Pneumonia: "If the pneumologist does not notice, gives cortisone" 2

Pneumonia: "If the pneumologist does not notice, gives cortisone"

What can still be done to treat patients with severe pneumonia except prescribed antibiotics? Cortisone probably does not bring anything but immunoglobulins can experience the Renaissance.

severity pneumonia can be developed in two directions: up to Bacteremia and sepsis or pronounced organ damage to an acute respiratory failure. One does not exclude others. Within one and the same species of bacteria there are significant differences, explained Tobias Welte of the Medical School in Hannover. For pneumococcus, for example, serotype 3 causes little lung damage but acts aggressively invasively. Serotype 19 is just the opposite.

antibiotic therapy as well as in the case of outpatient pneumonia which was initially empirical. The German guidelines recommend betaltam plus macrolide, where it is not clear what macrolide should do – fight against atypical pathogens, if any? Add antibiotic effect to beta-lactam immunomodulatory effects? asked prof. Welte.

However, if the patient responds to therapy, which should be visible no later than three days, there is no indication atypical spikes before, macrolide can give up. If there is no improvement in sight, the treatment strategy must be reconsidered. Until then, hopefully, the results of culture testing and blood resistance will also be available.

Supportive therapy without clear evidence, but …

from suportive measures fluid intake (30 ml / kg KG in crystalline form) with hypotension and / or lactate value above 4 mmol / l and in the absence of controversial vasopressor. The target is arterial pressure medium of at least 65 mmHg. Although the original study that established this strategy could never be reproduced. However, according to prof. Welte, that's because the process became so prevalent. It was almost impossible to make a study that would be left out in the control arm of fluid and vasopressors.

cricket gift Pneumonia has been studied several times in studies with inconsistent results. Pulmologists personally consider this topic, said prof. Welte: "If the pneumologist can not remember anything, he gives cortisone," he said with laughter from the audience. For lung inflammation this seems to be a few reasons is not a good idea be acute respiratory distress syndrome (Good Stock InvestS) certainly not.

Good Stock InvestS is based on a high percentage of viral infections, especially flu. In order to prevent viruses, the body needs Th1 cells and interferon, and cortisone is one of the strongest suppressors of Th1 immune response, said prof. Welte. Therefore cortisone can dramatically exacerbate the course of serious viral infections.

It's also time to excuse cortisone from lung inflammation. Most studies have shown the effect of steroids that rely heavily on the fever of soft end points such as intensive care or clinical outcomes. But: "Nothing reduces the temperature just as effectively as cortisone."

Update with immunoglobulins

By the way, all the cortisone studies did not go away – some have also found adverse effects. In conclusion, there is no solid evidence of cortisone in severe cases of pneumonia. Subgroups could benefit, for example, in patients with lung inflammation based on existing COPD or those with a very high level of immune response.

For flowing in immunoglobulins Sam prof. Welte gave stage II study.1 In fact, they are considered outdated, but this is probably because only pure IgG preparations have been tested. In the current study, the enzyme enriched with IgM called trimodulin was used.

Phase III study for IgM therapy in mind

IgM has a greater structure and greater binding ability than IgG. It modulates immune response by inhibition and excessive release of cytokines and complement activation, as well as by providing "immune paralysis" that prevents pathogens control. It can also directly bind to bacterial toxins.

In a study titled CIGMA, 81 ventilated patients with severe lung disease in the community received trimodulin, 79 received placebo. At the primary end point, days without fan, the trimodulin group was performed numerically but was not significantly better (plus 1.4 days). It is worth mentioning the reduction of total and specific mortality from pneumonia for a total of 5.6 and 6.5%. Patients with high inflammatory parameters and low IgM obviously have the most benefit.

CIGMA has not been designed or large enough to fully demonstrate a reduction in mortality. The results, however, impressed the American Food and Drug Administration at their place for the third stage study. It starts in October.

sources:
60th Congress of DGP *
1. Worlds T et al. Intensive Care Medicine 2018; 44: 438-448

* German Society for Psychology and Respiratory Medicine