When are steroids indicated in a patient with pneumonia?

Steroids in Pneumonia: When to Use and When to Avoid

Use low-dose corticosteroids (≤400 mg hydrocortisone equivalent daily for 5-7 days) in patients with severe community-acquired pneumonia requiring ICU admission, particularly those with septic shock requiring vasopressors, but avoid steroids entirely in influenza pneumonia and do not use them routinely in non-severe pneumonia. 1, 2, 3

Specific Indications for Steroid Use

Severe Community-Acquired Pneumonia (CAP) with Septic Shock

• Initiate hydrocortisone 50 mg IV every 6 hours plus fludrocortisone 50 μg daily for 7 days in patients with severe CAP and refractory septic shock requiring vasopressors despite adequate fluid resuscitation. 2, 3
• This regimen reduces mortality with an absolute risk reduction of approximately 9.8% (number needed to treat = 18 patients to prevent one death). 2, 4
• The mortality benefit is most pronounced in severe CAP (RR 0.58,95% CI 0.40-0.84), not in non-severe cases. 5, 3

Severe CAP Requiring ICU Admission (Without Shock)

• Consider low-dose corticosteroids (hydrocortisone ≤400 mg/day equivalent or methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days) in ICU patients with severe CAP who have elevated inflammatory markers (CRP >150 mg/L). 1, 3
• Benefits include reduced mechanical ventilation need (RR 0.45), prevention of ARDS (RR 0.24), and shortened hospital stay by approximately 3 days. 1, 3

Screening for Adrenal Insufficiency

• Screen hypotensive, fluid-resuscitated patients with severe CAP for occult adrenal insufficiency using cortisol stimulation testing. 2
• Provide stress-dose steroids (200-300 mg hydrocortisone per day) if inadequate cortisol response is documented. 3
• Patients with underlying COPD warrant particular attention for screening due to frequent intermittent steroid use. 2

Absolute Contraindications

Influenza Pneumonia

• Never use corticosteroids in influenza pneumonia—meta-analyses consistently demonstrate increased mortality (OR 3.06,95% CI 1.58-5.92) and increased risk of superinfection. 1, 2, 3

Non-Severe CAP

• Do not use steroids routinely in mild-to-moderate CAP requiring hospitalization but not ICU care—there is no mortality benefit and a strong recommendation against routine use. 2, 3
• Steroids have no place in non-severe pneumonia treatment according to multiple guidelines. 2

Dosing Parameters When Indicated

• Do not exceed 400 mg hydrocortisone equivalent daily (or methylprednisolone 1-2 mg/kg/day). 3
• Limit duration to 5-7 days to minimize complications. 1, 3
• Avoid high-dose steroids (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) as they increase hospital-acquired infections, hyperglycemia, and GI bleeding without mortality benefit. 3
• Taper slowly to prevent rebound phenomenon. 6

Mandatory Monitoring and Prophylaxis

Hyperglycemia Management

• Monitor glucose closely—hyperglycemia occurs in nearly twice as many steroid-treated patients (RR 1.72,95% CI 1.38-2.14) and is the most common adverse effect requiring intervention. 1, 3, 5

GI Protection

• Provide proton pump inhibitor prophylaxis for all patients receiving steroids to prevent GI bleeding. 3

Infection Surveillance

• Maintain vigilant infection surveillance, as secondary infections remain a concern despite non-significant statistical differences in trials. 2, 6
• Consider Pneumocystis pneumonia prophylaxis for patients receiving ≥20 mg methylprednisolone equivalent for ≥4 weeks. 3

Additional Monitoring

• Supplement with calcium and vitamin D for prolonged steroid courses. 3
• Watch for increased rehospitalization rates in the 30-90 days following treatment. 3

Clinical Decision Algorithm

Step 1: Identify pneumonia severity

• Severe CAP = ICU admission required, septic shock, or APACHE II score ≥25. 2
• PaO2/FiO2 ratio <150 indicates severe hypoxemia requiring aggressive management. 2

Step 2: Exclude contraindications

• Rule out influenza pneumonia (absolutely contraindicated). 1, 2, 3
• Confirm bacterial CAP, not viral pneumonia. 2

Step 3: Apply steroids only if:

• Severe CAP with septic shock requiring vasopressors after adequate fluid resuscitation, OR 2, 3
• Severe CAP requiring ICU admission with CRP >150 mg/L, OR 3
• Documented adrenal insufficiency on cortisol stimulation testing. 2, 3

Step 4: Do NOT use steroids if:

• Non-severe CAP (hospitalized but not ICU). 2, 3
• Influenza pneumonia confirmed or suspected. 1, 2, 3
• Mild-to-moderate pneumonia without shock or ICU requirement. 2