High-Dose Steroids in Hospital-Acquired Pneumonia (HAP): The CAPE COD Trial
High-dose steroids are not recommended as routine treatment for Hospital-Acquired Pneumonia (HAP) based on current evidence, though the CAPE COD trial provides emerging evidence supporting early hydrocortisone use in severe community-acquired pneumonia. 1
Understanding the CAPE COD Trial
The CAPE COD trial is a recent large randomized controlled trial that specifically investigated the use of corticosteroids in severe pneumonia. Unlike previous smaller studies, this trial:
- Examined hydrocortisone administration within 24 hours of developing severe pneumonia
- Found improved 28-day all-cause mortality
- Demonstrated reduced risk of intubation and vasopressor-dependent shock 1
This contrasts with the ESCAPe trial, which studied methylprednisolone initiated within 72-96 hours of hospital admission and showed no mortality benefit or improvement in secondary outcomes 1.
Current Guidelines on Steroids in HAP
Current guidelines from major societies do not recommend routine use of corticosteroids for HAP:
The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) do not recommend steroids specifically for HAP 2
The 2018 Anaesthesia guidelines explicitly state: "We did not identify any studies published on the eventual role of corticosteroids administered for HAP in ICU patients" 2
Guidelines for HAP treatment focus primarily on appropriate antibiotic selection based on risk factors for multidrug-resistant organisms 2
Evidence for Steroids in Different Types of Pneumonia
While evidence doesn't support routine steroid use in HAP, there is some evidence supporting their use in other pneumonia types:
Community-Acquired Pneumonia (CAP)
- Corticosteroids reduce excessive systemic inflammation, shorten time to clinical stability, and may prevent severe complications in CAP 3
- They are particularly beneficial in severe CAP with elevated inflammatory markers (C-reactive protein >150 mg/L) 3, 4
- A Cochrane review found that corticosteroids reduced mortality in adults with severe CAP (RR 0.58,95% CI 0.40 to 0.84) 5
ARDS
- For ARDS, methylprednisolone may be considered at 1 mg/kg/day for early ARDS (up to day 7) and 2 mg/kg/day for late persistent ARDS (after day 6) 2
- Slow tapering over 13 days is recommended rather than rapid discontinuation 2
Potential Benefits and Risks
Benefits when appropriate:
- Reduced treatment failure rates
- Shorter time to clinical stability
- Decreased duration of mechanical ventilation
- Reduced hospital length of stay
Risks:
- Hyperglycemia (most common adverse effect, especially in first 36 hours) 2, 3, 5
- Potential for increased infections
- May increase mortality in influenza-associated pneumonia 3
Clinical Approach to Steroids in Pneumonia
For HAP specifically:
- Current evidence does not support routine use of high-dose steroids
- Follow standard antibiotic protocols based on local resistance patterns 2
For severe CAP with high inflammatory response:
For patients with ARDS:
Monitoring and Precautions
- Monitor blood glucose levels, especially in the first 36 hours after initiation
- Implement infection surveillance as steroid treatment blunts febrile response
- Avoid in patients with influenza pneumonia due to increased mortality risk
- Consider diabetes status when deciding on steroid therapy (higher risk population)
The CAPE COD trial represents important emerging evidence for early hydrocortisone use in severe pneumonia, but more research is needed to determine optimal dosing regimens and long-term outcomes, particularly for HAP specifically.