In an adult with community‑acquired pneumonia, when should corticosteroids be given, what dosing regimen is recommended, and what are the contraindications?

Corticosteroids in Community-Acquired Pneumonia

Do not routinely administer corticosteroids to adults with community-acquired pneumonia, regardless of severity, except in cases of refractory septic shock. 1, 2

When Corticosteroids Should NOT Be Given

Non-Severe CAP (Ward-Level Care)

• Strong recommendation against routine use in patients who do not meet ICU admission criteria 1, 2
• No mortality benefit demonstrated, and risks outweigh any modest improvements in fever resolution 1
• Hyperglycemia requiring treatment occurs significantly more often (RR 1.76) 1, 3

Influenza Pneumonia (Any Severity)

• Absolutely avoid corticosteroids in confirmed or suspected influenza pneumonia 1, 2, 4
• Meta-analyses show a three-fold increase in mortality (OR 3.06,95% CI 1.58-5.92) 1, 4
• Corticosteroids impair innate immunity critical for viral clearance and increase secondary bacterial infections 1, 4
• Test all CAP patients for influenza before considering any steroid therapy 2, 4

When Corticosteroids MAY Be Considered

Severe CAP with Specific Criteria

The 2019 ATS/IDSA guidelines provide a conditional recommendation against routine use even in severe CAP, but acknowledge potential benefit in highly selected patients 1, 2:

Patient selection criteria (all must be met):

• ICU-level severity defined by either:
  • One major criterion: invasive mechanical ventilation OR septic shock requiring vasopressors 5
  • OR at least three minor criteria: respiratory rate ≥30/min, PaO₂/FiO₂ <250, multilobar infiltrates, confusion, BUN ≥20 mg/dL, leukopenia, thrombocytopenia, hypothermia, or need for aggressive fluid resuscitation 5
• AND C-reactive protein >150 mg/L on admission 2
• AND negative influenza testing 2, 4
• AND no response to adequate fluid resuscitation and vasopressor support (refractory septic shock) 1, 2

Refractory Septic Shock

• This is the primary indication where corticosteroids have proven mortality benefit 1, 2
• The ATS/IDSA guidelines explicitly endorse the Surviving Sepsis Campaign recommendations for corticosteroids in CAP patients with refractory septic shock 1

Recommended Dosing Regimen (When Criteria Met)

Choose one of the following evidence-based regimens:

Option 1: Methylprednisolone

• 0.5 mg/kg IV every 12 hours for 5 days 2, 5
• No taper required for this short duration 2

Option 2: Hydrocortisone

• 200 mg IV daily (continuous infusion or divided doses) for 5-7 days 1, 2, 5
• Maximum daily dose should not exceed 400 mg 1, 5
• May taper to complete 8-14 day total course 5
• Continuous infusion preferred over bolus administration 5

The SCCM/ESICM guidelines suggest corticosteroids for 5-7 days at <400 mg hydrocortisone equivalent daily in hospitalized severe CAP patients, though this represents a conditional recommendation with moderate-quality evidence 1

Contraindications

Absolute Contraindications

• Influenza pneumonia (confirmed or suspected) 1, 2, 4
• Active untreated systemic fungal infection 2

Relative Contraindications

• Non-severe CAP (ward-level care) 1, 2
• Uncontrolled diabetes mellitus (relative—requires intensive glucose monitoring if steroids necessary) 5
• Active gastrointestinal bleeding 5

Adverse Effects and Monitoring Requirements

Common Adverse Effects

• Hyperglycemia requiring treatment occurs in approximately 50% more patients (RR 1.49-1.76) 1, 5, 3
• Monitor blood glucose closely, especially during first 36 hours 5
• Aggressive insulin therapy should be readily available 5

Other Potential Complications

• Trend toward higher secondary infection rates 1
• Increased 30-90 day rehospitalization rates 1, 5
• No significant increase in gastrointestinal bleeding with short courses (RR 1.07) 5

Clinical Benefits (When Appropriately Used)

In properly selected severe CAP patients, corticosteroids demonstrate:

• Reduced mortality (RR 0.46-0.67) in severe CAP 1, 6, 3
• Prevention of ARDS (RR 0.21-0.24) 1, 5, 7
• Reduced need for mechanical ventilation (RR 0.45-0.50) 1, 3
• Shortened hospital length of stay (approximately 3 days reduction) 1, 6
• Improved shock reversal rates in septic shock (RR 1.20) 5

Critical Pitfalls to Avoid

Do Not Use Steroids As:

• Routine therapy for all hospitalized CAP patients 1, 2
• Treatment for fever reduction alone 1
• Empiric therapy before influenza testing in appropriate season 2, 4

Always Remember:

• Corticosteroids are adjunctive therapy only—always provide appropriate antibacterial coverage per standard CAP guidelines 5
• Document clear clinical rationale when deviating from guideline recommendations 2
• Higher doses (>400 mg hydrocortisone equivalent daily) provide no additional benefit and increase adverse effects 1, 5

Special Populations

• Continue necessary corticosteroids in patients with chronic conditions (asthma, COPD exacerbation, adrenal insufficiency) regardless of CAP diagnosis 2, 4
• These patients should maintain their baseline steroid requirements 4