Community-Acquired Pneumonia : Evaluation of Corticosteroids
Community-Acquired Pneumonia : Evaluation of Corticosteroids
Mortality of severe Community-Acquired Pneumonia (CAP) has not declined over time and is
 between 25 and 30% in sub-groups of patients. Corticosteroids (CTx) could down-regulate
 pulmonary and systemic inflammation, accelerate clinical resolution and decrease the rate of
 inflammation-associated systemic complications. Two recent meta-analyses suggest a positive
 effect on severe CAP day 28 survival when CTx are added to standard therapy. However they are
 based on only four trials gathering less than 300 patients, of which only one was positive.
 Recently published guidelines do not recommend CTx as part of CAP treatment. Therefore a
 well-powered trial appears necessary to test the hypothesis that CTx - and more specifically
 hydrocortisone - could improve day 28 survival of critically-ill patients with severe CAP,
 severity being assessed either on a Pulmonary Severity Index ≥ 130 (Fine class V) or by the
 use of mechanical ventilation or high-FiO2 high-flow oxygen therapy.

 A phase-III multicenter add-on randomized controlled double-blind superiority trial assessing
 the efficacy of hydrocortisone vs. placebo on Day 28 all-causes mortality, in addition to
 antibiotics and supportive care, including the correction of hypoxemia.

 Randomization will be stratified on: (i) centers; (ii) use of mechanical ventilation at the
 time of inclusion.
Patients will receive state-of-the-art standard therapy for severe Community-Acquired
 Pneumonia (CAP), including antibiotics and supportive care. Correction of hypoxemia will use
 standard low-flow oxygen therapy, high-flow oxygen therapy, non-invasive-ventilation or
 invasive ventilation with endotracheal tube, as required. Patients in the treatment group
 will receive intra-venous hydrocortisone. Patients of the control group will receive an
 intravenous placebo by intravenous route at the same frequency.

 Hydrocortisone or placebo will be given in a double-blind fashion for 8 or 14 full days. The
 intravenous route will be used. The treatment course will include 4 or 7 days of full dose
 (200 mg/day by continuous infusion), 2 or 4 days of half dose (100 mg/day by continuous
 infusion), and 2 or 3 days of tapering dose (50 mg/day by continuous infusion). Duration of
 treatment is chosen upon patient initial improvement.

 A substantial amendment to the CAPE COD study has been submitted to the Competent Authorities
 in order to conduct a specific analysis on the sub-group of patients included with COVID19
 (coronavirus disease 2019), in order to get a quick response in this specific population and
 in the context of an epidemic emergency.

 The aim is to answer as quickly as possible a therapeutic question of major importance in the
 treatment of severe respiratory infections with CoV-2 SARS (severe acute respiratory syndrome
 coronavirus 2). Modifications made to the original study for patients with COVID (coronavirus
 disease) include some inclusion criteria, the primary endpoint, and secondary endpoints.
Inclusion Criteria:

 -  Age ≥ 18 years

 -  Patients affiliated to social security scheme

 -  Admission to an Intensive Care Unit (ICU) or intermediate care unit participating to
 the trial

 -  Diagnosis of Community- Acquired Pneumonia (CAP) suggested by at least two of the
 following: cough, purulent sputum, chest pain and dyspnea

 -  Focal shadowing/infiltrate on chest X-ray or CT-scan

 -  Diagnosis of Community- Acquired Pneumonia (CAP) during the 48 hours post-hospital
 admission

 -  Study drug infusion initiated no longer than 24 hours post first severity criterion

 -  Severity defined by at least one of the following:

 -  Pneumonia Severity Index (PSI) > 130 (Fine class V)

 -  Patient placed on mechanical ventilation (invasive or not) for acute respiratory
 failure, with a PEEP level of 5 cm of water or more

 -  Patient treated by high-flow oxygen therapy with a FiO2 of 50% or more and a P/F
 ratio less than 300

 -  Patient treated by 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) less than 180 210 240 270 300

 -  Patient already treated by antibiotics (at least one dose since admission to hospital)

 -  Informed consent signed by the patient, its relatives or emergency procedure

 On the sub-group of patients included with COVID19 :

 -  Diagnosis of COVID19 either as certain (PCR) or probable (evocative clinical and
 radiological features AND epidemic context AND absence of other microbiological
 documentation).

 -  Study drug infusion initiated no longer than 24 hours post first severity criterion ;
 in case of transfer from another hospital, this period will be prolonged to 48 hours

 -  Patient receiving the best available treatment as define by up-to-date scientific
 knowledge

 Exclusion Criteria:

 -  Patient treated by vasopressors for septic shock at the time of inclusion

 -  Clinical history suggesting of aspiration of gastric content

 -  Patient treated by invasive mechanical ventilation within 14 days before current
 hospital admission

 -  Patient treated by antibiotics for a respiratory infection for more than seven days at
 the admission to the hospital (except if a pathogen resistant to this antibiotics is
 isolated)

 -  History of cystic fibrosis

 -  Post-obstructive pneumonia

 -  Patients in which rapid PCR-test is positive for flu

 -  Active tuberculosis or fungal infection

 -  Active viral hepatitis or active infection with herpes viruses

 -  Myelosuppression

 -  Decision of withholding mechanical ventilation or endotracheal intubation

 -  Hypersensitivity to corticosteroids

 -  Patient needing anti-inflammatory corticosteroids or substitutive hydrocortisone for
 any reason

 -  Patients under treatment by more than 15 mg/d of prednisone (or equivalent) for more
 than 30 days

 -  Patient already enrolled in another drug trial with mortality as an end-point. If the
 patient is already participating in another therapeutic trial with a different
 endpoint, the investigator must verify that inclusion in CAPE COD can not prejudice
 it.

 -  Pregnant or breastfeeding woman

 -  Patient on judicial protection