In a patient with community‑acquired pneumonia who has no adrenal insufficiency, no refractory septic shock, and no COPD or asthma exacerbation, should injectable hydrocortisone be administered?

Hydrocortisone Should NOT Be Administered in This Clinical Scenario

In a patient with community-acquired pneumonia who has no adrenal insufficiency, no refractory septic shock, and no COPD or asthma exacerbation, injectable hydrocortisone should not be given. 1

Primary Guideline Recommendation

The American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) issues a strong recommendation against routine corticosteroid therapy for all adults with community-acquired pneumonia, regardless of severity, except when refractory septic shock is present. 1 This represents the highest level of guideline evidence and should direct clinical practice. 2, 1

When Hydrocortisone Is Absolutely Contraindicated

Your patient explicitly lacks the only accepted indication for steroids in pneumonia:

• No refractory septic shock: Steroids are reserved exclusively for patients who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy. 2, 1
• No adrenal insufficiency: The 2007 IDSA/ATS guidelines support stress-dose steroids only when inadequate cortisol response is documented in hypotensive, fluid-resuscitated patients. 2
• No COPD/asthma exacerbation: These represent separate indications unrelated to pneumonia treatment. 1

The Single Exception: Refractory Septic Shock

Hydrocortisone is indicated only when all of the following criteria are met simultaneously: 1

• ICU-level severity requiring invasive mechanical ventilation or vasopressors
• Failure to respond to adequate fluid resuscitation and vasopressor support
• C-reactive protein > 150 mg/L on admission
• Negative influenza testing

If these criteria are met, use hydrocortisone 200 mg IV daily for 5-7 days (or methylprednisolone 0.5 mg/kg IV every 12 hours for 5 days). 1, 3

Why Guidelines Recommend Against Routine Use

The ATS/IDSA reviewed extensive evidence and concluded: 1

• No mortality benefit in non-severe or severe CAP without shock
• Significant hyperglycemia requiring treatment occurs 50-76% more frequently (RR 1.49-1.76) 1
• Increased secondary infection rates and 30-90 day rehospitalization 1, 4
• The modest improvement in fever resolution is outweighed by harms 1

Most Recent High-Quality Evidence

The 2023 CAPE COD trial (N=800) published in the New England Journal of Medicine showed mortality benefit with hydrocortisone in severe CAP (6.2% vs 11.9%, P=0.006). 5 However, this trial enrolled only ICU patients with severe pneumonia requiring intensive support—not the general pneumonia population described in your question. 5 The guideline committees reviewed this and similar evidence but maintained their strong recommendation against routine use because the benefits apply only to the narrow subset with refractory shock. 2, 1

Critical Pitfall to Avoid

Never use steroids if influenza is suspected or confirmed—meta-analyses demonstrate a three-fold increase in mortality (OR 3.06,95% CI 1.58-5.92) due to impaired innate antiviral immunity. 2, 1 Perform influenza testing in all CAP presentations before considering any steroid use. 1

Algorithm for Decision-Making

1. Does the patient have refractory septic shock? (hypotension despite adequate fluids + vasopressors)

   • No → Do not give hydrocortisone 1
   • Yes → Proceed to step 2

2. Is CRP > 150 mg/L and influenza testing negative?

   • No → Do not give hydrocortisone 1
   • Yes → Give hydrocortisone 200 mg IV daily for 5-7 days 1, 3

Since your patient has no refractory septic shock, the algorithm stops at step 1 with a clear directive: do not administer hydrocortisone. 1