Corticosteroid Therapy in Community-Acquired Pneumonia

Indications and Dosage

The American Thoracic Society recommends hydrocortisone for severe community-acquired pneumonia (CAP), with a dosage of less than 400 mg/day IV for 5-7 days, which reduces mortality, hospital stay, need for mechanical ventilation, and prevents acute respiratory distress syndrome (ARDS) 1, 2
The American College of Chest Physicians and the Infectious Diseases Society of America strongly recommend against the routine use of corticosteroids in non-severe CAP, based on high-quality evidence showing no benefit in mortality 2

In patients with CAP and septic shock, hydrocortisone is indicated when hemodynamic stability is not achieved with adequate fluid resuscitation and vasopressor therapy, with a recommended dosage of 200 mg/day, preferably as a continuous infusion 1
For moderate to severe ARDS secondary to pneumonia, corticosteroids may be beneficial, with a probable reduction in mortality (RR 0.84) and duration of mechanical ventilation (mean difference -4 days) 2, 3

The use of corticosteroids is absolutely contraindicated in influenza pneumonia due to increased mortality (OR 3.06) 2
In COVID-19 patients with pneumonia, dexamethasone 6 mg daily for 10 days (equivalent to approximately 160 mg of hydrocortisone) is recommended for those requiring supplemental oxygen or ventilation 1

Hyperglycemia is a common adverse effect, occurring in approximately 50% more patients (RR 1.72), and requires close monitoring of blood glucose levels, especially in the first 36 hours after initial bolus 2, 3
There is no significant increase in secondary infections (RR 1.19), gastrointestinal bleeding (RR 1.20), or neuromuscular weakness (RR 0.85) with short-term, low-dose corticosteroid therapy 2

Refractory septic shock – Persistent hypotension that requires vasopressor support after adequate fluid resuscitation qualifies as a major severity criterion for starting hydrocortisone in severe CAP. 4
Invasive mechanical ventilation – Need for endotracheal intubation (invasive ventilation) is the second major severity criterion that alone justifies hydrocortisone therapy in severe CAP. 5
Minor severity criteria (require any 2 of 3) – In patients without a major criterion, the presence of at least two of the following defines severe CAP eligible for corticosteroids:
- Systolic blood pressure ≤ 90 mm Hg,
- PaO₂/FiO₂ ratio ≤ 250,
- Multilobar or bilateral pneumonia. 5
Single minor criterion is insufficient – The presence of only one minor severity criterion does not meet the threshold for hydrocortisone treatment in severe CAP. 5

In hypotensive patients who have received adequate fluid resuscitation, screening for occult adrenal insufficiency is recommended; if an inadequate cortisol response is documented, a stress‑dose regimen of hydrocortisone (200–300 mg per day) should be administered. 4

Strict glycaemic control is essential throughout the course of corticosteroid treatment for severe CAP to mitigate the common adverse effect of hyperglycaemia. 4