Aetiology and prognostic risk factors of mortality in pneumonia patients receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study

Objectives: Long-term use of high-dose glucocorticoids can lead to severe
immunosuppression and increased risk of treatment-resistant pneumonia and
mortality. We investigated the aetiology and prognostic risk factors of
mortality in hospitalised patients who developed pneumonia while receiving
glucocorticoid therapy alone or glucocorticoid and other immunosuppressant
therapies. Design: Retrospective cohort study Setting: Six secondary and
tertiary academic hospitals in China Participants: Patients receiving
glucocorticoids who were hospitalised with pneumonia between 1st January
2013 and 31st December 2019. Main Outcomes: We analysed the prevalence of
comorbidities, microbiology, antibiotic susceptibility patterns, 30-day
and 90-day mortality rates, and prognostic risk factors. Results: A total
of 716 patients were included, with pneumonia pathogens identified in
69.8% of patients. Significant morbidities occurred, including respiratory
failure (50.8%), intensive care unit (ICU) transfer (40.8%), and
mechanical ventilation (36%), with a 90-day mortality rate of 26.0%.
Diagnosis of pneumonia occurred within 6 months of glucocorticoid
initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and
79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens,
including Pneumocystis, CMV, and multidrug-resistant bacteria, were
identified more frequently in patients with persistent lymphocytopenia and
high-dose glucocorticoid treatment (≥ 30 mg/day of prednisolone or
equivalent within 30 days before admission). The 90-day mortality rate was
significantly lower for non-CMV viral pneumonias than for PCP (P <
0.05), with a similar mortality rate as CMV pneumonias (24.2% vs 38.1% vs
27.4%, respectively).Cox regression analysis indicated several independent
negative predictors for mortality in this patient population, including
septic shock, respiratory failure, persistent lymphocytopenia,
interstitial lung disease, and high-dose glucocorticoid use. Conclusions:
Patients who developed pneumonia while receiving glucocorticoid therapy
experienced high rates of opportunistic infections, with significant
morbidity and mortality. These findings should be carefully considered
when determining treatment strategies for this patient population.