The CAPE COD trial was a multicentre, randomised, double-blind, placebo-controlled study evaluating early intravenous hydrocortisone in adults with severe community-acquired pneumonia.
759 patients were enrolled in intensive care or high-dependency settings with severe disease defined by respiratory failure, need for ventilatory support, or septic shock.
Participants received continuous-infusion hydrocortisone (200 mg/day with taper) started early after hospital admission, compared with placebo alongside standard care.
The primary outcome was 28-day all-cause mortality.
Hydrocortisone significantly reduced 28-day mortality compared with placebo.
| Outcome | Hydrocortisone | Placebo |
|---|---|---|
| 28-day mortality | 25/400 (6.2 %) | 47/395 (11.9 %) |
| 90-day mortality | 36/388 (9.3 %) | 57/389 (14.7 %) |
| Intubation by day 28 (among non-ventilated at baseline) | 40/222 (18 %) | 65/220 (29.5 %) |
| Vasopressors by day 28 (among no baseline vasopressor) | 55/359 (15.3 %) | 86/344 (25 %) |
| ICU-acquired infection | ~9.8 % | ~11.1 % |
| GI bleeding | ~2.2 % | ~3.3 % |
| Hyperglycaemia requiring insulin (first week) | higher than placebo | lower than steroid arm (EMRA) |
The steroid group also had reduced need for endotracheal intubation among patients not ventilated at baseline.
There was a lower requirement for vasopressor support in the hydrocortisone arm, suggesting attenuation of septic shock physiology.
Duration of ICU stay and organ support tended to be shorter with hydrocortisone, though not all secondary outcomes reached statistical significance.
Rates of serious adverse events, including hospital-acquired infection and gastrointestinal bleeding, were not meaningfully increased.
Hyperglycaemia requiring insulin was more common with steroids but was clinically manageable.
Results contrasted with earlier neutral trials using methylprednisolone, suggesting benefit may depend on steroid choice, timing, and dosing strategy.
The findings support early adjunctive hydrocortisone in carefully selected patients with severe CAP requiring critical care.
Conclusion:
Early low-dose hydrocortisone appears to improve survival and reduce organ support requirements in severe community-acquired pneumonia without major safety concerns, making it one of the most practice-changing recent trials in the critical care management of severe CAP.
