What are the guidelines for using steroids in Community-Acquired Pneumonia (CAP)?

Guidelines for Using Steroids in Community-Acquired Pneumonia (CAP)

Current guidelines do not recommend routine use of corticosteroids in all patients with CAP, but suggest their use in specific scenarios such as severe CAP with septic shock or high inflammatory markers. 1, 2

General Recommendations

• The Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) 2019 guideline provides a strong conditional recommendation against routine use of adjunctive steroids in patients treated for CAP 1
• The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017 guideline suggests using corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent in hospitalized patients with CAP (conditional recommendation, moderate quality of evidence) 1
• The American Thoracic Society recommends that hydrocortisone should not be routinely used for severe CAP except in patients with refractory septic shock 2

Recommendations Based on CAP Severity

Non-Severe CAP

• Corticosteroids are not recommended for routine use in non-severe CAP, as evidence shows no mortality benefit or reduction in organ failure in this population 2

Severe CAP

• For severe CAP with septic shock refractory to fluid resuscitation and vasopressor use, adjunctive glucocorticoids are suggested, especially in those with elevated CRP >150 mg/L 1
• The Surviving Sepsis Campaign recommends hydrocortisone for patients with CAP and refractory septic shock, with a regimen of 50 mg IV every 6 hours plus fludrocortisone 50 μg daily 2
• The American College of Critical Care Medicine recommends hydrocortisone at a daily dose less than 400 mg IV for 5-7 days for severe CAP 3

Dosing Recommendations

• For severe CAP with septic shock: Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days or Prednisone 50 mg daily for those who can take oral medication 1
• The Surviving Sepsis Campaign recommends 200 mg hydrocortisone per day when hemodynamic stability cannot be restored with adequate fluid resuscitation and vasopressor therapy, with continuous infusion preferred over bolus administration 3
• For hospitalized patients with CAP: Corticosteroids for 5-7 days at a daily dose <400 mg IV hydrocortisone or equivalent 1

Special Considerations

Viral Pneumonia

• Corticosteroids should be avoided in influenza pneumonia, as meta-analyses show increased mortality with corticosteroid use in influenza patients 1, 2
• For COVID-19 pneumonia requiring oxygen or ventilation, dexamethasone 6 mg daily for 10 days (equivalent to approximately 160 mg hydrocortisone) is recommended 3

Potential Benefits and Risks

Benefits

• Corticosteroids may reduce the risk of ARDS and need for mechanical ventilation 1, 4
• They may shorten time to clinical stability and hospital length of stay by approximately 1 day 1, 4
• Recent meta-analyses suggest mortality reduction in severe CAP (RR 0.62 [95% CI 0.45 to 0.85]) 5
• A 2023 meta-analysis found a non-linear dose-response relationship with an optimal dose of approximately 6 mg dexamethasone (or equivalent) for 7 days (RR 0.44 [95% CI 0.30 to 0.66]) 5

Risks

• Increased risk of hyperglycemia requiring treatment (RR 1.49 [CI 1.01 to 2.19]) 4, 5
• Potential for secondary infections 2
• Possible increased rehospitalization rates 2

Monitoring Recommendations

• The American College of Chest Physicians recommends monitoring for hyperglycemia, which is the most common side effect requiring therapy 2
• Watch for potential secondary infections, which may be increased with corticosteroid use 2

Evidence Evolution

• Earlier meta-analyses showed mixed results, with some showing mortality benefits in severe CAP subgroups 1, 6
• More recent evidence from 2023 meta-analyses shows stronger support for corticosteroid use in severe CAP, with a reduction in all-cause mortality by day 30 (RR 0.67; 95% CI 0.53 to 0.85) 7
• The benefits appear more pronounced in patients with severe pneumonia 7, 5