Should patients with pneumonia be treated with steroids?

Steroid Use in Pneumonia

Steroids should not be routinely used in patients with pneumonia, with the critical exception of severe community-acquired pneumonia (CAP) requiring ICU admission, where low-dose corticosteroids reduce mortality. 1

General Recommendation Against Routine Steroid Use

• Steroids have no place in the treatment of pneumonia unless septic shock is present. 1
• European Respiratory Society guidelines explicitly state that steroids have not been shown to be useful in pneumonia treatment. 1
• Two meta-analyses demonstrate that steroids cannot be recommended for routine treatment of patients with CAP. 1

Exception: Severe Community-Acquired Pneumonia

For adults with severe CAP requiring ICU admission, low-dose corticosteroids (≤400 mg hydrocortisone equivalent daily) significantly reduce mortality. 2, 3

Evidence for Severe CAP:

• Corticosteroids reduce mortality in severe pneumonia (RR 0.58,95% CI 0.40 to 0.84), meaning treatment of 18 patients prevents one death. 2
• A meta-analysis of 7 randomized trials involving 1,689 ICU patients with severe bacterial CAP showed hydrocortisone ≤400 mg daily for ≤8 days reduced 30-day mortality from 16% to 10%. 3
• Early clinical failure rates (death, radiographic progression, or clinical instability at days 5-8) are significantly reduced in severe pneumonia (RR 0.32,95% CI 0.15 to 0.7). 2

Specific Indications for Steroid Use:

• Septic shock: Hydrocortisone has been shown to be beneficial in patients with septic shock complicating pneumonia. 1
• Severe CAP with ICU admission: Stress doses of corticosteroids (hydrocortisone 50 mg IV every 6 hours plus fludrocortisone 50 μg daily for 7 days) decreased mortality from 51% to 39% in patients with CAP and septic shock. 3
• Acute respiratory distress syndrome (ARDS): Low-dose corticosteroids decreased in-hospital mortality from 45% to 34% in ARDS patients. 3

Non-Severe Pneumonia

• Corticosteroids do NOT reduce mortality in adults with non-severe pneumonia (RR 0.95% CI 0.45 to 2.00). 2
• While early clinical failure rates are reduced (RR 0.68,95% CI 0.56 to 0.83), this benefit does not translate to mortality reduction and must be weighed against adverse effects. 2

Pediatric Pneumonia

• In children with bacterial pneumonia, corticosteroids reduce early clinical failure rates (RR 0.41,95% CI 0.24 to 0.70) and time to clinical cure, though evidence is based on two small trials. 2

Viral Pneumonia (Including Influenza and COVID-19)

Influenza:

• Corticosteroids should be avoided in influenza pneumonia. 4
• Corticosteroid use in influenza is associated with increased overall mortality, higher incidence of hospital-acquired pneumonia, longer mechanical ventilation duration, and prolonged ICU stays. 4
• Current use should be restricted to very selected cases and clinical trial settings only. 4

COVID-19:

• Dexamethasone 6 mg daily for 10 days reduces 28-day mortality (from 26% to 23%) in hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation. 3

Adverse Effects to Monitor

Hyperglycemia is the most common adverse effect, occurring significantly more often with corticosteroid treatment (RR 1.72,95% CI 1.38 to 2.14). 2

Additional adverse effects include: 2, 3

• Gastrointestinal bleeding
• Neuropsychiatric disorders
• Muscle weakness
• Hypernatremia
• Secondary infections (though not statistically significant: RR 1.19,95% CI 0.73 to 1.93)
• Superinfections and increased length of stay 5

Practical Implementation Algorithm

Step 1: Assess pneumonia severity

• Non-severe pneumonia (outpatient or ward): Do not use steroids 1
• Severe pneumonia requiring ICU: Proceed to Step 2

Step 2: Identify specific indications

• Septic shock present: Use hydrocortisone 50 mg IV every 6 hours + fludrocortisone 50 μg daily for 7 days 3
• Severe bacterial CAP without septic shock: Use hydrocortisone ≤400 mg daily (or equivalent) for ≤8 days 3
• ARDS present: Consider low-dose corticosteroids 3
• COVID-19 requiring oxygen: Use dexamethasone 6 mg daily for 10 days 3

Step 3: Exclude contraindications

• Influenza pneumonia: Avoid steroids 4
• Viral pneumonia (non-COVID): Avoid steroids 4

Critical Pitfalls to Avoid

• Do not use steroids routinely for all pneumonia cases - this increases adverse effects without mortality benefit in non-severe cases. 1
• Do not use steroids in influenza pneumonia - this consistently increases mortality across studies of varying quality and sample sizes. 4
• Do not use high-dose or prolonged corticosteroid regimens - limit to stress doses (≤400 mg hydrocortisone equivalent daily) for ≤8 days. 3
• Monitor glucose closely - hyperglycemia occurs in nearly twice as many steroid-treated patients. 2
• Wean steroids slowly - abrupt discontinuation may cause rebound phenomenon. 6
• Maintain infection surveillance - secondary infections remain a concern despite non-significant statistical differences. 6