What is the recommended dosage of hydrocortisone (corticosteroid) for severe pneumonia?

Hydrocortisone Dosage for Severe Pneumonia

For severe community-acquired pneumonia, the recommended dosage is hydrocortisone at less than 400 mg IV daily for 5-7 days. 1

Dosage Recommendations Based on Clinical Scenario

Severe Community-Acquired Pneumonia

• Hydrocortisone should be administered at a daily dose less than 400 mg IV for 5-7 days 1
• Recent evidence shows that hydrocortisone 200 mg daily (followed by tapering) significantly reduces mortality in ICU patients with severe CAP 2
• Benefits include shortened hospital stay, reduced need for mechanical ventilation, and prevention of ARDS 1

Pneumonia with Septic Shock

• For patients with septic shock not responsive to fluid and moderate-to-high-dose vasopressor therapy, use IV hydrocortisone at less than 400 mg/day for at least 3 days at full dose 1
• The Surviving Sepsis Campaign suggests 200 mg per day when hemodynamic stability cannot be restored with adequate fluid resuscitation and vasopressor therapy 1
• Continuous infusion is preferred over bolus administration 1
• Taper hydrocortisone when vasopressors are no longer required 1

Specific Administration Protocol

• One effective protocol demonstrated in research: 200 mg IV bolus followed by continuous infusion at 10 mg/hour for 7 days 3
• Another validated approach: 50 mg IV every 6 hours plus fludrocortisone 50 μg daily for patients with pneumonia and septic shock 4

Important Clinical Considerations

When to Avoid Corticosteroids

• Corticosteroids are not recommended for pneumonia without shock 1
• Avoid corticosteroids in patients with influenza pneumonia 1, 5
• Do not use corticosteroids routinely in non-severe CAP 5

Monitoring and Adverse Effects

• Monitor for hyperglycemia, which is the most common adverse effect requiring treatment 1, 5
• Watch for potential secondary infections, though recent evidence suggests the risk is not significantly increased with low-dose, short-course therapy 4
• Other possible adverse effects include hypernatremia, gastrointestinal bleeding, and muscle weakness 1, 4

Evidence Quality and Clinical Impact

• The quality of evidence for corticosteroid use in severe CAP is moderate 1
• The most recent high-quality trial (CAPE COD) showed significant mortality reduction (6.2% vs 11.9%) with hydrocortisone in severe CAP 2
• Low-dose corticosteroids (≤400 mg hydrocortisone equivalent daily) have been shown to reduce mortality in severe community-acquired pneumonia compared to placebo (10% vs 16%) 4

Special Populations

• For COVID-19 pneumonia requiring oxygen or ventilation, dexamethasone 6 mg daily for 10 days (equivalent to approximately 160 mg hydrocortisone) is recommended 1, 4
• For Pneumocystis pneumonia in HIV patients, low-dose corticosteroids have shown mortality benefit 4

Remember that timing of administration is crucial, with earlier treatment showing better outcomes, and tapering is recommended rather than abrupt discontinuation 1, 2.