What is the role of corticosteroids (steroids) in the management of severe pneumonia?

Use of Corticosteroids in Severe Pneumonia

For adults with severe community-acquired pneumonia (CAP), corticosteroids should be administered as adjunctive therapy to reduce mortality and treatment failure, with methylprednisolone 0.5 mg/kg IV every 12 hours for 5-7 days being the preferred regimen, particularly in patients with high inflammatory markers (CRP >150 mg/L). 1, 2

Evidence for Mortality Benefit in Severe CAP

The mortality benefit of corticosteroids is most pronounced in severe pneumonia:

• In patients with severe CAP, corticosteroids reduce mortality with a risk ratio of 0.58 (95% CI 0.40-0.84), meaning you need to treat 18 patients to prevent one death. 3
• Meta-analyses demonstrate significant mortality reduction in severe bacterial CAP treated in the ICU, with 30-day mortality of 10% versus 16% with placebo. 4
• For patients with severe CAP and high inflammatory response (CRP >150 mg/L), corticosteroids reduce treatment failure from 31% to 13% (absolute risk reduction of 18%). 2

The evidence is clear that this benefit applies specifically to severe pneumonia, not mild cases. 1, 5, 3

Recommended Dosing Regimens

Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days is the most strongly supported regimen based on the highest quality randomized trial. 1, 2

Alternative acceptable regimens include:

• Hydrocortisone <400 mg daily IV for 5-7 days 1, 5
• Prednisone 50 mg daily orally for patients who can tolerate oral medication 5
• Dexamethasone 6 mg daily for up to 10 days (specifically for COVID-19 pneumonia requiring oxygen) 1, 4

Early initiation (<72 hours of admission) is critical for optimal benefit. 1

Patient Selection Criteria

The ideal candidates for corticosteroid therapy are:

• Patients with severe CAP requiring ICU admission 6, 3
• High inflammatory markers, particularly CRP >150 mg/L 1, 2
• Septic shock requiring vasopressors despite fluid resuscitation 6, 1
• Early moderate to severe ARDS (PaO₂/FiO₂ <200 within 14 days of onset) 6, 1
• Risk of developing ARDS (corticosteroids reduce ARDS development with RR 0.24,95% CI 0.10-0.56) 5

Important Contraindications

Do NOT use corticosteroids in influenza pneumonia, as they may increase mortality. 1, 5 This is a critical pitfall to avoid.

Corticosteroids are not recommended for mild CAP where the risk-benefit ratio does not favor their use. 1, 5, 3

Clinical Benefits Beyond Mortality

Corticosteroids provide multiple morbidity benefits in severe CAP:

• Reduce early clinical failure rates (RR 0.32,95% CI 0.15-0.7 in severe pneumonia) 3
• Decrease mechanical ventilation duration by approximately 4-7 days 6, 1
• Shorten time to clinical stability 1
• Reduce hospital length of stay by approximately 8 days 6
• Prevent development of ARDS 1, 5
• Decrease rates of respiratory failure or shock 3

Adverse Effects and Monitoring

Hyperglycemia is the most common adverse effect (RR 1.49-1.72), particularly within the first 36 hours. 6, 1, 5, 3

Other potential adverse effects include:

• Gastrointestinal bleeding (RR 1.20, though with wide confidence intervals) 6
• Neuromuscular weakness (uncertain effect) 6
• Secondary infections (no significant increase demonstrated, RR 1.19,95% CI 0.73-1.93) 3

Close glucose monitoring and tight glycemic control are required when using corticosteroids. 6

Screening for Adrenal Insufficiency

Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency, as stress-dose corticosteroids (200-300 mg hydrocortisone daily) improve outcomes in vasopressor-dependent septic shock patients without appropriate cortisol response. 6

Guideline Consensus Position

The 2024 American Thoracic Society ARDS guideline provides a conditional recommendation for corticosteroids in ARDS with moderate certainty of evidence, noting they probably decrease mortality (RR 0.84,95% CI 0.73-0.96). 6

The IDSA/ATS gives a conditional recommendation against routine use in all CAP patients, but explicitly acknowledges potential benefit in severe cases. 1, 5 This nuance is critical: the recommendation is against routine use in all patients, not against targeted use in severe disease.