When are steroids used to treat pneumonia?

Steroid Use in Pneumonia Treatment

Steroids are recommended for hospitalized patients with community-acquired pneumonia (CAP) at a dose of <400 mg IV hydrocortisone or equivalent daily for 5-7 days, as they can reduce mortality in severe pneumonia, shorten hospital stays, reduce mechanical ventilation needs, and prevent ARDS. 1

Recommendations Based on Pneumonia Type and Severity

Community-Acquired Pneumonia (CAP)

• Corticosteroids are recommended for hospitalized patients with CAP, with evidence showing benefits including shortened hospital stay, reduced need for mechanical ventilation, and prevention of ARDS 1
• The recommended regimen is 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent 1
• Mortality reduction is most pronounced in patients with severe pneumonia rather than mild cases 1
• The American Thoracic Society does not recommend routine steroid use in non-severe CAP but considers their use in severe CAP with septic shock refractory to fluid resuscitation and vasopressors 1, 2

Influenza Pneumonia

• Corticosteroids are NOT recommended for patients with influenza pneumonia 1
• Evidence from observational studies shows increased odds of mortality (OR 3.06,95% CI 1.58-5.92) with corticosteroid use in influenza 1
• Increased risk of superinfection has been observed in influenza patients treated with steroids 1

Pneumonitis (Non-Infectious)

• For grade 1 pneumonitis: Consider oral steroids such as prednisone 1 mg/kg daily 3
• For grade 2 pneumonitis: Methylprednisolone 1 mg/kg/day (IV or oral equivalent) 3
• For grade 3-4 pneumonitis: High-dose IV corticosteroids (methylprednisolone 2-4 mg/kg/day) 3

Biomarker-Guided Approach

• Evidence suggests that steroid use is more beneficial when guided by inflammatory biomarkers 4
• Steroid therapy is more effective when given to patients with C-reactive protein (CRP) ≥150 mg/L 4
• Biomarker-concordant steroid use is associated with faster resolution of lung injury and increased ICU- and hospital-free days 4

Benefits and Risks

Benefits

• Reduced mortality in severe pneumonia (RR 0.58,95% CI 0.40 to 0.84) 5
• Reduced early clinical failure rates in both severe (RR 0.32,95% CI 0.15 to 0.7) and non-severe pneumonia (RR 0.68,95% CI 0.56 to 0.83) 5
• Shortened hospital stay (risk difference -2.96 days, 95% CI -5.18 to -0.75) 1
• Reduced need for mechanical ventilation (RR 0.45,95% CI 0.26-0.79) 1
• Prevention of ARDS (RR 0.24,95% CI 0.10-0.56) 1

Risks and Adverse Effects

• Increased risk of hyperglycemia (RR 1.72,95% CI 1.38 to 2.14) 5
• Potential for higher rehospitalization rates 1
• Concerns about complications in the 30-90 days following treatment 2
• No significant increase in secondary infections observed in clinical trials (RR 1.19,95% CI 0.73 to 1.93) 5

Important Clinical Considerations

• Always rule out infection before initiating immunosuppressive treatment for pneumonitis 3
• Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 3
• Monitor for steroid-related complications including hyperglycemia 3
• Consider calcium and vitamin D supplementation with prolonged steroid use 3
• For patients with CAP and septic shock, hydrocortisone may be beneficial as per Surviving Sepsis Campaign guidelines 2