Hydrocortisone Dosing for Severe Community-Acquired Pneumonia
For patients with severe CAP requiring ICU admission, administer hydrocortisone at a dose of less than 400 mg IV daily (typically 200 mg/day given as 50 mg every 6 hours) for 5-7 days. 1, 2
Specific Dosing Regimens
The evidence supports two main approaches:
- Standard regimen: Hydrocortisone 200 mg/day IV for 4-7 days based on clinical improvement, followed by tapering for a total treatment duration of 8-14 days 3
- Alternative regimen: 200 mg IV bolus followed by continuous infusion at 10 mg/hour for 7 days 4
- Divided dosing: 50 mg IV every 6 hours for 7 days (total 200 mg/day) 1, 5
The key threshold is keeping the daily dose below 400 mg hydrocortisone equivalent—higher doses have not been studied and may increase adverse effects. 1, 2
Patient Selection Criteria
Hydrocortisone should be used specifically for:
- Patients with severe CAP requiring ICU admission with high inflammatory markers (CRP >150 mg/L) 6
- Patients meeting major severity criteria: those requiring invasive mechanical ventilation and/or presenting with septic shock 7
- Patients with septic shock refractory to fluid resuscitation and vasopressor therapy 2, 6
The mortality benefit is most pronounced in these severely ill patients, with 28-day mortality reduced from 31% to 18% in matched cohorts 7, and from 11.9% to 6.2% in the largest recent trial 3.
Clinical Benefits
When used appropriately, hydrocortisone provides:
- Reduced mortality in severe CAP (OR 0.26,95% CI: 0.11-0.64) 6
- Decreased need for mechanical ventilation (RR 0.45,95% CI: 0.26-0.79) 1, 6
- Prevention of ARDS development (RR 0.24,95% CI: 0.10-0.56) 1, 6
- Shortened hospital length of stay (mean reduction of approximately 3 days) 1, 4
- Reduced need for vasopressor initiation (15.3% vs 25.0% in those not on vasopressors at baseline) 3
Critical Caveats and Contraindications
Do not use corticosteroids in influenza pneumonia—this is associated with increased mortality 1, 6. The recommendation against corticosteroids in influenza is consistent across multiple guideline bodies 2, 6.
Corticosteroids are not recommended for non-severe CAP (patients not requiring ICU admission or without shock) 2. In patients who did not meet major severity criteria, no mortality benefit was observed 7.
For COVID-19 pneumonia, use dexamethasone 6 mg daily for 10 days instead (equivalent to approximately 160 mg hydrocortisone), not the higher doses used for bacterial CAP 2, 5.
Monitoring Requirements
During hydrocortisone treatment, monitor for:
- Hyperglycemia (occurs in approximately 50% more patients; RR 1.49) 1, 6—maintain tight glucose control with insulin as needed 1
- Secondary infections 6
- Gastrointestinal bleeding (though rates are similar to placebo in most studies) 5, 3
Treatment Duration
Limit treatment to 5-7 days at full dose—prolonged courses beyond 7 days are unnecessary and increase adverse effects 1, 2, 6. If using the tapering regimen, the total duration including taper should not exceed 14 days 3.