Adjunctive corticosteroids for Pneumocystis jiroveci pneumonia in patients with HIV infection

• Published in: Cochrane database of systematic reviews 2015-04, Vol.2015 (4), p.CD006150
• Main Authors: Ewald, Hannah, Raatz, Heike, Boscacci, Remy, Furrer, Hansjakob, Bucher, Heiner C, Briel, Matthias
• Format: Article
• Language: English
• Subjects: Adrenal Cortex Hormones - therapeutic use; Adult; AIDS-Related Opportunistic Infections - drug therapy; Chemotherapy, Adjuvant; Child health; Humans; Hypoxia - etiology; Hypoxia - therapy; Infectious disease; Pneumocystis carinii; Pneumonia, Pneumocystis - drug therapy; Randomized Controlled Trials as Topic; Respiration, Artificial; Reviews of Therapeutics, Prognostics and Diagnostics
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD006150.pub2

Pneumocystis jiroveci pneumonia (PCP) remains the most common opportunistic infection in patients infected with the human immunodeficiency virus (HIV). Among patients with HIV infection and PCP the mortality rate is 10% to 20% during the initial infection and this increases substantially with the need for mechanical ventilation. It has been suggested that corticosteroids adjunctive to standard treatment for PCP could prevent the need for mechanical ventilation and decrease mortality in these patients. To assess the effects of adjunctive corticosteroids on overall mortality and the need for mechanical ventilation in HIV-infected patients with PCP and substantial hypoxaemia (arterial oxygen partial pressure < 70 mmHg or alveolar-arterial gradient > 35 mmHg on room air). For the original review we searched The Cochrane Library (2004, Issue 4), MEDLINE (January 1980 to December 2004) and EMBASE (January 1985 to December 2004) without language restrictions. We further reviewed the reference lists from previously published overviews, searched UptoDate version 2005 and Clinical Evidence Concise (Issue 12, 2004), contacted experts in the field and searched the reference lists of identified publications for citations of additional relevant articles.In this update of our review, we searched the above-mentioned databases in September 2010 and April 2014 for trials published since our original review. We also searched for ongoing trials in ClinicalTrials.gov and the World Health Organization International Clinical Trial Registry Platform (ICTRP). We searched for conference abstracts via AEGIS. Randomised controlled trials that compared corticosteroids to placebo or usual care in HIV-infected patients with PCP in addition to baseline treatment with trimethoprim-sulfamethoxazole, pentamidine or dapsone-trimethoprim, and reported mortality data. We excluded trials in patients with no or mild hypoxaemia (arterial oxygen partial pressure > 70 mmHg or an alveolar-arterial gradient < 35 mmHg on room air) and trials with a follow-up of less than 30 days. Two teams of review authors independently evaluated the methodology and extracted data from each primary study. We pooled treatment effects across studies and calculated a weighted average risk ratio of overall mortality in the treatment and control groups using a random-effects model.In this update of our review, we used the GRADE methodology to assess evidence quality. Of 2029 screened records, we included seven studies in