Recommended Steroid Dose for Severe Pneumonia
For severe community-acquired pneumonia, use methylprednisolone 1 mg/kg/day (typically 40-80 mg daily, not exceeding 2 mg/kg/day) intravenously for 5-7 days. 1, 2
Specific Dosing by Clinical Severity
Moderate-to-Severe CAP (CRP >150 mg/L or requiring oxygen)
- Methylprednisolone 0.5 mg/kg IV every 12 hours (total 1 mg/kg/day) for 5 days is the evidence-based regimen that reduced treatment failure from 31% to 13% in the highest quality RCT 3
- Alternative: Dexamethasone 6 mg once daily (oral or IV) for up to 10 days for patients requiring supplemental oxygen, which reduced mortality by 20-35% in mechanically ventilated patients 2
- Hydrocortisone 200-300 mg/day IV can be used as an equivalent alternative 2
Severe CAP with Septic Shock
- Use methylprednisolone 1-2 mg/kg/day for patients with septic shock refractory to fluid resuscitation and vasopressors 2
- Hydrocortisone <400 mg/day (stress-dose: 200-300 mg/day) is an acceptable alternative for 5-7 days 2
ARDS from Pneumonia
- Early ARDS (within 7 days, PaO2/FiO2 <200): methylprednisolone 1 mg/kg/day 1
- Late ARDS (after day 6): methylprednisolone 2 mg/kg/day followed by slow tapering over 13 days 1
- Taper slowly over 6-14 days, never stop abruptly as deterioration may occur from reconstituted inflammatory response 1
Critical Dosing Limits and Safety
Never exceed 2 mg/kg/day methylprednisolone equivalent - higher doses increase hospital-acquired infections, hyperglycemia, and gastrointestinal bleeding without mortality benefit 1, 2
The 2017 SCCM/ESICM guidelines explicitly warn against high-dose steroids (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) 2. A recent 2023 RCT confirmed that prolonged higher-dose methylprednisolone (80 mg daily) showed no mortality benefit over conventional dexamethasone 6 mg and actually prolonged hospitalization 4.
Treatment Duration
- Standard course: 5-7 days for severe CAP 2, 3
- Short courses of 3-5 days are appropriate based on dyspnea and chest imaging progression 2
- Avoid prolonged courses beyond 5-10 days as infection risk increases significantly 2
- If extending beyond a few days, taper slowly over 2-4 months to prevent rebound phenomenon 2
Essential Supportive Measures During Steroid Therapy
Mandatory prophylaxis and monitoring:
- PCP prophylaxis (trimethoprim-sulfamethoxazole) for patients receiving ≥20 mg methylprednisolone equivalent for ≥4 weeks 2
- Proton pump inhibitor for GI prophylaxis in all patients receiving steroids 2
- Calcium and vitamin D supplementation with prolonged steroid use 2
- Tight glucose control as hyperglycemia risk increases (RR 1.49), though mostly within 36 hours following initial bolus 1, 2
- Infection surveillance as glucocorticoids blunt febrile response - monitor for bacterial superinfection 1, 2
Clinical Context for Use
Use steroids when:
- Severe CAP with CRP >150 mg/L 2, 3
- Septic shock refractory to fluid resuscitation and vasopressors 2
- Mechanical ventilation or high-flow oxygen (FiO2 ≥50%) required 2, 5
- Risk of ARDS progression (steroids reduce ARDS risk by 76%, RR 0.24) 2, 6
Do NOT use steroids when:
- Influenza pneumonia - increases mortality (OR 3.06 for death) 2
- Mild pneumonia not requiring oxygen - shows no benefit and possible harm (RR 1.22 for mortality) 2
- Before adequate fluid resuscitation in septic shock 1
Common Pitfalls to Avoid
- Never start steroids before ruling out infection, especially in immunocompromised patients 2
- Do not use rapid or abrupt discontinuation - always taper slowly to prevent rebound inflammation 1
- Avoid routine use in non-severe CAP - the 2016 IDSA/ATS guidelines recommend against routine steroids in hospital-acquired pneumonia without specific indications 1
- Monitor for hyperglycemia especially within first 36 hours after initial bolus 1
- Screen for occult adrenal insufficiency in hypotensive, fluid-resuscitated patients with severe CAP using cortisol stimulation testing 2