CAPE COD ESCAPe

Method A multicentre, double-blind, placebo controlled RCT from 31 ICUs in France. A multicentre, double-blind, placebo controlled RCT from 42 American
N= 795, Male = 552 (69.4%)
Inclusion Adult patient with severe CAP admitted to ICU, CAP diagnosed during 48H
criteria post hospital admission,
Severe CAP defined by at least one of the following.
 mechanical ventilation with PEEP of at least 5 cm water
 PaO2:FiO2 ratio estimated to be less than 300.
 Pulmonary Severity Index score of more than 130.
 oxygen therapy with a partial rebreathing-mask with a reservoir bag,
provided that the PaO2 is less than (cf. table)
Oxygen flow (L/min) 6 7 8 9 10 or more
PaO2 (mmHg) <180 210 240 270 300
Exclusion Pneumonia caused by influenza, septic shock on vasopressors, history
criteria suggestive of aspiration, baseline steroid use equivalent to 15mg/d of
prednisone or more for more than 30d , active tuberculosis or fungal
infection, known cystic fibrosis, post-obstructive pneumonia, treated by
invasive mechanical ventilation 14 days prior to admission
Intervention Hydrocortisone, given as a continuous infusion of 200 mg/day intravenously,
with a planned taper, for a total of either 8 or 14 days depending on whether
the patient was improving on day 4., median of 5days
- initiated within 24H of meeting eligible criteria
Outcome significant decrease in mortality at 28 days, with 6.2% of the hydrocortisone
group and 11.9% of the placebo group dead
(absolute difference −5.6% [95%CI: −9.6 to −1.7%], p = 0.006).
hospitals. N= 584, Male = 562 (96.2%)
Adult patients with severe community acquired pneumonia being
admitted to the ICU, enrolment within 72-96H
Severe CAP defined by 2017 IDSA/ATS criteria.
Major Criteria (1) Minor Criteria (≥3)
 Septic shock  Respiratory rate ≥ 30 breaths/min
requiring  PaO2/FiO2 ratio ≤ 250
vasopressors.  Multilobar infiltrates
 Respiratory failure  Confusion/disorientation
requiring  Uremia (blood urea nitrogen level ≥ 20 mg/dl)
mechanical  Leukopenia* (white blood cell count < 4,000 cells/μl)
ventilation  Thrombocytopenia (platelet count < 100,000/μl)
 Hypothermia (core temperature < 36°C)
 Hypotension requiring fluid resuscitation
Multiple/ high dose vasopressor >2H in patient adequately fluid resus
(typical 2-4L of crystalloids) or CVP >/=8mmHg (nonventilated) >/=
12mmHg (ventilated)*
GI bleeding needing >5unit PCT transfusion recent 3m
Condition need >/= 20mg/d prednisolone or equivalent >14days within
past 3m
COPD with acute exacerbation required glucocorticoid on admission.
Post obstructive pneumonia/ cystic fibrosis Aspiration pneumonia, active
fungal or TB
Methylprednisolone infusion for 20 days. (40 mg loading dose, then 40
mg/day on days 1–7, 20 mg/day on days 8–14, 12 mg/day on days 15–17
and 4 mg/day on days 18–20). At the time of ICU discharge patients were
switched from an infusion to twice a day dosing.
no significant difference in 60-day mortality
(16% vs. 18% [95%CI: -8−5%], p = 0.61) or any other secondary outcomes.