Corticosteroid Utilization and Outcomes in HIV Associated Pneumocystis Carinii Pneumonia: Three-fold Higher Mortality Among Severely Ill Patients when Corticosteroids given by CEC Guidelines

Bennett CL, Ilraith T. Corticosteroid Utilization and Outcomes in HIV Associated Pneumocystis Carinii Pneumonia: Three-fold Higher Mortality Among Severely Ill Patients when Corticosteroids given by CEC Guidelines. Paper presented at: VA HSR&D National Meeting; 1999 Feb 25; Washington, DC.

Objectives: Experience with the management of Pneumocystis carinii pneumonia (PCP) exploded with the onset of hte AIDS epidemic. Anecdotal reports of improved outcome when steroids were used as adjuncts to appropriate anti-microbial therapy let to controlled trials demonstrating their efficacy. [Bozette S, NEJM] The CDC created guidelines supporting adjunctive therapy with corticosteroids. PCP management during 1995 to 1997 was evaluated for variations in guideline adherence and outsomes. Methods: Chart reviews from 7 states, 74 hospitals (66 non-VA and 8 VA), and 1,660 empirically diagnosed or confirmed PCP cases. Results: 735 (44.2%) met CDC guidelines for adjunctive steriods (Aa oxygen gradient > 35 mm Hg or p02 < 70mm Hg) and 606 (82.4% received steroids as directed by the guidelines (w/in 3 days on anti-PCP medications). Higher rates of appropriate steroid use were associated with African-American race/ethnicity (84%) versus white (81%) or Hispanics (73%) (p = 0.02), younger age (p = 0.002), or receiving care in Chicago or Seattle (90%) vs NY, Miami, or LA (71%) (p = 0.001). Among severely ill patients with Aa oxygen gradient > 53 mm Hg, 73% were confirmed PCP cases and 82% received corticosteroids per the CDC guidelines. Among these patients, mortality rates were three-fold higher for those who DID receive steroids (18% vs 6%, p = 0.02). Similar findings were noted for severely ill persons with confirmed PCP (17% vs 6%). In addition, receiving PCP prophylaxis was associated with higher mortality rates (30% vs 16%, p = .001). Conclusions: Adherence to CDC guidelines for adjunctive corticosteroid use varied according to city and patient sociodemographics. More importantly, improved outcomes seen in randomized controlled trials were not realized in practice. Among severely ill PCP patients, mortality was three-fold higher when corticosteroids were given according to CDC guidelines. Our findings suggest that the utility of adjunctive corticosteroids in severe PCP needs to be revisted.