When should corticosteroids be used in the treatment of pneumonia?

From the Guidelines

Corticosteroids should not be routinely used in adults with nonsevere community-acquired pneumonia (CAP), but may be considered in severe CAP, particularly in patients with refractory septic shock, as recommended by the Surviving Sepsis Campaign 1. The use of corticosteroids in pneumonia is a topic of ongoing debate, with some studies suggesting a mortality benefit in severe cases, while others have raised concerns about potential side effects, such as hyperglycemia and increased risk of secondary infections. Key considerations for the use of corticosteroids in pneumonia include:

• Disease severity: Corticosteroids may be more beneficial in severe CAP, particularly in patients with high inflammatory markers, septic shock, or acute respiratory distress syndrome (ARDS) 1.
• Patient population: Corticosteroids are not recommended for routine use in nonsevere CAP or viral pneumonia without ARDS, due to the potential for adverse effects without clear benefit 1.
• Treatment regimen: If corticosteroids are used, a recommended regimen is intravenous methylprednisolone 0.5 mg/kg every 12 hours for 5 days, or an equivalent dose of another corticosteroid like dexamethasone.
• Timing: Treatment should be started within 36 hours of hospital admission, and ideally within 48 hours of symptom onset for patients with influenza 1.
• Potential contraindications and risks: Always consider potential contraindications and risks of steroid use, such as uncontrolled diabetes, active gastrointestinal bleeding, or certain infections like fungal pneumonia. It is essential to weigh the potential benefits and risks of corticosteroid use in each individual patient, taking into account the latest evidence and guidelines, such as those from the American Thoracic Society and Infectious Diseases Society of America 1.

From the Research

Use of Corticosteroids in Pneumonia Treatment

• Corticosteroids may be used in the treatment of pneumonia, but their use is still controversial and should be restricted to specific cases 2, 3.
• The current evidence suggests that corticosteroids may not be beneficial for patients with mild-to-moderate pneumonia, and their use may even be harmful in some cases 2.
• However, some studies suggest that corticosteroids may be beneficial for patients with severe pneumonia, particularly those with high inflammatory responses or septic shock 4, 5.

Patient Selection for Corticosteroid Therapy

• Patient selection is crucial when considering corticosteroid therapy for pneumonia, and clinicians should carefully evaluate the potential benefits and risks of treatment 3, 5.
• Corticosteroids may be beneficial for patients with severe pneumonia who have:
  • High inflammatory responses 5
  • Septic shock 5, 6
  • Acute respiratory distress syndrome (ARDS) 6
• However, corticosteroids may not be beneficial for patients with mild-to-moderate pneumonia or those without high inflammatory responses or septic shock 2, 5.

Dosage and Duration of Corticosteroid Therapy

• The optimal dosage and duration of corticosteroid therapy for pneumonia are still unclear, but low-dose corticosteroids (less than or equal to 400 mg hydrocortisone equivalent daily) may be associated with improved outcomes 6.
• The duration of therapy should be limited to the shortest duration necessary to achieve the desired clinical effect, and clinicians should carefully monitor patients for potential adverse effects 6.

Potential Adverse Effects of Corticosteroid Therapy

• Corticosteroid therapy can be associated with several potential adverse effects, including:
  • Hyperglycemia 2, 6
  • Gastrointestinal bleeding 6
  • Neuropsychiatric disorders 6
  • Muscle weakness 6
  • Hypernatremia 6
  • Secondary infections 6