What is the role of corticosteroids (steroids) in the treatment of pneumonia, as studied in the Cape Cod study?

From the Guidelines

Corticosteroids should not be routinely used in adults with nonsevere community-acquired pneumonia (CAP), but may be considered in patients with severe CAP, particularly those with hypoxemia requiring supplemental oxygen or mechanical ventilation, as they may reduce mortality, shorten hospital stays, and decrease the need for mechanical ventilation 1.

Key Points

• The use of corticosteroids in CAP should be individualized, taking into account the severity of the disease and the presence of comorbidities.
• For patients with severe CAP, corticosteroids may be beneficial in reducing mortality and improving clinical outcomes, particularly when started within 36 hours of hospital admission.
• The preferred regimen is dexamethasone 6 mg daily for 10 days, though methylprednisolone 40 mg twice daily for 5-7 days is an acceptable alternative.
• Patients with certain comorbidities, such as diabetes, may experience transient hyperglycemia requiring monitoring.
• Corticosteroids should be used cautiously in patients with active bacterial infections outside the lungs, as they may mask symptoms or worsen infections.

Benefits and Risks

• Benefits of corticosteroids in pneumonia include reduced mortality, shorter hospital stays, decreased need for mechanical ventilation, and faster clinical improvement.
• Risks include hyperglycemia, potential increased risk of secondary infections, and masking of symptoms or worsening of infections outside the lungs.

Recent Evidence

• A 2019 guideline from the American Thoracic Society and Infectious Diseases Society of America recommends against routine use of adjunctive steroids in patients treated for CAP, but suggests considering their use in severe cases 1.
• A 2021 review of updates on community-acquired pneumonia management in the ICU suggests that corticosteroids may be beneficial in patients with severe CAP, particularly those with septic shock refractory to fluid resuscitation and vasopressor use 1.

From the Research

Cape Cod Study on Pneumonia and Steroids

• The use of corticosteroids in the treatment of pneumonia has been evaluated in several studies, including the Cape Cod study, although the specific details of this study are not provided in the given evidence 2, 3, 4, 5, 6.
• The available evidence suggests that corticosteroids may be beneficial in reducing mortality and improving clinical outcomes in patients with severe community-acquired pneumonia (CAP) and high inflammatory responses 2.
• A study published in Critical Care found that corticosteroid therapy reduced the 28-day mortality risk in patients with CAP who met major severity criteria, such as septic shock and/or requirement for invasive mechanical ventilation 2.
• Another study published in Acta Medica Academia suggested that inhaled corticosteroids, with or without inhaled beta agonists, may offer potential benefits in select groups of patients with more severe pneumonia, although further research is needed to establish the ideal timing, dose, route of delivery, duration, and patient selection 3.
• A review published in the Bosnian Journal of Basic Medical Sciences proposed a biomarker-guided, precision medicine approach to corticosteroid treatment in patients with pneumonia, aiming to provide these medications at the appropriate dose and time, and only to patients with exaggerated inflammation 4.

Key Findings

• Corticosteroids may be beneficial in reducing mortality and improving clinical outcomes in patients with severe CAP and high inflammatory responses 2.
• Inhaled corticosteroids, with or without inhaled beta agonists, may offer potential benefits in select groups of patients with more severe pneumonia 3.
• A biomarker-guided approach to corticosteroid treatment may help identify patients who are most likely to benefit from these medications 4.
• The evidence from randomized controlled trials suggests that corticosteroids can improve oxygenation, reduce the need for mechanical ventilation, and accelerate the resolution of symptoms in patients with pneumonia 5, 6.

Corticosteroid Use in Pneumonia

• The use of corticosteroids in pneumonia remains a controversial issue, with some studies suggesting benefits and others raising concerns about potential adverse effects 2, 3, 4, 5, 6.
• International guidelines on pneumonia provide varying recommendations on the use of corticosteroids, with some suggesting stress doses in severe episodes with sepsis 6.
• Further research is needed to establish the optimal use of corticosteroids in pneumonia, including the ideal timing, dose, route of delivery, duration, and patient selection 3, 6.