THE USE OF CORTICOSTEROIDS IN PNEUMOCYSTIS-CARINII PNEUMONIA

NOTE FROM DR. MERLE A. SANDE–The history of seeking a therapeutic use for corticosteroids in an infectious disease is somewhat checkered. These agents failed to show benefit in carefully controlled clinical trials of septic shock and adult respiratory distress syndrome; however, when started early with antimicrobials, corticosteroid therapy in AIDS patients with pneumocystis pneumonia appears to ameliorate the deterioration in pulmonary function and gas exchange that accompanies conventional therapy. If initiated after this deterioration, steroids do not enhance oxygenation or show other clinical benefit. TIming is key. Steroids are effective in experimental models of endotoxic shock if given before the septic state develops; a similar pattern is emerging in adjunctive dexamethasone therapy for bacterial meningitis. Recent clinical studies in Dallas and Costa Rica indicate that beneficial effects are maximal if the steroid is given just before or concomitant with the antibiotic. Adjunctive corticosteroid therapy for moderate to severe pneumocystis pneumonia in AIDS patients is the recommendation of a panel that evaluated the existing data in the summer of 1990. Dr. Bozzette was the principal investigator of the largest of these studies and here presents data from the critical trials and discusses use of adjunctive antiinflammatory therapy to reduce lung injury in patients with pneumocystis pneumonia. © 1990, by The University of Chicago.