Indications for Steroids in Pneumonia
Steroids have no place in the treatment of pneumonia unless septic shock is present. 1
Primary Indications for Steroids in Pneumonia
- Septic shock refractory to fluid resuscitation and vasopressors 1, 2
- Severe community-acquired pneumonia (CAP) with high inflammatory markers (CRP >150 mg/L) 2
- Pneumocystis jiroveci pneumonia with hypoxemia (prednisolone 2 × 40 mg/day for 5 days, then 1 × 40 mg/day for 5 days, followed by 1 × 20 mg for 10 days) 1
Dosing Recommendations
- For septic shock: Hydrocortisone <400 mg daily 2, 3
- For severe CAP with high inflammatory response: Methylprednisolone 0.5 mg/kg IV every 12 hours or prednisone 50 mg daily for 5-7 days 2
- Treatment duration should be limited to 5-7 days to minimize adverse effects 2, 3
Evidence of Benefit
- Decreased mortality in severe CAP (OR = 0.26,95% CI: 0.11–0.64) 2, 4
- Reduced need for mechanical ventilation (RR, 0.45; 95% CI, 0.26−0.79) 2, 3
- Prevention of ARDS development (RR, 0.24; 95% CI, 0.10−0.56) 2, 3
- Recent CAPE COD trial showed hydrocortisone improved 28-day mortality and reduced risk of intubation or vasopressor-dependent shock when administered within 24 hours of developing severe CAP 5
Contraindications and Cautions
- Steroids are NOT recommended for:
Potential Adverse Effects
- Hyperglycemia (RR, 1.49; 95% CI, 1.01−2.19) 2, 4
- Increased risk of hospital-acquired infections 1, 4
- Gastrointestinal bleeding 3
- Neuropsychiatric disorders 3
- Muscle weakness 3
- Hypernatremia 3
Monitoring During Treatment
- Blood glucose levels should be regularly monitored 2, 4
- Vigilance for signs of secondary infections 2, 4
- Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 1
- Consider calcium and vitamin D supplementation with prolonged steroid use 1
- Proton pump inhibitor therapy for GI prophylaxis in patients with grade 2-4 pneumonitis receiving steroids 1