Steroid Use in Pneumonia: Clinical Indications and Laboratory Guidance

Introduction to Steroid Use

The American Thoracic Society recommends against routine corticosteroid use in pneumonia patients except in cases of refractory septic shock 1

The Infectious Diseases Society of America suggests that hypotensive, fluid-resuscitated patients with severe community-acquired pneumonia should be screened for occult adrenal insufficiency 2, 3, 4
The mortality benefit of low-dose corticosteroids is most pronounced in patients with severe community-acquired pneumonia requiring ICU admission, with an absolute risk reduction of approximately 9.8% 4

The Infectious Diseases Society of America recommends screening for adrenal insufficiency in hypotensive, fluid-resuscitated patients with severe community-acquired pneumonia using cortisol stimulation testing 2, 3, 4
A PaO2/FiO2 ratio <150 indicates severe hypoxemia and poor candidacy for non-invasive ventilation, suggesting the need for more aggressive management including steroids 2, 3
An APACHE II score ≥25 is associated with the greatest mortality benefit from adjunctive therapies in severe community-acquired pneumonia 4

The American Journal of Respiratory and Critical Care Medicine reports that steroids may increase mortality in influenza pneumonia according to meta-analyses of predominantly retrospective studies 1
The 2019 ATS/IDSA guidelines explicitly recommend against routine corticosteroid use except in refractory septic shock 1

Patients with underlying COPD are at higher risk for adrenal insufficiency due to frequent intermittent steroid use and warrant screening for inadequate cortisol response when presenting with severe community-acquired pneumonia 2, 3

The European Respiratory Society guidelines state that steroids have no place in the treatment of pneumonia unless septic shock is present, as they have not been shown to be useful in pneumonia treatment, with two meta-analyses demonstrating that steroids cannot be recommended for routine treatment of patients with community-acquired pneumonia (CAP) 5, 6, 7, 8
Steroids have no benefit in reducing mortality in adults with non-severe pneumonia, and their use should be restricted to specific indications such as septic shock or severe CAP requiring ICU admission 5, 6, 7, 8

The European Respiratory Society recommends that for adults with severe CAP requiring ICU admission, low-dose corticosteroids (≤400 mg hydrocortisone equivalent daily) significantly reduce mortality, with a relative risk of 0.58, and treatment of 18 patients prevents one death 5, 6, 7, 8

The European Respiratory Society guidelines suggest that hydrocortisone has been shown to be beneficial in patients with septic shock complicating pneumonia, with a recommended dose of 50 mg IV every 6 hours plus fludrocortisone 50 μg daily for 7 days 5, 6, 7

The European Respiratory Society recommends assessing pneumonia severity and identifying specific indications for steroid use, such as septic shock or severe bacterial CAP, and excluding contraindications such as influenza pneumonia or viral pneumonia (non-COVID) 5, 6, 7, 8
The guidelines also recommend monitoring glucose closely, as hyperglycemia occurs in nearly twice as many steroid-treated patients, and maintaining infection surveillance, as secondary infections remain a concern despite non-significant statistical differences 5, 6, 7, 8