We acknowledge the Letter to the Editor regarding the recommendation for the use of corticosteroids in patients with severe community-acquired pneumonia (CAP) and the need for admission to the intensive care unit, included in the document generated from the inaugural meeting of the group OPENIN (Optimización de procesos clínicos para el diagnóstico y tratamiento de infecciones) [Optimisation of clinical processes for the diagnosis and treatment of infections].1 Specifically questioned was the choice of methylprednisolone (at a dose of 0.5&#¿;mg/kg every 12&#¿;hours in the first 24&#¿;hours for no more than 5–7 days) instead of hydrocortisone. In fact, hydrocortisone was the corticosteroid used (at a dose of 200&#¿;mg daily for 4–7 days with progressive reduction until day 14) in the CAPE COD trial, which demonstrated a benefit for the experimental group in terms of mortality and the need for intubation and support with vasoactive drugs.2 In contrast, Meduri et al. found no significant differences in the ESCAPe trial, which was based on the administration of 40&#¿;mg of methylprednisolone daily for 7 days.3 It should be noted that both regimens have comparable anti-inflammatory potency. Different explanations have been suggested, regardless of the type of corticosteroid, to justify these discordant results, such as the demographic characteristics of the patients, the exclusion criteria of the two studies and, in particular, the maximum window allowed from recruitment to the start of corticosteroid treatment (24&#¿;hours in the CAPE COD trial versus 96&#¿;hours in ESCAPe).1 A recent meta-analysis revealed differences in 30-day mortality between patients with CAP who received high cumulative doses (≥400&#¿;mg of prednisone or equivalent) and those treated with lower doses.4 Based on this finding, we proposed a methylprednisolone regimen which, for a patient weighing 70&#¿;kg, would be equivalent to a total dose of 430&#¿;mg of prednisone, although we also recognise the limited evidence available for establishing the optimal regimen.1 Lastly, we would like to emphasise that this recommendation from the group OPENIN is in line with the ERS/ESICM/ESCMID guidelines for the management of severe CAP published in 2023,5 as well as the recent SCCM update on the use of corticosteroids in critically ill patients with severe bacterial CAP.6
Funding
The meeting of the group OPENIN had the financial help of MSD España. The funding source did not participate in the preparation of this manuscript, its contents or the decision to submit it for publication.
