Steroid Use in Pneumonia

Evidence for Steroid Use

The American College of Physicians and other medical societies support the use of corticosteroids in severe pneumonia, as they reduce mortality and morbidity, although they carry specific risks including hyperglycemia and potential for secondary infections that require monitoring 1, 2, 3
For severe Community-Acquired Pneumonia (CAP) with septic shock or requiring mechanical ventilation, corticosteroids reduce mortality (RR 0.58, 95% CI 0.40-0.84), with a number needed to treat of 18 patients to prevent one death 3
The Infectious Diseases Society of America recommends corticosteroids for 5-7 days at doses <400 mg IV hydrocortisone daily (or equivalent) in hospitalized CAP patients meeting severity criteria 4, 2

For septic shock not responsive to fluid resuscitation and moderate-to-high dose vasopressors, hydrocortisone 200 mg/day IV for ≥3 days reduces 28-day mortality by approximately 2% (RR 0.84, 95% CI 0.73-0.96) 1, 2, 3
The recommendation applies to patients with infection and SOFA score ≥2, with greater absolute mortality benefit in sicker patients 1

Hyperglycemia is the most common adverse effect (RR 1.72, 95% CI 1.38-2.14), requiring tight glucose control 1
Neuromuscular weakness may occur (low-quality evidence from seven RCTs), potentially compromising independent function and delaying recovery 1
Hypernatremia occurs more frequently with corticosteroid use 1, 5

Use hydrocortisone 200 mg/day IV (divided doses or continuous infusion) for pneumonia with septic shock requiring vasopressors after adequate fluid resuscitation 2, 3
Consider corticosteroids for severe CAP with CRP >150 mg/L, mechanical ventilation requirement, or multiple organ dysfunction 4, 3
Do not use corticosteroids for sepsis without shock—no benefit demonstrated 5, 2
Monitor blood glucose closely and use sliding scale insulin to maintain tight glycemic control 6, 2
Check serum sodium for hypernatremia 1, 5
Avoid abrupt discontinuation—taper over 6-14 days when vasopressors are discontinued to prevent hemodynamic rebound 5, 2