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

Hydrocortisone in Severe Pneumonia

Hydrocortisone is recommended for patients with severe community-acquired pneumonia (CAP) at a dose of less than 400 mg IV daily for 5-7 days, as it reduces mortality and improves clinical outcomes. 1

Evidence for Corticosteroid Use in Severe CAP

Benefits in Severe CAP

• The most recent high-quality evidence from a 2023 phase 3 multicenter randomized controlled trial showed that hydrocortisone (200 mg daily for 4-7 days followed by tapering) significantly reduced 28-day mortality compared to placebo (6.2% vs 11.9%, absolute difference -5.6 percentage points) in patients with severe CAP admitted to the ICU 1
• Hydrocortisone treatment in severe CAP is associated with:
  • Reduced need for mechanical ventilation (18.0% vs 29.5% in patients not initially ventilated) 1
  • Decreased need for vasopressors (15.3% vs 25.0% in patients not initially requiring vasopressors) 1
  • Shortened hospital stay 2
  • Prevention of ARDS (RR 0.24,95% CI 0.10-0.56) 2

Dosing and Duration

• The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 guidelines recommend corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent in hospitalized patients with CAP 2
• For severe CAP with elevated CRP >150 mg/L, methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days or prednisone 50 mg daily for patients who can take oral medication is suggested 2

Special Considerations

Patient Selection

• Corticosteroid benefit is most pronounced in patients with severe rather than mild pneumonia 2
• Patients with severe CAP and high inflammatory response (CRP >150 mg/L) showed reduced treatment failure with methylprednisolone compared to placebo (13% vs 31%) 3
• Early administration of hydrocortisone in severe CAP has been associated with improvements in PaO2:FiO2 ratio, chest radiograph scores, and reduction in C-reactive protein levels 4

Cautions and Contraindications

• Corticosteroids are not recommended for patients with influenza pneumonia, as they may increase mortality 2
• The 2019 IDSA/ATS guidelines give a conditional recommendation against routine use of corticosteroids in all CAP patients but acknowledge potential benefits in severe cases 2
• Potential adverse effects include:
  • Hyperglycemia (RR 1.49,95% CI 1.01-2.19) 2
  • Possible increased risk of secondary infections 5
  • Higher insulin requirements during treatment 1

Implementation in Clinical Practice

Recommended Approach

1. Assess severity of CAP using validated tools (CURB-65, PSI, or IDSA/ATS criteria for severe CAP)
2. Consider hydrocortisone for patients with:
   • Severe CAP requiring ICU admission 1
   • High inflammatory markers (CRP >150 mg/L) 3
   • Septic shock refractory to fluid resuscitation and requiring vasopressors 2
3. Administer hydrocortisone at doses <400 mg IV daily for 5-7 days 2
4. Monitor for hyperglycemia and treat appropriately 2, 1
5. Avoid corticosteroids in confirmed influenza pneumonia 2

Monitoring During Treatment

• Blood glucose levels should be closely monitored due to increased risk of hyperglycemia 2, 5
• Watch for signs of secondary infections 5
• Monitor for clinical improvement (oxygenation, respiratory parameters, inflammatory markers) 4

In summary, the most recent high-quality evidence strongly supports the use of hydrocortisone in severe community-acquired pneumonia, with demonstrated mortality benefits and reduced need for mechanical ventilation and vasopressor support 1.