When are steroids, such as prednisolone (corticosteroid), indicated in patients with community-acquired pneumonia (CAP)?

When Steroids Are Given in Pneumonia

Steroids should be used in hospitalized patients with severe community-acquired pneumonia (CAP) for 5-7 days at doses equivalent to <400 mg IV hydrocortisone daily, but are absolutely contraindicated in influenza pneumonia. 1

Primary Indication: Severe Community-Acquired Pneumonia

Use corticosteroids in hospitalized CAP patients meeting severity criteria, specifically:

• Patients with CRP >150 mg/L at admission should receive methylprednisolone 0.5 mg/kg IV every 12 hours (or prednisone 50 mg daily) for 5 days 2
• Patients with septic shock refractory to fluid resuscitation and vasopressors benefit from corticosteroid therapy 3
• Patients requiring ICU admission show the most pronounced mortality benefit (RR 0.67,95% CI 0.45-1.01) 1

The Society of Critical Care Medicine and European Society of Intensive Care Medicine recommend corticosteroids for 5-7 days at daily doses <400 mg IV hydrocortisone equivalent in hospitalized CAP patients, with moderate quality evidence showing reduced need for mechanical ventilation (RR 0.45,95% CI 0.26-0.79) and prevention of ARDS (RR 0.24,95% CI 0.10-0.56) 1

Proven Benefits in Severe CAP

Corticosteroids provide multiple clinical benefits:

• Reduce treatment failure by 18% absolute risk reduction (13% vs 31%, P=0.02) in patients with high inflammatory markers 2
• Shorten hospital stay by approximately 3 days (risk difference -2.96 days, 95% CI -5.18 to -0.75) 1
• Accelerate time to clinical stability by approximately 1 day 1
• Prevent ARDS development with a 76% relative risk reduction 1
• Decrease mechanical ventilation requirements by 55% 1

Meta-analyses of severe CAP specifically show significant mortality reduction (OR 0.26,95% CI 0.11-0.64) when corticosteroids are used in appropriately selected patients 1

Absolute Contraindication: Influenza Pneumonia

Never use corticosteroids in influenza pneumonia, including H1N1:

• Meta-analyses demonstrate increased mortality (OR 3.06,95% CI 1.58-5.92) when corticosteroids are used in influenza patients 1
• The Infectious Diseases Society of America and American Thoracic Society explicitly recommend against corticosteroid use in severe influenza pneumonia (conditional recommendation, low quality evidence) 4
• Immunosuppressive effects impair viral clearance and worsen outcomes in viral CAP 4, 3
• This contraindication applies regardless of shock state or severity of illness 4

The Society of Critical Care Medicine emphasizes that H1N1 positivity is an absolute contraindication to steroids, and bacterial severe CAP steroid guidelines should never be applied to influenza pneumonia 4

Clinical Decision Algorithm

Follow this stepwise approach:

1. First, rule out influenza with rapid testing or PCR before considering corticosteroids 3

   • If influenza positive: Do not give steroids 1, 4
   • If influenza negative: Proceed to step 2

2. Assess pneumonia severity:

   • Mild-moderate CAP (outpatient or stable inpatient): Do not use corticosteroids 3
   • Severe CAP (ICU admission, high PSI/CURB-65): Proceed to step 3

3. Check inflammatory markers:

   • CRP >150 mg/L: Strong indication for corticosteroids 2
   • Septic shock requiring vasopressors: Strong indication for corticosteroids 3
   • Neither criterion met: Consider risk-benefit; routine use not recommended 1

4. If indicated, use appropriate regimen:

   • Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days 2, OR
   • Prednisone 50 mg daily for 5-7 days 3, OR
   • Hydrocortisone <400 mg/day IV equivalent for 5-7 days 1

Special Populations

Pneumocystis pneumonia (PCP) has different steroid indications:

• Use methylprednisolone 1 mg/kg/day for grade 2 pneumonitis in non-HIV patients 5
• Use higher doses (2-4 mg/kg/day) for severe cases (grade 3-4 pneumonitis) 5
• Always rule out other infections before initiating immunosuppressive treatment 5

Critical Pitfalls to Avoid

Common errors that increase mortality:

• Applying bacterial CAP steroid guidelines to influenza pneumonia increases mortality risk 4
• Using corticosteroids in mild-moderate CAP without severity criteria shows no benefit and may increase late failure (19.2% vs 6.4%, P=0.04) 6
• Assuming rising inflammatory markers alone justify steroids without confirming bacterial etiology 4
• Failing to obtain viral testing before initiating corticosteroids in severe pneumonia 3

The American College of Internal Medicine recommends against routine corticosteroid use in CAP, reserving it only for severe cases meeting specific criteria 3

Adverse Effects to Monitor

Expect and manage these complications:

• Hyperglycemia occurs in 18% of patients (RR 1.49,95% CI 1.01-2.19) 1
• Monitor blood glucose closely and adjust insulin accordingly 1
• Provide GI prophylaxis with proton pump inhibitors for all patients receiving steroids 5
• Consider calcium and vitamin D supplementation for prolonged courses 5
• Watch for secondary infections, though rates are not significantly increased in short courses 1

Dosing Specifics

Use these evidence-based regimens:

• Methylprednisolone: 0.5 mg/kg IV every 12 hours for 5 days (most studied regimen) 2
• Prednisone: 40-50 mg daily orally for 5-7 days 3, 6
• Hydrocortisone: <400 mg/day IV in divided doses for 5-7 days 1
• Duration: 5-7 days without tapering in most studies 1

The Torres trial, which showed significant reduction in treatment failure, used methylprednisolone 0.5 mg/kg every 12 hours for exactly 5 days in patients with CRP >150 mg/L 2