Hydrocortisone Use in Severe Pneumonia

Recommendations Based on Pneumonia Severity

The American Thoracic Society recommends that hydrocortisone should not be routinely used for severe community-acquired pneumonia (CAP) except in patients with refractory septic shock 1, 2
Corticosteroids, including hydrocortisone, are not recommended for routine use in non-severe CAP, with a strong recommendation based on evidence showing no mortality benefit or reduction in organ failure in this population 1, 2
Hydrocortisone is not routinely recommended for patients with severe CAP, with a conditional recommendation, and some meta-analyses have shown mortality benefit in severe CAP, but no consistent definition of disease severity was used across studies 1, 2

The Surviving Sepsis Campaign guidelines recommend hydrocortisone for patients with CAP and refractory septic shock, with a regimen of 50 mg IV every 6 hours plus fludrocortisone 50 μg daily showing mortality benefit compared to placebo 1, 2
Hydrocortisone is not recommended for patients with severe influenza pneumonia, with a meta-analysis suggesting increased mortality in patients with influenza who receive corticosteroids 1, 2

The American College of Chest Physicians recommends monitoring for hyperglycemia, which is the most common side effect requiring therapy, and watching for potential secondary infections, which may be increased with corticosteroid use 1
Rehospitalization rates may be higher with corticosteroid use, and concerns about complications in the 30-90 days following treatment have been raised, with a recommendation to weigh the benefit-risk ratio in patients with severe CAP 1

The Infectious Diseases Society of America recommends avoiding hydrocortisone in influenza pneumonia unless there are other indications for its use, and considering that the evidence base is evolving, with recent trials showing mortality benefit in severe CAP 1, 2