Duration of Steroid Therapy for Severe Community-Acquired Pneumonia
For severe CAP, corticosteroids should be administered for 5-7 days without tapering in most cases. 1, 2, 3
Recommended Steroid Regimens and Duration
The Society of Critical Care Medicine and European Society of Intensive Care Medicine recommend the following specific durations and dosing:
- Hydrocortisone: <400 mg/day IV in divided doses (or as continuous infusion at 200 mg/day for septic shock) for 5-7 days 1, 2, 3
- Methylprednisolone: 0.5 mg/kg IV every 12 hours for 5 days 1, 2
- Prednisone: 50 mg daily orally for 5-7 days (for patients able to take oral medications) 1, 2
No tapering is required after the 5-7 day course in most studies showing benefit 1
When to Use Steroids in Severe CAP
Corticosteroids are indicated specifically for:
- Severe CAP requiring ICU admission with high inflammatory markers (CRP >150 mg/L) 1
- Septic shock refractory to fluid resuscitation and vasopressors 1, 3
- Within 24 hours of developing severe CAP for maximum mortality benefit 4
The benefits include reduced mortality (RR 0.67), decreased mechanical ventilation need (RR 0.45), and prevention of ARDS (RR 0.24) 1, 5, 6
Critical Contraindication
Steroids are absolutely contraindicated in influenza pneumonia due to increased mortality (OR 3.06) 1, 2, 3. Rule out influenza with rapid testing or PCR before initiating corticosteroids 1
Important Monitoring During the 5-7 Day Course
- Hyperglycemia occurs in 18-50% of patients (RR 1.49-1.72), requiring close blood glucose monitoring especially in the first 36 hours 1, 2, 3
- Adjust insulin accordingly throughout the treatment course 3
- No significant increase in secondary infections with short 5-7 day courses 3
Common Pitfall to Avoid
The ESCAPe trial, which showed no mortality benefit, used a 20-day prolonged tapering regimen initiated 72-96 hours after hospital admission 7, 4. In contrast, the CAPE COD trial showing mortality benefit used hydrocortisone for 8 days (4 days full dose, 4 days half dose) initiated within 24 hours of severe CAP development 4. Earlier initiation (within 24 hours) and shorter duration (5-7 days) appear superior to delayed, prolonged courses 4