Should steroids be given for pneumonia?

From the Guidelines

Steroids should not be routinely used in adults with nonsevere community-acquired pneumonia (CAP), but may be considered in severe CAP or in patients with septic shock refractory to fluid resuscitation and vasopressor use. The use of corticosteroids in pneumonia is a topic of ongoing debate, with some studies suggesting a potential benefit in reducing mortality and improving outcomes in severe cases 1. However, the evidence is not uniform, and the decision to use steroids should be individualized based on the severity of illness, type of pneumonia, and patient comorbidities.

Some studies have shown that corticosteroids may be beneficial in severe CAP, particularly in patients with septic shock or those requiring mechanical ventilation 1. For example, a meta-analysis of randomized controlled trials found that adjunctive corticosteroids were associated with reduced all-cause mortality, acute respiratory distress syndrome (ARDS), and need for invasive mechanical ventilation (IMV) in severe CAP 1. However, other studies have found no significant benefit or even potential harm from corticosteroid use in CAP, particularly in patients with viral pneumonia or those with mild to moderate disease 1.

The choice of corticosteroid and dosage may also be important, with some studies suggesting that lower doses of corticosteroids (e.g., methylprednisolone 0.5 mg/kg IV every 12 hours) may be more effective and safer than higher doses 1. Additionally, the timing of corticosteroid initiation may be crucial, with some studies suggesting that early treatment (within 48 hours of symptom onset) may be more effective than delayed treatment 1.

Key considerations when deciding whether to use corticosteroids in pneumonia include:

• Severity of illness: Corticosteroids may be more beneficial in severe CAP or in patients with septic shock.
• Type of pneumonia: Corticosteroids may be more effective in bacterial pneumonia than in viral pneumonia.
• Patient comorbidities: Patients with certain comorbidities, such as diabetes or immunosuppression, may be at higher risk for corticosteroid-related side effects.
• Potential side effects: Corticosteroids can cause hyperglycemia, increased risk of secondary infections, and gastrointestinal bleeding, among other side effects.

In summary, while corticosteroids may have a role in the treatment of severe CAP or in patients with septic shock, their use should be individualized and based on a careful consideration of the potential benefits and risks. The most recent and highest-quality evidence suggests that corticosteroids should not be routinely used in adults with nonsevere CAP, but may be considered in severe cases or in patients with septic shock refractory to fluid resuscitation and vasopressor use 1.

From the Research

Steroid Use in Pneumonia

• The use of steroids in pneumonia treatment is a topic of ongoing debate, with some studies suggesting potential benefits in specific cases, while others indicate no significant impact on outcomes 2, 3.
• A study published in 2021 found that corticosteroid therapy may reduce 28-day mortality risk in patients with community-acquired pneumonia (CAP) who have septic shock and/or a high inflammatory response and require invasive mechanical ventilation 2.
• However, another study from 2012 concluded that there is no evidence to support the use of systemic steroids as a standard of care in pneumonia, due to the lack of impact on survival and potential adverse effects such as hyperglycemia and superinfections 3.
• Other research has suggested that anti-inflammatory treatment options, including corticosteroids, may be beneficial in modifying the immune response and improving prognosis in pneumonia patients 4.
• A 2013 study found that systemic corticosteroids were frequently used in clinical practice for CAP, but their use was not associated with improved outcomes, and instead was linked to a longer length of hospital stay 5.
• An earlier review from 2007 concluded that corticosteroids cannot be recommended for adjunctive treatment of severe CAP due to the lack of proven benefit on clinically meaningful endpoints and adverse events 6.

Specific Patient Groups

• Patients with severe CAP, septic shock, and/or a high inflammatory response may benefit from corticosteroid therapy, as suggested by the 2021 study 2.
• However, patients without these severe features may not experience any benefits from corticosteroid use, and may instead be at risk of adverse effects 2, 3.
• The use of corticosteroids in patients with chronic respiratory comorbidities or severe clinical presentation may be more common, but their effectiveness in these groups is still unclear 5.