Use of Steroids in Pneumonia
Primary Recommendation
For hospitalized adults with severe community-acquired pneumonia (CAP), particularly those with high inflammatory markers (CRP >150 mg/L) or septic shock, use corticosteroids at doses <400 mg hydrocortisone equivalent daily for 5-7 days. 1, 2
Severity-Based Treatment Algorithm
Severe CAP (ICU-level care, septic shock, or high inflammatory response)
- Initiate corticosteroids with methylprednisolone 0.5 mg/kg IV every 12 hours OR prednisone 50 mg daily for 5-7 days 1, 2, 3
- Hydrocortisone <400 mg daily is an acceptable alternative 1
- This recommendation is supported by moderate-quality evidence showing mortality reduction (RR 0.67,95% CI 0.45-1.01) and significant decreases in treatment failure (13% vs 31%, P=0.02) 1, 3
- The number needed to treat to prevent one death is 18 patients 4
Non-Severe CAP (ward-level care, stable patients)
- Do not routinely use corticosteroids 1
- The IDSA/ATS 2019 guideline provides a strong conditional recommendation against routine adjunctive steroids in this population 1
- While corticosteroids reduce early clinical failure rates (RR 0.68,95% CI 0.56-0.83), they do not reduce mortality in non-severe cases 4
Key Clinical Indicators for Steroid Use
When to Use Steroids
- CRP >150 mg/L at admission 1, 2, 3
- Septic shock refractory to fluid resuscitation and requiring vasopressors 1, 2
- Pneumonia Severity Index class IV-V 1
- Need for mechanical ventilation or high risk of ARDS development 1
When NOT to Use Steroids
- Influenza pneumonia: Strong recommendation against use due to increased mortality (OR 3.06,95% CI 1.58-5.92) and higher rates of superinfection 1, 2
- Mild or moderate CAP without high inflammatory markers 1
- Active systemic fungal infections 5
- Latent tuberculosis without chemoprophylaxis 5
Clinical Benefits in Severe CAP
The evidence demonstrates multiple benefits when corticosteroids are appropriately used:
- Mortality reduction in severe CAP (OR 0.26,95% CI 0.11-0.64) 1, 2
- Decreased mechanical ventilation need (RR 0.45,95% CI 0.26-0.79) 1
- ARDS prevention (RR 0.24,95% CI 0.10-0.56) 1
- Shortened hospital stay by approximately 1-3 days 1
- Reduced treatment failure from 31% to 13% in patients with high inflammatory response 3
Adverse Effects and Monitoring
Common Adverse Effects
- Hyperglycemia occurs more frequently (RR 1.72,95% CI 1.38-2.14) and requires monitoring 1, 4
- Gastrointestinal bleeding risk may increase (RR 1.20,95% CI 0.43-3.34) 1
- Secondary infections do not appear significantly increased (RR 1.19,95% CI 0.73-1.93) 4
Monitoring Requirements
- Blood glucose monitoring during treatment 1, 2
- Watch for signs of secondary bacterial or fungal infections 5
- Screen for latent tuberculosis before prolonged therapy 5
- Monitor for hepatitis B reactivation in carriers 5
Special Populations
Children with Bacterial Pneumonia
- Corticosteroids reduce early clinical failure (RR 0.41,95% CI 0.24-0.70) 4
- Evidence is based on small trials with clinical heterogeneity 4
ARDS from Any Cause
- Use corticosteroids for patients with ARDS (conditional recommendation, moderate certainty) 1
- Corticosteroids probably decrease mortality (RR 0.84,95% CI 0.73-0.96) and may reduce duration of mechanical ventilation by 4 days 1
COVID-19 Pneumonia
- Dexamethasone 6 mg daily for 10 days decreases 28-day mortality (23% vs 26%) in patients requiring supplemental oxygen or mechanical ventilation 6
Critical Pitfalls to Avoid
Do not exceed 400 mg hydrocortisone equivalent daily as higher doses are not recommended and increase adverse effects without additional benefit 1, 2
Do not extend treatment beyond 7 days as prolonged courses are unnecessary and increase complications 2
Do not use corticosteroids in influenza pneumonia due to documented harm 1, 2
Do not use in patients with active fungal infections unless treating drug reactions 5
Avoid in non-immune patients with varicella or measles exposure without appropriate prophylaxis 5
Biomarker Considerations
- CRP levels decrease by approximately 46% with prednisone treatment by days 3-7, making it less useful for monitoring infection resolution 7
- Procalcitonin (PCT) levels are not affected by corticosteroids and may better reflect ongoing infection 7
- Leukocyte counts increase by 27% with corticosteroid use, limiting their utility for infection monitoring 7