For an adult admitted to the intensive‑care unit with severe community‑acquired pneumonia (high Pneumonia Severity Index, requiring mechanical ventilation or FiO₂ > 50% with PaO₂/FiO₂ < 300 mm Hg) and no contraindications to glucocorticoids, should early hydrocortisone be given, and what dosing and taper schedule is recommended?

Hydrocortisone for Severe Community-Acquired Pneumonia: The CAPE COD Trial Evidence

For adults admitted to the ICU with severe community-acquired pneumonia meeting the criteria described, early hydrocortisone at 200 mg/day should be administered, given as a continuous infusion or divided doses for 4-7 days followed by tapering to complete 8-14 days total treatment. 1

The CAPE COD Trial: Landmark Evidence

The CAPE COD trial (2023) represents the highest quality and most recent evidence specifically addressing this clinical scenario. 1 This phase 3, multicenter, double-blind RCT enrolled 800 ICU patients with severe CAP and demonstrated:

• Mortality reduction: 6.2% death rate with hydrocortisone vs 11.9% with placebo at 28 days (absolute risk reduction 5.6%, P=0.006) 1
• Reduced need for intubation: 18.0% vs 29.5% in patients not mechanically ventilated at baseline (HR 0.59) 1
• Reduced vasopressor requirement: 15.3% vs 25.0% in patients not on vasopressors at baseline (HR 0.59) 1

Recommended Dosing Protocol

Hydrocortisone 200 mg/day administered as: 1, 2, 3

• Continuous IV infusion (preferred over bolus) 2, 3
• OR divided doses if continuous infusion unavailable
• Duration: 4-7 days at full dose based on clinical improvement 1
• Followed by tapering to complete 8-14 days total treatment 1

The dose must remain below 400 mg/day hydrocortisone equivalent to optimize benefit-risk ratio. 4, 2, 3 Higher doses have not shown additional benefit and may increase adverse effects.

Patient Selection Criteria

Hydrocortisone is indicated for patients meeting severe CAP criteria as defined by: 4

Major criteria (any one requires ICU admission):

• Invasive mechanical ventilation 4
• Septic shock requiring vasopressors 4

Minor criteria (≥3 of the following):

• Respiratory rate ≥30 breaths/min 4
• PaO₂/FiO₂ ratio <250 (or <300 in your specified population) 4
• Multilobar infiltrates 4
• Confusion/disorientation 4
• BUN ≥20 mg/dL 4
• Leukopenia (WBC <4000/mm³) 4
• Thrombocytopenia (platelets <100,000/mm³) 4
• Hypothermia (core temperature <36°C) 4
• Hypotension requiring aggressive fluid resuscitation 4

Supporting Evidence from Meta-Analyses

Recent systematic reviews corroborate the CAPE COD findings:

• 2025 meta-analysis (43 RCTs, n=10,853): Corticosteroids reduced short-term mortality (RR 0.85), ICU stay (-2.02 days), hospital stay (-2.66 days), and mechanical ventilation duration (-4.24 days) 5
• 2024 meta-analysis (15 RCTs, n=3,252): Mortality reduction specifically with hydrocortisone in severe CAP (RR 0.69), with greater benefit in younger patients 6
• 2025 meta-analysis (30 RCTs, n=7,519): Reduced short-term mortality (RR 0.82) and need for invasive mechanical ventilation (RR 0.63) 7

The subgroup analyses consistently show that early initiation (≤72 hours), low-dose (<400 mg/day), and prolonged therapy (≥7 days) provides optimal mortality benefit. 5

Guideline Recommendations

Society of Critical Care Medicine/European Society of Intensive Care Medicine (2018) suggests corticosteroids for 5-7 days at daily dose <400 mg IV hydrocortisone equivalent in hospitalized patients with CAP (conditional recommendation, moderate quality evidence). 4

American College of Physicians recommends hydrocortisone <400 mg/day (typically 200 mg/day) for 5-7 days as alternative regimen for severe CAP, particularly in septic shock. 2

Critical Contraindication

Do NOT use corticosteroids in influenza pneumonia. 4, 2, 8 Observational data shows increased mortality (OR 3.06) and secondary bacterial infections with corticosteroid use in influenza. 4, 8 The American Thoracic Society explicitly recommends against corticosteroids in this population. 2

Adverse Effects and Monitoring

Hyperglycemia is the primary adverse effect requiring intervention: 4, 8, 5

• Occurs in approximately 50% more patients (RR 1.72) 8
• Requires close glucose monitoring, especially first 36 hours 8
• Increased insulin requirements during first week of treatment 1

No significant increase in: 4, 8, 5, 1

• Secondary infections (RR 1.01) 5
• Gastrointestinal bleeding (RR 1.07) 5
• Hospital-acquired infections 1

Concomitant Therapy Requirements

Always provide standard antibacterial coverage according to CAP guidelines alongside corticosteroids. 2 Corticosteroids are adjunctive therapy only and never replace appropriate antimicrobial treatment. 2

Additional Benefits

Beyond mortality reduction, hydrocortisone prevents ARDS development (RR 0.24) 4, 2 and reverses shock in septic patients (RR 1.20). 5 The 2016 pilot study by Confalonieri showed similar benefits with 200 mg bolus followed by 10 mg/hour infusion for 7 days. 9

Clinical Implementation

Initiate hydrocortisone within 72 hours of ICU admission for maximum benefit. 5 Monitor for clinical improvement by day 4-7 to determine whether to use 4-day or 7-day full-dose regimen before tapering. 1 Ensure glucose monitoring protocols are in place before starting therapy. 8