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

Steroid Use in Pneumonia

Corticosteroids should be used in hospitalized patients with severe community-acquired pneumonia (CAP), particularly those with high inflammatory markers (CRP >150 mg/L), at doses of methylprednisolone 0.5 mg/kg IV every 12 hours or prednisone 50 mg daily for 5-7 days, but should be avoided in influenza pneumonia where they increase mortality. 1, 2

Severe Community-Acquired Pneumonia

The evidence strongly supports corticosteroid use in severe CAP:

• The SCCM/ESICM guidelines recommend corticosteroids for 5-7 days at daily doses <400 mg IV hydrocortisone equivalent in hospitalized CAP patients 1
• Corticosteroids reduce treatment failure by 18% (13% vs 31% in placebo) in patients with severe CAP and CRP >150 mg/L 3
• Mortality reduction is most pronounced in severe pneumonia (RR 0.58,95% CI 0.40-0.84), with a number needed to treat of 18 patients to prevent one death 4
• For severe CAP with elevated inflammatory markers, use methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days 2

Key benefits in severe CAP include:

• Shortened hospital stay (risk difference -2.96 days) 1
• Reduced need for mechanical ventilation (RR 0.45,95% CI 0.26-0.79) 1
• Prevention of ARDS development (RR 0.24,95% CI 0.10-0.56) 1, 2
• Reduced early clinical failure rates (RR 0.32,95% CI 0.15-0.7) 4

Non-Severe Community-Acquired Pneumonia

The recommendation is more nuanced for non-severe CAP:

• The ATS/IDSA give a conditional recommendation against routine corticosteroid use in all CAP patients 2
• However, corticosteroids still reduce early clinical failure rates in non-severe CAP (RR 0.68,95% CI 0.56-0.83) 4
• One well-designed trial showed no benefit with prednisolone 40 mg daily in general hospitalized CAP patients, with increased late failure (19.2% vs 6.4%) 5

The key is identifying severity: Use corticosteroids when patients have severe pneumonia defined by septic shock refractory to fluids and vasopressors, or CRP >150 mg/L 2, 6

ARDS Secondary to Pneumonia

For patients who develop ARDS from CAP:

• Corticosteroids are recommended for early moderate-to-severe ARDS (PaO₂/FiO₂ <200 within 14 days of onset) 1
• Use methylprednisolone 1 mg/kg/day for early ARDS (up to day 7) 1
• For late persistent ARDS (after day 6), increase to methylprednisolone 2 mg/kg/day followed by slow tapering over 13 days 1
• Meta-analysis shows decreased in-hospital mortality (34% vs 45%) in ARDS patients treated with low-dose corticosteroids 7

Critical Contraindication: Influenza Pneumonia

Corticosteroids are contraindicated in influenza:

• Meta-analyses show increased mortality with corticosteroid use in influenza (OR 3.06,95% CI 1.58-5.92) 1
• The SCCM/ESICM recommend against corticosteroid use in adults with influenza 1
• Corticosteroids also increase risk of superinfection in influenza patients 1
• This caution extends to viral pneumonias generally 6

Pneumocystis Pneumonia (PCP)

Corticosteroids have established benefit in moderate-to-severe PCP:

• For HIV patients with moderate-to-severe PCP, corticosteroids reduce mortality (13% vs 25%) 7
• Use methylprednisolone 1 mg/kg/day for grade 2 pneumonitis 6
• For severe cases (grade 3-4), use higher doses of 2-4 mg/kg/day 6
• Always rule out other infections before initiating steroids 6

Adverse Effects and Monitoring

The primary adverse effect is hyperglycemia:

• Hyperglycemia occurs more frequently with corticosteroids (RR 1.49-1.72) 1, 2
• However, this hyperglycemia is not associated with increased morbidity 1
• No increased risk of gastrointestinal bleeding, neuromuscular weakness, or nosocomial infections in short-term use 1
• Monitor for secondary infections, especially in prolonged courses 6

For patients on prolonged steroids (≥4 weeks at ≥20 mg methylprednisolone equivalent):

• Provide PCP prophylaxis 6
• Add calcium and vitamin D supplementation 6
• Use proton pump inhibitor for GI prophylaxis 6

Critical Pitfall: ICU-Acquired Pneumonia

Avoid corticosteroids in ICU-acquired pneumonia:

• Observational data shows corticosteroid use is associated with increased 28-day mortality in ICU-acquired pneumonia (adjusted HR 2.503,95% CI 1.176-5.330) 8
• This applies particularly to patients without established indications and those with lower baseline severity 8
• The distinction between community-acquired and ICU-acquired pneumonia is critical for decision-making 8