What steroid do you recommend for Pneumonia (Pna)?

From the Guidelines

I strongly recommend dexamethasone as the steroid of choice for pneumonia requiring hospitalization, particularly in cases of moderate to severe disease, due to its efficacy in reducing mortality, length of stay, and need for mechanical ventilation, as supported by recent guidelines 1. The typical regimen is dexamethasone 6 mg once daily for 7-10 days, either orally or intravenously depending on the patient's condition.

• Steroids are not routinely recommended for mild pneumonia treated in outpatient settings.
• Before starting steroids, it's essential to ensure appropriate antibiotic coverage is in place, as steroids should complement rather than replace antimicrobial therapy.
• Steroids work by reducing the inflammatory response in the lungs, which can decrease lung injury and potentially prevent progression to respiratory failure.
• They are particularly beneficial in pneumonia associated with significant inflammation, such as COVID-19 pneumonia or severe community-acquired pneumonia.
• Patients should be monitored for potential side effects including hyperglycemia, secondary infections, and psychiatric disturbances, as noted in recent studies 1. Alternative steroids include methylprednisolone (40-80 mg daily in divided doses) or prednisone (40-60 mg daily), though dexamethasone is often preferred due to its longer duration of action and good penetration into lung tissue. Key considerations in the use of corticosteroids for pneumonia include the severity of the disease, the presence of comorbidities, and the potential for side effects, as outlined in recent guidelines 1.

From the Research

Steroid Recommendations for Pneumonia (Pna)

• The use of corticosteroids in the management of pneumonia is still a controversial issue 2.
• Some studies suggest that low-dose methylprednisolone treatment can be effective in treating severe community-acquired pneumonia (CAP) 3, 4.
• A Cochrane review found that prolonged low doses of glucocorticoids can be beneficial in severe community-acquired pneumonia, decreasing vasopressor dependency and appearing to be safe 5.
• However, the evidence from these trials is not strong enough to make any recommendations, and larger trials with more patients and clinically important end-points are needed 5.
• A study comparing pulse-dose and high-dose corticosteroids with no corticosteroid treatment for COVID-19 pneumonia in the intensive care unit found that high-dose corticosteroids reduced mortality compared to no receipt, while pulse-dose corticosteroids increased the odds of acute kidney injury requiring renal replacement therapy 6.

Types of Steroids Used

• Methylprednisolone is a commonly used steroid in the treatment of pneumonia, with studies using doses ranging from 20 mg per day to 1 gm per day 3, 4, 6.
• Glucocorticoids are also used, with studies suggesting that prolonged low doses can be beneficial in severe community-acquired pneumonia 2, 5.

Important Considerations

• Infection surveillance is critical in patients treated with corticosteroids, and the drug should be weaned slowly to prevent the rebound phenomenon 2.
• The use of corticosteroids in pneumonia should be carefully considered, taking into account the potential benefits and risks, as well as the individual patient's condition and needs 2, 5, 6.