Are steroids indicated for the treatment of bacterial pneumonia?

Steroids Are Not Recommended for Bacterial Pneumonia

Steroids are not recommended for routine use in the treatment of bacterial pneumonia. 1

Evidence Against Routine Steroid Use

The most recent and authoritative guidelines from major respiratory societies consistently recommend against routine steroid use in bacterial pneumonia:

• The American Thoracic Society and Infectious Diseases Society of America (2019) explicitly recommend not routinely using corticosteroids in adults with nonsevere CAP (strong recommendation, high quality evidence) and suggest not routinely using corticosteroids in adults with severe CAP (conditional recommendation, moderate quality evidence) 1

• The European Respiratory Society guidelines (2011) state that "steroids are not recommended in the treatment of pneumonia" 1

• The only exception to this recommendation is for patients with refractory septic shock, where the Surviving Sepsis Campaign recommendations for corticosteroid use are endorsed 1

Potential Harms of Steroid Use

Corticosteroid use in bacterial pneumonia carries several risks:

• Increased hyperglycemia requiring therapy 1
• Potentially higher secondary infection rates 1, 2
• Increased length of hospital stay in some studies 2
• Possible higher rehospitalization rates 1

Special Considerations

Severe vs. Non-severe Pneumonia

While some meta-analyses have suggested potential mortality benefits in severe pneumonia 3, the evidence remains inconsistent and insufficient to recommend routine use:

• No consistent definition of disease severity was used across studies 1
• The most recent guidelines still recommend against routine use even in severe cases 1

Influenza Pneumonia

For pneumonia associated with influenza, evidence suggests potential harm:

• A meta-analysis of predominantly retrospective studies suggests increased mortality in patients receiving corticosteroids for influenza pneumonia 1
• Guidelines specifically recommend against routine corticosteroid use in severe influenza pneumonia 1

Management Approach for Bacterial Pneumonia

Instead of corticosteroids, the following approach is recommended:

1. Appropriate antibiotic therapy based on severity and risk factors 1
2. Early mobilization of all patients 1
3. Low molecular weight heparin for patients with acute respiratory failure 1
4. Consider non-invasive ventilation particularly in patients with COPD and pneumonia 1
5. Monitor response using clinical parameters (temperature, respiratory rate, oxygenation) 1
6. Measure C-reactive protein on days 1 and 3-4 for patients with unfavorable clinical parameters 1

When Steroids Might Be Considered

The only scenario where steroids are clearly recommended in the context of pneumonia is:

• Patients with pneumonia and refractory septic shock, following the Surviving Sepsis Campaign recommendations 1

Conclusion

Based on current high-quality evidence and guidelines, corticosteroids should not be routinely administered to patients with bacterial pneumonia, regardless of severity. The potential harms outweigh the benefits in most cases, and antibiotics remain the cornerstone of therapy.