What is the recommended steroid dose and duration for severe pneumonia?

Steroid Dose and Duration in Severe Pneumonia

For severe community-acquired pneumonia, use methylprednisolone 0.5 mg/kg IV every 12 hours (or equivalent hydrocortisone <400 mg/day, or dexamethasone 6 mg daily) for 5-7 days, particularly in patients with high inflammatory markers (CRP >150 mg/L) or septic shock refractory to fluid resuscitation and vasopressors. 1, 2, 3

Specific Dosing Regimens by Agent

Methylprednisolone (Preferred for Severe CAP)

• Administer 0.5 mg/kg IV every 12 hours (total 1 mg/kg/day) for 5 days in patients with severe pneumonia and CRP >150 mg/L 1, 3
• Alternative dosing: 1-2 mg/kg/day IV for 3-5 days in cases with rapid deterioration 4, 1
• This regimen reduced treatment failure from 31% to 13% (absolute risk reduction 18%) in the highest quality randomized trial 3

Dexamethasone (Alternative Option)

• Give 6 mg once daily (oral or IV) for up to 10 days in severe pneumonia requiring supplemental oxygen or mechanical ventilation 1, 5
• This dose showed 35% mortality reduction in mechanically ventilated patients and 20% reduction in those on supplemental oxygen 1

Hydrocortisone (For Septic Shock)

• Use 200-300 mg/day IV (divided doses or continuous infusion) for 5-7 days when hemodynamic stability cannot be restored with adequate fluid resuscitation and vasopressors 2, 5
• Do not exceed 400 mg/day total dose 1, 2
• Continuous infusion is preferred over bolus administration 2

Treatment Duration

• Standard course is 5-7 days for severe CAP 1, 2
• Short courses of 3-5 days are appropriate based on degree of dyspnea and chest imaging progression 4
• If treatment extends beyond a few days, taper slowly over 2-4 months to prevent rebound phenomenon 1
• Avoid prolonged courses beyond 5-10 days as infection risk and complications increase 1

Patient Selection Criteria

Indications for Steroid Use

• Severe CAP with CRP >150 mg/L at admission 1, 3
• Septic shock refractory to fluid resuscitation requiring vasopressors 1, 2
• Mechanical ventilation or high-flow oxygen requirement (FiO2 ≥50%) 1
• Early moderate to severe ARDS (PaO₂/FiO₂ <200 within 14 days of onset) 1

Contraindications

• Do NOT use steroids in influenza pneumonia - increases mortality (OR 3.06 for death) 1, 6
• Mild pneumonia not requiring oxygen shows no benefit and possible harm (RR 1.22 for mortality) 1
• Routine use is not recommended for non-severe CAP 4, 6

Critical Safety Monitoring and Prophylaxis

Required Prophylaxis

• PCP prophylaxis (trimethoprim-sulfamethoxazole) for patients receiving ≥20 mg methylprednisolone equivalent for ≥4 weeks 1
• Proton pump inhibitor for GI prophylaxis in all patients receiving steroids for grade 2-4 pneumonitis 1
• Calcium and vitamin D supplementation with prolonged steroid use 1

Monitoring Requirements

• Tight glucose control - hyperglycemia risk increases (RR 1.49-1.72) and is the most common adverse effect within 36 hours 1, 6, 7
• Monitor for secondary infections, particularly bacterial superinfection 1
• Screen for occult adrenal insufficiency in hypotensive, fluid-resuscitated patients using cortisol stimulation testing 1
• Monitor for gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, and hypernatremia 5

Evidence Quality and Clinical Benefits

The recommendation is based on high-quality evidence showing that low-dose corticosteroids in severe CAP:

• Reduce mortality in severe pneumonia (RR 0.58) but not in non-severe cases 7
• Decrease early clinical failure rates (RR 0.32 for severe, RR 0.68 for non-severe) 7
• Reduce mechanical ventilation duration by approximately 7 days 6
• Prevent ARDS progression (RR 0.24) 1
• Shorten hospital stay by 3 days 1

Important Caveats

• High-dose steroids (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) increase hospital-acquired infections, hyperglycemia, and gastrointestinal bleeding without mortality benefit 1
• Do not start steroids before adequate fluid resuscitation in septic shock 1
• Early initiation (<72 hours) shows better response than late initiation (≥7 days) 6
• One large VA trial (n=584) showed no mortality benefit with prolonged low-dose methylprednisolone, but this used a 20-day tapering course rather than the recommended 5-7 day course 8