Why are steroids given in Pneumocystis pneumonia (PCP)?

Steroids in Pneumocystis Pneumonia (PCP)

Steroids are given in Pneumocystis pneumonia (PCP) to reduce the inflammatory response and prevent respiratory deterioration, particularly in moderate-to-severe cases, as they significantly reduce mortality, respiratory failure, and deterioration of oxygenation.

Mechanism and Benefits of Steroids in PCP

• Corticosteroids reduce overwhelming inflammation by decreasing cytokines and help with inadequate adrenal response in critically ill patients 1
• In HIV-associated PCP, early adjunctive corticosteroid therapy (within 72 hours of starting anti-pneumocystis treatment) has been shown to improve outcomes including decreased mortality, respiratory failure, and deterioration of oxygenation 2
• The inflammatory response to Pneumocystis organisms, rather than the direct pathogen damage, appears to be a major determinant of the severity of PCP, which can be diminished by high-dose corticosteroid therapy 3

Steroid Regimens for PCP

• For HIV patients with moderate-to-severe PCP (PaO2 <70 mmHg or alveolar-arterial gradient >35 mmHg), the recommended regimen is prednisone 40 mg twice daily (days 1-5), then 40 mg daily (days 6-10), then 20 mg daily (days 11-21) 2
• For non-HIV patients with grade 2 pneumonitis, methylprednisolone 1 mg/kg/day (IV or oral equivalent) is recommended 4
• For severe cases (grade 3-4 pneumonitis), higher doses of methylprednisolone (2-4 mg/kg/day) are recommended 4

Differences Between HIV and Non-HIV PCP

• While the benefit of adjunctive steroids is well-established in HIV-associated PCP, the evidence for non-HIV PCP is less conclusive 5
• Some studies suggest that high-dose adjunctive corticosteroids may accelerate recovery in severe adult non-HIV PCP cases, with shorter duration of mechanical ventilation, ICU stays, and supplemental oxygen use 6
• However, other research indicates that adjunctive corticosteroid use may not improve outcomes of moderate-to-severe PCP in non-HIV-infected patients 5

Important Considerations and Precautions

• Always rule out infection before initiating immunosuppressive treatment, especially in grade 2 or higher pneumonitis 4
• Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 4
• Provide calcium and vitamin D supplementation with prolonged steroid use 4
• All patients with grade 2-4 pneumonitis receiving steroids should also be on proton pump inhibitor therapy for GI prophylaxis 1
• Monitor for steroid-related complications including hyperglycemia and increased risk of secondary infections 4
• Carefully monitor for relapses of pneumonitis during steroid tapering, as early relapses can occur when steroids are discontinued too quickly 7

When to Avoid Steroids

• Caution should be exercised in the setting of viral pneumonia, since meta-analyses in influenza patients show increased mortality with corticosteroid use 1
• The IDSA/ATS guidelines give a strong conditional recommendation against routine use of adjunctive steroids in patients treated for community-acquired pneumonia (CAP) 1
• However, adjunctive glucocorticoids may be beneficial in severe CAP patients with septic shock refractory to fluid resuscitation and vasopressor use, especially with elevated CRP >150 mg/L 1