What is the role of hydrocortisone (corticosteroid) in treating pneumonia?

Role of Hydrocortisone in Treating Pneumonia

Hydrocortisone should not be used routinely in pneumonia but is recommended for specific scenarios such as severe community-acquired pneumonia (CAP) with septic shock or severe acute respiratory distress syndrome (ARDS). 1, 2

Indications for Hydrocortisone in Pneumonia

Recommended Use:

• Severe CAP with refractory septic shock

  • Hydrocortisone 200-300 mg/day IV for 5-7 days 1, 2
  • Screen for occult adrenal insufficiency in hypotensive, fluid-resuscitated patients 2

• Severe ARDS due to pneumonia (within 14 days of onset)

  • For PaO₂/FiO₂ < 200 2
  • Methylprednisolone preferred at 1 mg/kg/day for early ARDS (< 7 days) 2

• Recent evidence for severe CAP

  • The 2023 CAPE COD trial showed hydrocortisone (200 mg daily for 4-7 days followed by tapering) reduced 28-day mortality from 11.9% to 6.2% in ICU patients with severe CAP 3

Not Recommended:

• Routine use in non-severe CAP 1
• Pneumonia without significant hypoxemia 1
• Viral pneumonia (particularly influenza) without other indications 1

Dosing Regimens

• For septic shock with CAP:

  • Hydrocortisone 200-300 mg/day IV for 5-7 days 1, 2

• For severe CAP requiring ICU (based on recent evidence):

  • Hydrocortisone 200 mg daily (either as continuous infusion or divided doses) for 4-7 days, followed by tapering 3

• For early severe ARDS:

  • Methylprednisolone 1 mg/kg/day (preferred over hydrocortisone for lung penetration) 2

Benefits and Risks

Benefits:

• Reduced mortality in severe CAP (absolute reduction of 5.6% in recent trial) 3
• Decreased need for mechanical ventilation (18% vs 29.5%) 3
• Reduced need for vasopressors (15.3% vs 25%) 3
• Improved oxygenation (PaO₂/FiO₂ ratio) 4
• Shorter hospital stay 4
• Earlier resolution of pneumonia 4

Risks:

• Hyperglycemia (RR 1.72,95% CI 1.38-2.14) 5
• Potential for secondary infections (though not significantly increased in recent studies) 5
• Gastrointestinal bleeding (though not significantly increased in recent studies) 5

Monitoring During Treatment

• Regular blood glucose monitoring (hyperglycemia is the most common adverse effect) 2, 1
• Oxygen saturation monitoring every 2-3 days 1
• Screening for secondary infections 1
• Clinical assessment for improvement in respiratory status 1

Special Considerations

• For patients already on corticosteroids who develop pneumonia, increase dose to at least 1-2 mg/kg/day until clinical improvement 1
• Consider PCP prophylaxis if prednisone dose ≥20 mg/day for ≥4 weeks 1
• Add proton pump inhibitor therapy for GI prophylaxis in moderate-severe pneumonia 1

Common Pitfalls

1. Inappropriate use in non-severe pneumonia - Corticosteroids should not be used routinely in non-severe CAP
2. Failure to screen for adrenal insufficiency in hypotensive patients with severe CAP
3. Inadequate glucose control during corticosteroid therapy
4. Not considering steroid tapering after treatment of severe pneumonia
5. Overlooking the risk of secondary infections during prolonged corticosteroid therapy

The evidence for hydrocortisone in pneumonia has evolved significantly, with the most recent high-quality trial 3 showing clear mortality benefit in severe CAP requiring ICU admission.