EM Lens of the Month

Severe CAP in ED: Does Early Steroid Intervention Tilt Outcomes?

CAPE COD Trial 2023 – Level 1B Evidence

Infographic by Dr Aravind Giri A/L Arunagiri (PPUM) • Designed by Dr Salha Mohd Fadil (PPUM)

Scroll to explore – PDF download at bottom

CAPE COD Trial 2023

Double blinded RCT in 31 ICUs, France – Level 1B Evidence (OCEBM)

N=795 Adults with Severe CAP

On mechanical ventilation
High Flow Nasal Cannula
FiO2 >50% or PF ratio <300
Pneumonia Severity Index >130

Exclusion: Septic shock, Partially treated Pneumonia, Myelosuppression

Intervention: IV Hydrocortisone 200mg/day for 4-7 days followed by taper VS Placebo

Key Benefits

Significant reduction in 28-days mortality (treatment effect -5.6%) (p= 0.006)
NNT=18, treat 18 patients to prevent a death
Reduced need for intubation & vasopressor
No increase in GI bleeding or HAI incidence

Reference: https://www.nejm.org/doi/full/10.1056/NEJMoa2215145

Limitations of Study

Patients with suspected/confirmed viral, inhalation pneumonia, PTB were excluded
Hyperglycemia exacerbation, prone increment usage of Insulin
Prominent generalisability gap, Potential steroid response may differ
Underpowered to detect harm in DM & immunocompromised

Reference: https://www.cebm.ox.ac.uk/resources/ebm-tools/levels-of-evidence

Bottom Line for EM

For adults with severe CAP requiring significant oxygen, early IV Hydrocortisone in the ED reduces 28-days mortality & need for intubation/vasopressor

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