From the Guidelines
Steroids, such as prednisone, are not routinely recommended for most cases of community-acquired pneumonia (CAP), except in specific situations like severe CAP with significant inflammation or in patients with certain underlying conditions, as suggested by the most recent guideline from the American Thoracic Society and Infectious Diseases Society of America 1. The use of corticosteroids in CAP has been extensively studied, with conflicting results. However, the majority of evidence suggests that corticosteroids should not be used routinely in patients with non-severe CAP, as they do not provide a significant benefit in terms of mortality or organ failure 1. Some key points to consider when deciding whether to use steroids in CAP include:
- The severity of the illness: patients with severe CAP may benefit from corticosteroids, particularly those with high inflammatory markers or requiring ICU admission 1.
- Underlying conditions: patients with certain underlying conditions, such as COPD exacerbations, may also benefit from corticosteroids 1.
- Risks and side effects: corticosteroids carry risks including hyperglycemia, secondary infections, and gastrointestinal bleeding, and should be used cautiously 1.
- Individualized decision-making: the decision to use steroids should be based on the severity of illness, patient comorbidities, and risk factors, rather than a one-size-fits-all approach 1. It's also important to note that the IDSA/ATS 2019 guideline gives a strong conditional recommendation against routine use of adjunctive steroids in patients treated for CAP, but suggests that corticosteroids may be beneficial in patients with severe CAP, particularly those with septic shock refractory to fluid resuscitation and vasopressor use 1. When indicated, prednisone is typically given at 40-50mg daily for 5-7 days, although the optimal dose and duration of therapy are not well established 1. In summary, the use of steroids in CAP should be reserved for specific situations, and should be individualized based on the severity of illness, patient comorbidities, and risk factors, with careful consideration of the potential benefits and risks.
From the Research
Role of Steroids in Community-Acquired Pneumonia
The use of steroids, such as prednisone, in the treatment of community-acquired pneumonia (CAP) has been studied in various clinical trials. The evidence suggests that:
- Corticosteroids may be beneficial in reducing treatment failure and improving outcomes in patients with severe CAP and high inflammatory response 2.
- The use of systemic corticosteroids in CAP is frequent in clinical practice, but its benefits are not clear, and it may be associated with prolonged length of hospital stay 3.
- Adjunctive prednisolone treatment does not improve outcome in hospitalized patients with CAP, and may be associated with increased late failure 4.
Benefits and Risks of Steroids in CAP
The benefits of steroids in CAP include:
- Reduced time to clinical stability and length of hospital stay 5.
- Improved outcomes in patients with severe CAP and high inflammatory response 2. The risks of steroids in CAP include:
- Hyperglycemia, which is the most common adverse effect of corticosteroid therapy in CAP 5.
- Potential impact on the rate of CAP-related rehospitalizations, which requires further investigation 5.
Current Recommendations and Future Directions
Current clinical practice guidelines do not recommend the routine use of corticosteroids in CAP, except in cases of refractory septic shock 5. Further research is needed to better define the ideal role of corticosteroids in CAP, including the identification of patient populations that may benefit from steroid therapy, and the optimal dosing and duration of treatment 5. Low-dose corticosteroids may be beneficial in reducing mortality in patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia 6.