Can a short course of steroids be given in children with severe bacterial pneumonia along with antibiotics?

Steroids in Children with Severe Bacterial Pneumonia

Corticosteroids should not be routinely administered as adjunctive therapy to children with severe bacterial pneumonia, as current pediatric pneumonia treatment guidelines do not recommend their use in this population. 1

Standard of Care for Severe Bacterial Pneumonia in Children

The management of severe bacterial pneumonia in children should focus on appropriate antibiotic therapy and supportive care:

Antibiotic Therapy

• For hospitalized children with severe pneumonia:
  • Intravenous antibiotics are recommended when the child is unable to absorb oral antibiotics or presents with severe signs and symptoms 2
  • Appropriate IV antibiotics include:
    • Co-amoxiclav
    • Cefuroxime
    • Cefotaxime
    • If S. pneumoniae is the suspected pathogen: amoxicillin, ampicillin, or penicillin alone may be used 2
  • For infants with severe pneumonia, if penicillin-resistant S. pneumoniae is suspected, the American Academy of Pediatrics recommends:
    • Increasing ampicillin dose to 300-400 mg/kg/day or
    • Switching to ceftriaxone (50-100 mg/kg/day every 12-24 hours) 1

Supportive Care

• Supplemental oxygen if saturation is <92%
• Adequate hydration
• Fever management
• Respiratory support as needed 1
• For the severely ill child, minimal handling may reduce metabolic and oxygen requirements 2
• Patients on oxygen therapy should have at least 4-hourly observations including oxygen saturation 2

Evidence Regarding Corticosteroid Use

The evidence for corticosteroid use in bacterial pneumonia in children is limited and conflicting:

1. Cochrane Review (2017): While this review found that corticosteroids reduced early clinical failure rates in children with bacterial pneumonia (RR 0.41,95% CI 0.24 to 0.70), this was based on only two small, clinically heterogeneous trials. The review noted that corticosteroids were associated with more adverse events, especially hyperglycemia 3.

2. Potential Adverse Effects: Corticosteroid therapy has been associated with:

   • Hyperglycemia (RR 1.72,95% CI 1.38 to 2.14)
   • Risk of secondary infections (though not statistically significant)
   • Potential for longer hospital stays 3, 4

3. Limited Pediatric-Specific Data: Most studies on corticosteroids in pneumonia have focused on adults, with limited high-quality evidence in the pediatric population 3.

Clinical Considerations and Caveats

When Corticosteroids Might Be Considered

Despite the lack of routine recommendation, there may be specific circumstances where corticosteroids could be considered:

• In cases of Mycoplasma pneumoniae pneumonia, early corticosteroid therapy might reduce disease morbidity and prevent disease progression, as suggested by a 2019 study 5. However, this is specific to mycoplasma pneumonia, not typical bacterial pneumonia.

• In cases with severe inflammatory response or rapid deterioration despite appropriate antibiotic therapy.

Important Caveats

• Any use of corticosteroids should be carefully weighed against potential risks
• Close monitoring for adverse effects is essential if corticosteroids are used
• The focus should remain on appropriate antibiotic selection and supportive care
• If no clinical improvement is seen after 48-72 hours of antibiotic therapy, re-evaluation is necessary with consideration given to possible complications 2

Conclusion

Current pediatric pneumonia guidelines do not include corticosteroids as standard treatment for severe bacterial pneumonia in children. The mainstay of treatment remains appropriate antibiotic therapy based on likely pathogens and local resistance patterns, along with supportive care. While some evidence suggests potential benefits of corticosteroids in specific circumstances, these must be weighed against known risks, and decisions should be made on a case-by-case basis when standard therapy fails to produce clinical improvement.