this process by giving another 15 grams of carbohydrates. This is commonly known as the 15-15 rule, signifying the 15 grams of carbohydrates and waiting 15 minutes before checking the blood glucose levels (Centers for Disease Control and Prevention, 2024).

The nurse should prepare alternative methods to raise blood glucose levels if they cannot swallow safely or are unconscious, like most intensive care unit patients. If the blood glucose levels are under 70 mg/dL, then the nurse should give 25mL of 50% dextrose as an intravenous push as soon as possible to correct the level (Rushakoff, 2019). The nurse should wait fifteen minutes before re-checking the patient's blood glucose levels after giving dextrose. The nurse should continue to monitor the patient and repeat the above treatment until the blood glucose levels are over 100 mg/dL (Rushakoff, 2019).

Mortality Outcomes

In Chen et al.'s study (2019), her team found that the mortality rate was higher in the CAP group that received corticosteroids than in the group that did not. Although no exact mortality rates were provided in the multicenter study, the corticosteroid group was more than twice as likely to expire within 30 days as the control group. They found a 0.2% chance that the increased mortality rate could be due to factors other than corticosteroid therapy (Chen et al., 2019). However, the research conducted about corticosteroid therapy and its impacts on mortality outcomes in CAP patients vary widely.

A meta-analysis done by Stern et al. (2017) analyzed 17 randomized controlled trials comprising 2264 participants, 1954 adults and 310 children. They discussed that the outcomes varied across population groups with pneumonia. They deemed that corticosteroids significantly reduced mortality in adults who had severe pneumonia. Although corticosteroid therapy did not significantly alter the rates of mortality of adults with moderate pneumonia, it reduced morbidity rates. They discovered that early clinical failure rates including death, radiographic progression, or clinical instability starting from day 5 to day 8, were significantly reduced in CAP patients.
The reduction was 68% for patients with severe CAP and 32% for those with moderate CAP.

Stern's team expanded their meta-analysis to include two smaller clinical heterogeneous trials of children with bacterial pneumonia. They found that corticosteroids lowered early clinical failure rates, defined by Stern's team as death, radiographic progression, or clinical instability starting from day 5 to day 8, by 59%. Overall, Stern's team found that corticosteroids reduced mortality and morbidity in adults with severe pneumonia, clarifying that one death is prevented for every 18 people treated (Stern et al., 2017). They cited Mandell's textbook "Principles and Practice of Infectious Diseases" from 2015, possibly explaining how corticosteroids reduce pulmonary inflammation in severe pneumonia cases, preventing respiratory failure and mortality (Mandell et al., 2015).

Limitations

There are several limitations to this literature review. First, hospital CAP protocols vary considerably such that the outcomes of their respective control groups will also differ. Secondly, the research did not consider socioeconomic factors' impact or race and ethnicity's roles in corticosteroid therapy. Further research needs to be conducted to fully understand the impacts of corticosteroid therapy across various patient demographics.

Clinical Implications

The table below (figure 1.1), in addition to the reference pages, shows sources that were reviewed and taken into account before creating the literature review. The figure is listed by year and sorted by the significance of the study relating to the potential benefits of corticosteroid initiation for CAP patients. It is worth noting that the data is heavily mixed. However, there is more evidence to show that corticosteroid therapy has positive outcomes for severe CAP patients.

The findings in this literature review indicate that although corticosteroid therapy may lead to adverse effects such as hyperglycemia and increased mortality in specific populations, other evidence suggests that corticosteroids may decrease mortality in particular populations, such as adults with severe CAP. The medical team should consider corticosteroid therapy's potential benefits and risks individually. Nurses play an essential role in the health outcomes of CAP patients undergoing either treatment route. The nurse must advocate for the patient for any necessary adjustments in treatment, such as obtaining a PRN insulin order with IV 50% dextrose for blood glucose balancing. Ongoing nursing assessment is critical to tailor CAP interventions. Ultimately, the medical team must weigh all treatment options, including corticosteroid therapy, for patients with CAP.

 

		meta-analysis.	the type of corticosteroids.”
2021	Wittermans, E., Vestjens, S. M.	Adjunctive treatment with oral	“Oral dexamethasone reduced LOS	Mildly
	T., Spoorenberg, S. M. C., Blok,	dexamethasone in non-ICU	and ICU admission rate in adults	Beneficial
	W. L., Grutters, J. C., Janssen,	patients hospitalized with	hospitalized with CAP. It remains
	R., Rijkers, G. T., Smeenk, F.	community-acquired pneumonia:	unclear for which patients the
	W. J. M., Voorn, G. P., van de	a randomized clinical trial.	risk-benefit ratio is optimal.”
	Garde, E. M. W., Bos, W. J. W.,
	Santeon-CAP Study Group, &
	Members of the Santeon-CAP
	Study Group
2011	Fernández-Serrano, S., Dorca,	Effect of corticosteroids on the	“MPDN treatment, in combination	Beneficial
	J., Garcia-Vidal, C.,	clinical course of	with antibiotics, improves
	Fernández-Sabé, N., Carratalà,	community-acquired pneumonia:	respiratory failure and accelerates
	J., Fernández-Agüera, A.,	a randomized controlled trial.	the timing of clinical resolution of
	Corominas, M., Padrones, S.,		severe CAP needing hospital
	Gudiol, F., & Manresa, F.		admission.”
2011	Meijvis, S. C., Hardeman, H.,	Dexamethasone and length of	“Dexamethasone can reduce length	Beneficial
	Remmelts, H. H., Heijligenberg,	hospital stay in patients with	of hospital stay when added to
	R., Rijkers, G. T., van	community-acquired pneumonia:	antibiotic treatment in
	Velzen-Blad, H., Voorn, G. P.,	a randomised, double-blind,	non-immunocompromised patients
	van de Garde, E. M., Endeman,	placebo-controlled trial.	with community-acquired
	H., Grutters, J. C., Bos, W. J., &		pneumonia”
	Biesma, D. H.
2015	Torres, A., Sibila, O., Ferrer,	Effect of corticosteroids on	“Among patients with severe	Beneficial
	M., Polverino, E., Menendez,	treatment failure among	community-acquired pneumonia
	R., Mensa, J., Gabarrús, A.,	hospitalized patients with severe	and high initial inflammatory
	Sellarés, J., Restrepo, M. I.,	community-acquired pneumonia	response, the acute use of
	Anzueto, A., Niederman, M. S.,	and high inflammatory response:	methylprednisolone compared with
	& Agustí, C.	a randomized clinical trial.	placebo decreased treatment failure.
			If replicated, these findings would
			support the use of corticosteroids as
			adjunctive treatment in this clinical
			population.”
2015	Blum, C. A., Nigro, N., Briel,	Adjunct prednisone therapy for	“Prednisone treatment for 7 days in	Beneficial
	M., Schuetz, P., Ullmer, E.,	patients with	patients with community-acquired
	Suter-Widmer, I., Winzeler, B.,	community-acquired pneumonia:	pneumonia admitted to hospital
	Bingisser, R., Elsaesser, H.,	a multicentre, double-blind,	shortens time to clinical stability
	Drozdov, D., Arici, B., Urwyler,	randomised, placebo-controlled	without an increase in
	S. A., Refardt, J., Tarr, P., Wirz,	trial.	complications. This finding is
	S., Thomann, R., Baumgartner,		relevant from a patient perspective
	C., Duplain, H., Burki, D.,		and an important determinant of
	Zimmerli, W., … Christ-Crain,		hospital costs and efficiency.”
	M.
2015	Siemieniuk, R. A., Meade, M.	Corticosteroid Therapy for	“For hospitalized adults with CAP,	Beneficial
	O., Alonso-Coello, P., Briel, M.,	Patients Hospitalized With	systemic corticosteroid therapy may
	Evaniew, N., Prasad, M.,	Community-Acquired	reduce mortality by approximately
	Alexander, P. E., Fei, Y.,	Pneumonia: A Systematic Review	3%, need for mechanical ventilation
	Vandvik, P. O., Loeb, M., &	and Meta-analysis.	by approximately 5%, and hospital
	Guyatt, G. H		stay by approximately 1 day.”
2016	Tian, X. L., Jiang, M., Sun, X.	The indications for	“This meta-analysis suggested that	Beneficial
	F., Zhan, Y. Z., Wang, S. B., &	glucocorticoids in treating	GCS should only be rigorously used
	Kang, S. S.	community-acquired pneumonia	in severe CAP patients.”
		in adults: a meta-analysis
2018	Wu, W. F., Fang, Q., & He, G. J.	Efficacy of corticosteroid	“Corticosteroids adjuvant therapy in	Beneficial
		treatment for severe	patients with severe CAP may
		community-acquired pneumonia:	reduce the rate of in-hospital
		A meta-analysis.	mortality, reduce the length of
			hospital stay, and reduce CRP
			levels.”

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Blum, C. A., Nigro, N., Briel, M., Schuetz, P., Ullmer, E., Suter-Widmer, I., Winzeler, B., Bingisser, R., Elsaesser, H., Drozdov, D., Arici, B., Urwyler, S. A., Refardt, J., Tarr, P., Wirz, S., Thomann, R., Baumgartner, C., Duplain, H., Burki, D., Zimmerli, W., … Christ-Crain, M. (2015). Adjunct prednisone therapy for patients with
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