From the Guidelines
The patient most likely to benefit from the addition of intravenous (IV) hydrocortisone to standard antibiotic therapy and supportive care is the patient admitted to the intensive care unit (ICU) who requires oxygen support with a nonrebreathing mask, with an estimated PaO2:FiO2 of 100. This recommendation is based on the findings from the Community-Acquired Pneumonia: Evaluation of Corticosteroids (CAPE COD) study, which suggest that patients with severe CAP and significant hypoxemia are more likely to benefit from corticosteroid therapy 1. The patient's PaO2:FiO2 ratio of 100 indicates severe hypoxemia, which is consistent with the criteria for benefit from corticosteroids in the CAPE COD study.
The use of corticosteroids in patients with severe CAP has been studied extensively, with some studies suggesting a benefit in reducing mortality and improving clinical outcomes 1. The IDSA/ATS 2019 guideline gives a strong conditional recommendation against routine use of adjunctive steroids in patients treated for CAP, but suggests that corticosteroids may be beneficial in patients with severe CAP, particularly those with septic shock refractory to fluid resuscitation and vasopressor use 1.
The recommended regimen for IV hydrocortisone would be 200 mg daily for 7 days, in addition to appropriate antibiotics and supportive care 1. This regimen is consistent with the guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients, which suggest the use of corticosteroids for 5-7 days at a daily dose < 400 mg IV hydrocortisone or equivalent in hospitalized patients with CAP 1.
Key points to consider when evaluating the potential benefit of corticosteroids in patients with CAP include:
- Severity of hypoxemia, as indicated by the PaO2:FiO2 ratio
- Presence of septic shock refractory to fluid resuscitation and vasopressor use
- Elevated CRP levels (> 150 mg/L)
- Need for mechanical ventilation or oxygen support
- Potential risks and benefits of corticosteroid therapy, including the risk of increased mortality in patients with viral CAP 1.
From the Research
Patient Selection for IV Hydrocortisone Therapy
The decision to add intravenous (IV) hydrocortisone to standard antibiotic therapy and supportive care for adults with community-acquired pneumonia (CAP) should be based on the severity of the disease and the patient's response to initial treatment.
- Patients with severe hypoxemia, defined as a PaO2:FiO2 ratio of less than 100 mmHg, may benefit from the addition of IV hydrocortisone to their treatment regimen 2.
- The use of IV hydrocortisone in patients with CAP has been studied in various clinical trials, including the CAPE COD study, which aimed to evaluate the effectiveness of corticosteroids in patients with CAP.
- Patients who require oxygen support with a nonrebreathing mask and have an estimated PaO2:FiO2 of 100 are more likely to benefit from IV hydrocortisone therapy compared to those with higher PaO2:FiO2 ratios 3, 4.
Comparison of Patient Scenarios
The following patient scenarios can be compared to determine which patient is most likely to benefit from IV hydrocortisone therapy:
- A patient admitted to a medical floor with a Pulmonary Severity Index (PSI) score of 120 may not require IV hydrocortisone therapy, as their condition is not severe enough to warrant corticosteroid treatment.
- A patient admitted to the intensive care unit (ICU) who requires mechanical ventilation with a positive end-expiratory pressure (PEEP) of 4 cm of water may benefit from IV hydrocortisone therapy, but their PaO2:FiO2 ratio is not provided.
- A patient admitted to the ICU who requires oxygen support with high-flow nasal cannula and has an estimated PaO2:FiO2 of 400 is less likely to benefit from IV hydrocortisone therapy, as their PaO2:FiO2 ratio is relatively high.
- A patient admitted to the ICU who requires oxygen support with a nonrebreathing mask and has an estimated PaO2:FiO2 of 100 is the most likely to benefit from IV hydrocortisone therapy, as their condition is severe and they have a low PaO2:FiO2 ratio 5, 6.