Cortisol levels and adrenal response in severe community-acquired pneumonia: A systematic review of the literature

• Published in: Journal of critical care Vol. 25; no. 3; pp. 541.e1 - 541.e8
• Main Authors: Salluh, Jorge I.F., MD, PhD, Shinotsuka, Cássia Righy, MD, MSc, Soares, Márcio, MD, PhD, Bozza, Fernando A., MD, PhD, Lapa e Silva, José Roberto, MD, PhD, Tura, Bernardo Rangel, MD, PhD, Bozza, Patrícia T., MD, PhD, Vidal, Carolina Garcia, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-09-2010; Elsevier Limited
• Subjects: Adrenal failure; Adrenal glands; Adrenal Glands - physiopathology; Adrenal Insufficiency - epidemiology; Community-Acquired Infections - blood; Community-Acquired Infections - mortality; Community-Acquired Infections - physiopathology; Community-acquired pneumonia; Corticosteroids; Cortisol; Critical Care; Critical Illness; Humans; Hydrocortisone - blood; Literature reviews; Mortality; Pneumonia; Pneumonia - blood; Pneumonia - mortality; Pneumonia - physiopathology; Respiratory distress syndrome; Sepsis; Severity of Illness Index; Sepsis; Cortisol; Corticosteroids; Community-acquired pneumonia; Adrenal failure
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2010.03.004

Abstract Objectives Our aim was to review the literature on the prevalence and impact of critical-illness related corticosteroid insufficiency (CIRCI) on the outcomes of patients with severe community-acquired pneumonia (CAP). Methods We reviewed Cochrane, Medline, and CINAHL databases (through July 2008) to identify studies evaluating the adrenal function in severe CAP. Main data collected were prevalence of CIRCI and its mortality. Results We screened 152 articles and identified 7 valid studies. Evaluation of adrenal function varied, and most studies used baseline total cortisol levels. The prevalence of CIRCI in severe CAP ranged from 0% to 48%. Among 533 patients, 56 (10.7%) had cortisol levels of 10 μ g/dL or less and 121 patients (21.2%) had cortisol levels of 15 μ g/dL or less. In a raw analysis, there was no significant difference in mortality when patients with cortisol levels less than 10 μ g/dL (8.6 vs 15.5%; P = .55) or less than 15 μ g/dL (12.4 vs 16%; P = .38) were compared with those with cortisol above these levels. In the meta-analysis, relative risk for mortality were 0.81 (confidence interval, 0.39-1.7; P = .59; χ2 = 1.04) for cortisol levels less than 10 μ g/dL and relative risk was 0.67 (confidence interval, 0.4-1.14; P = .84; χ2 = 1.4) for cortisol levels less than 15 μ g/dL. Conclusions A significant proportion of patients with severe CAP fulfilled criteria for CIRCI. However, CIRCI does not seem to affect the outcomes. Noteworthy, the presence of elevated cortisol levels is associated with increased mortality and may be useful as a prognostic marker in patients with severe CAP.