Hydrocortisone Use in Severe Pneumonia

Hydrocortisone should not be routinely used for severe community-acquired pneumonia (CAP) except in patients with refractory septic shock. 1

Recommendations Based on Pneumonia Severity

Corticosteroids including hydrocortisone are not recommended for routine use in non-severe CAP (strong recommendation) 1
No mortality benefit or reduction in organ failure has been demonstrated in this population 1

Hydrocortisone is not routinely recommended for patients with severe CAP (conditional recommendation) 1
Some meta-analyses have shown mortality benefit in severe CAP, but no consistent definition of disease severity was used across studies 1
Side effects of hydrocortisone (at doses around 240 mg/day) include significant increases in hyperglycemia and possible higher secondary infection rates 1

Hydrocortisone is recommended for patients with CAP and refractory septic shock (following Surviving Sepsis Campaign guidelines) 1
In patients with septic shock due to CAP, hydrocortisone 50 mg IV every 6 hours plus fludrocortisone 50 μg daily has shown mortality benefit compared to placebo (39% vs 51%) 2

Hydrocortisone is not recommended for patients with severe influenza pneumonia 1
A meta-analysis of predominantly small retrospective studies suggests increased mortality in patients with influenza who receive corticosteroids 1
This may reflect the importance of innate immunity in defense against viral pneumonia as opposed to bacterial pneumonia 1

The most recent high-quality evidence from a 2023 phase 3 randomized controlled trial (CAPE COD) showed that hydrocortisone (200 mg daily for 4-7 days followed by tapering) reduced 28-day mortality in ICU patients with severe CAP (6.2% vs 11.9%, absolute difference -5.6%) 3
This trial also demonstrated reduced need for mechanical ventilation and vasopressor support in patients treated with hydrocortisone 3
However, this evidence is more recent than the current guidelines and has not yet been incorporated into formal recommendations 1

When used for septic shock in CAP, hydrocortisone is typically administered as 50 mg IV every 6 hours 2
In clinical trials showing benefit, doses have ranged from:
- 200 mg IV bolus followed by 10 mg/hour infusion for 7 days 4
- 200 mg daily for 4-7 days with tapering 3
- Up to 240 mg hydrocortisone equivalent per day for a maximum of 7 days 1

Monitor for hyperglycemia, which is the most common side effect requiring therapy 1
Watch for potential secondary infections, which may be increased with corticosteroid use 1
Other potential adverse effects include gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, and hypernatremia 2
Rehospitalization rates may be higher with corticosteroid use, and concerns about complications in the 30-90 days following treatment have been raised 1

Despite some promising recent evidence, current guidelines still recommend against routine use of hydrocortisone in severe CAP 1
The benefit-risk ratio appears most favorable in patients with septic shock due to CAP 1, 2
Avoid hydrocortisone in influenza pneumonia unless there are other indications for its use 1
Consider that the evidence base is evolving, with the most recent high-quality trial showing mortality benefit 3