Daily Respiratory Research Analysis

PURPOSE: Pulmonary infections are one of the leading causes of intensive care unit (ICU) admission and contribute to high mortality rates. This paper aimed to determine the effect of low-dose corticosteroids on outcomes in patients with severe pulmonary infections, including coronavirus disease of 2019, community-acquired pneumonia (CAP), pneumocystis pneumonia, sepsis, septic shock, and acute respiratory distress syndrome. METHODS: We systematically reviewed randomised controlled trials (RCTs) comparing low-dose corticosteroids (≤400 mg hydrocortisone-equivalent daily) to placebo or standard care in adults with severe pulmonary infections. The primary outcome was short-term mortality (≤90 days). Secondary outcomes included 28-day mortality, 30-day mortality, number of patients with at least one serious adverse event, length of hospital stay and ICU stay. RESULTS: We analysed twelve RCTs including 4622 patients and 1203 events. The pooled OR showed a short-term mortality benefit: 0.83 (95% CI 0.70 to 0.98; p=0.029; I²=2.0%; number needed to treat: 37.84; Grading of Recommendations Assessment, Development and Evaluation (GRADE): low certainty). There was a reduction in length of ICU stay in patients with CAP, with a pooled mean difference of -0.78 days (95% CI -1.46 to -0.10, p=0.025). The use of corticosteroids did not significantly affect the length of hospital stay or severe adverse events. A significant difference remained in longer courses of steroids, whereas shorter courses had no significant difference (≤7 days vs >7 days; OR: 0.69; 95% CI 0.53 to 0.89; p=0.039 vs OR: 0.96; 95% CI 0.813 to 1.14; p=0.67; subgroup differences: p=0.03). Subgroup analyses in patients with CAP showed a significant benefit in short-term mortality (OR: 0.72, 95% CI 0.54 to 0.98; p=0.034; number needed to treat: 28.10). CONCLUSION: We found that low-dose corticosteroids significantly reduce 90-day mortality in severe CAP, although evidence for their benefit in other severe pulmonary infections and at shorter follow-up intervals remains inconclusive. PROSPERO REGISTRATION NUMBER: CRD42024627881.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of hospital admission for lower respiratory infection in infants worldwide, with more than 95% of deaths occurring in low-income and middle-income countries. Predictors of adverse outcomes following RSV hospitalisation remain poorly defined. We aimed to identify clinical and anthropometric predictors of mortality among infants admitted with RSV pneumonia and to assess changes in mortality over a 25-year surveillance period. METHODS: In this retrospective cohort study, we analysed 25 years of paediatric surveillance at Kilifi County Hospital, Kilifi, Kenya, spanning 25 successive RSV seasons. Neonates (aged <28 days) and post-neonatal infants (aged 28 days to 12 months) admitted with WHO-defined pneumonia were tested for RSV and demographic, anthropometric, and clinical data were recorded at admission. The primary outcome was in-hospital death among infants admitted with RSV pneumonia. Predictors of mortality were identified using random-forest and multivariable logistic regression, and temporal trends in mortality and anthropometric status were examined. FINDINGS: Of 75 482 admissions of infants to Kilifi County Hospital between Jan 1, 2001, and July 13, 2025, 19 299 (25·6%) met WHO pneumonia criteria and 2745 (22·7%) had RSV. Of these infants, 2390 (87·1%) were post-neonatal, of whom 58 (2·4%) died in hospital with 44 (76%) deaths within 7 days of admission. Mortality was independently associated with congenital heart disease (odds ratio 3·51 [95% CI 1·37-8·97]), severe undernutrition (per 1-unit reduction in weight-for-age Z score: 1·59 [1·28-1·99]), and hypoxaemia (per 1% decrease in peripheral oxygen saturation: 1·05 [1·03-1·08]). 38 (70·4%) of 54 infants with RSV who died in hospital had a mid-upper arm circumference below the severe acute malnutrition threshold of 11·5 cm. There was no evidence of a sustained decline in RSV-associated in-hospital mortality or improvement in anthropometric status over the 25-year study period. INTERPRETATION: RSV mortality in Kenyan infants remains high and has not declined over 25 years. Severe undernutrition and congenital heart disease identify infants with RSV who are at the highest risk of in-hospital death. These findings highlight the role of chronic anthropometric deficits in RSV outcomes and support targeted nutritional interventions to reduce mortality. FUNDING: Bill & Melinda Gates Foundation and Wellcome.

BACKGROUND: Clinical trials showed mRNA-1345 (mRESVIA) was highly efficacious against RSV-associated lower respiratory tract disease in adults; real-world studies are critical to confirm vaccine impact on RSV-related healthcare usage. METHODS: A retrospective test-negative case-control study used Veterans Health Administration electronic health records from the 2025-2026 respiratory season. Veterans aged ≥50 years with acute respiratory illness (ARI) who underwent RSV testing were included. Vaccine effectiveness (VE) of mRNA-1345 was estimated against RSV-positive ARI-associated hospitalization, urgent care/emergency department (UC/ED), and/or outpatient visits using conditional logistic regression. RESULTS: 1.4% of 91,397 tested persons received mRNA-1345. The matched analysis included 3673 RSV cases and 14,566 controls. Among RSV-positive ARI-associated hospitalizations, <5/649 cases and 49/2572 controls were vaccinated (VE: 85%[95% CI:39%-96%]). Effectiveness against medically attended RSV-ARI was 65%(45%-77%), 57%(28%-74%) against ED/UC visits and 71%(19%-90%) against outpatient visits. CONCLUSIONS: mRNA-1345 is associated with substantial protection against RSV-positive ARI-associated hospitalization that was generally consistent across medically-attended outcomes.