When should steroids be used in patients with pneumonia, including those with community-acquired pneumonia (CAP) or COVID-19 pneumonia?

When to Use Steroids in Pneumonia

Use low-dose corticosteroids (hydrocortisone ≤400 mg/day equivalent) for 5-7 days in hospitalized patients with severe community-acquired pneumonia, particularly those with septic shock requiring vasopressors or elevated CRP >150 mg/L, but avoid steroids entirely in influenza pneumonia where they increase mortality. 1, 2

Severe Community-Acquired Pneumonia (CAP)

Indications for Steroid Use

For patients with severe CAP requiring ICU admission:

• Use corticosteroids when septic shock is present and refractory to fluid resuscitation with ongoing vasopressor requirement 1, 2
• Consider steroids when CRP >150 mg/L at admission 1
• Meta-analyses demonstrate mortality reduction specifically in severe CAP (RR 0.67,95% CI 0.45-1.01), with benefits including reduced mechanical ventilation need (RR 0.45), prevention of ARDS (RR 0.24), and shortened hospital stay by ~3 days 1
• Recent high-quality evidence shows low-dose corticosteroids reduce 30-day mortality in ICU patients with severe bacterial CAP (10% vs 16% with placebo) 3

Specific Dosing Regimens

For severe CAP with septic shock:

• Hydrocortisone 50 mg IV every 6 hours PLUS fludrocortisone 50 μg daily for 7 days 2, 3
• This regimen reduced mortality from 51% to 39% in community-acquired pneumonia subgroup analysis 3

For severe CAP without shock but with high inflammatory markers:

• Methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days 1
• Alternative: Prednisone 50 mg daily orally for those able to take oral medication 1
• Do NOT exceed methylprednisolone 1-2 mg/kg/day equivalent 2

Duration: Limit to 5-7 days maximum 1, 2

Non-Severe CAP

Do NOT use steroids for mild-to-moderate CAP requiring hospitalization but not ICU care. 1, 2

• The 2011 European guidelines explicitly state steroids are NOT recommended in pneumonia treatment 1
• The 2019 IDSA/ATS guidelines give a strong conditional recommendation AGAINST routine steroid use in CAP 1
• No mortality benefit exists for non-severe disease, with increased risk of hyperglycemia, GI bleeding, and secondary infections 2, 4

COVID-19 Pneumonia

Use dexamethasone 6 mg daily for 10 days in hospitalized COVID-19 patients requiring supplemental oxygen or mechanical ventilation. 3

• This regimen reduced 28-day mortality from 26% to 23% in a trial of 6,425 patients 3
• Benefits are specific to patients with hypoxemia requiring respiratory support 3, 5
• Combined corticosteroids plus tocilizumab may further reduce mortality (risk of death 0.233 vs standard care) in severe COVID-19 pneumonia 6

Critical Contraindications

NEVER use steroids in influenza pneumonia - meta-analyses consistently demonstrate increased mortality with corticosteroid use in influenza patients 1, 2

Mandatory Monitoring and Prophylaxis

When steroids are indicated, implement these safeguards:

• Monitor glucose closely - hyperglycemia is the most common adverse effect requiring intervention 1, 2
• Provide GI prophylaxis with proton pump inhibitors for all patients receiving steroids 2
• Ensure adequate fluid resuscitation before initiating steroids in septic shock 2
• Avoid high-dose regimens (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) as they increase hospital-acquired infections without mortality benefit 2

Common Pitfalls to Avoid

• Do not use steroids routinely - the quality of evidence shows benefits only in severe CAP with specific high-risk features, not all hospitalized pneumonia 1, 2, 7
• Do not extend duration beyond 5-7 days - prolonged courses increase infection risk without additional benefit 1, 2
• Do not use in viral pneumonia other than COVID-19 - particularly contraindicated in influenza 1, 2
• Watch for increased rehospitalization rates in the 30-90 days following treatment 2
• Recognize the therapeutic window - benefits may be limited to early deterioration phases with respiratory failure <24 hours duration 7