Is steroid therapy indicated in post-viral pneumonia?

From the Guidelines

Steroid therapy is not routinely recommended for post-viral pneumonia, except in specific cases where the benefits outweigh the risks, such as in COVID-19 pneumonia requiring oxygen supplementation, where dexamethasone 6mg daily for up to 10 days has shown mortality benefit 1. For typical viral pneumonia, supportive care including rest, hydration, and antipyretics is the mainstay of treatment, as steroids may potentially prolong viral shedding and delay recovery. However, there are specific exceptions where steroids might be beneficial, such as in severe influenza pneumonia with inflammatory complications, where short courses of steroids might be considered on a case-by-case basis. The rationale for limiting steroid use in viral pneumonia is that while steroids reduce inflammation, they can also suppress immune function, potentially allowing continued viral replication and increasing the risk of secondary bacterial infections. According to the American Thoracic Society and Infectious Diseases Society of America guidelines, corticosteroids are not recommended for routine use in adults with nonsevere community-acquired pneumonia (CAP) or severe CAP, except in cases of refractory septic shock 1. The decision to use steroids should be individualized based on the specific virus, severity of illness, presence of hypoxemia, and the patient's overall clinical condition. If steroids are used, they should generally be limited to short courses at appropriate doses to minimize adverse effects, such as hyperglycemia and potential increased risk of secondary infections. Key considerations in the use of steroids in post-viral pneumonia include:

• The specific virus involved and its potential response to steroid therapy
• The severity of illness and the presence of hypoxemia or other complications
• The patient's overall clinical condition, including the presence of comorbidities or immunosuppression
• The potential risks and benefits of steroid therapy, including the risk of prolonged viral shedding and secondary bacterial infections. In general, the use of steroids in post-viral pneumonia should be guided by the principles of minimizing harm and maximizing benefit, with careful consideration of the individual patient's circumstances and the latest available evidence.

From the Research

Steroid Therapy in Post-Viral Pneumonia

• The use of steroid therapy in post-viral pneumonia is a topic of ongoing debate, with some studies suggesting its potential benefits and others highlighting its risks 2, 3, 4, 5, 6.
• In the context of COVID-19 pneumonia, some studies have shown that corticosteroids may be beneficial in reducing mortality, particularly in severe cases 2, 4, 6.
• However, other studies have raised concerns about the potential harmful effects of corticosteroids in certain types of pneumonia, such as influenza, where their use has been associated with increased mortality and nosocomial infections 3, 5.
• The evidence suggests that the decision to use steroid therapy in post-viral pneumonia should be made on a case-by-case basis, taking into account the individual patient's condition, the severity of the disease, and the potential risks and benefits of treatment 3, 4, 5.

Specific Considerations

• In patients with COVID-19 pneumonia, the use of corticosteroids, such as methylprednisolone, in combination with tocilizumab, may improve outcomes, including failure-free survival and overall survival 6.
• However, the use of corticosteroids in other types of viral pneumonia, such as influenza, is not recommended due to the potential for harmful effects 3, 5.
• The development of secondary infections, such as bacterial or fungal infections, is a potential risk of steroid therapy in post-viral pneumonia, and patients should be closely monitored for these complications 2, 6.

Current Recommendations

• The current evidence does not support the routine use of corticosteroids in all patients with post-viral pneumonia, but rather recommends their use in specific cases, such as severe COVID-19 pneumonia, where the benefits may outweigh the risks 3, 4, 5.
• Further studies are needed to fully understand the role of steroid therapy in post-viral pneumonia and to identify the subgroups of patients who may benefit from this treatment 3, 4, 5.