Steroids in Pneumocystis Pneumonia (PCP)

Mechanism and Benefits of Steroids in PCP

Corticosteroids reduce overwhelming inflammation by decreasing cytokines and help with inadequate adrenal response in critically ill patients 1

For non-HIV patients with grade 2 pneumonitis, methylprednisolone 1 mg/kg/day (IV or oral equivalent) is recommended 2
For severe cases (grade 3-4 pneumonitis), higher doses of methylprednisolone (2-4 mg/kg/day) are recommended 2

Always rule out infection before initiating immunosuppressive treatment, especially in grade 2 or higher pneumonitis 2
Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 2
Provide calcium and vitamin D supplementation with prolonged steroid use 2
All patients with grade 2-4 pneumonitis receiving steroids should also be on proton pump inhibitor therapy for GI prophylaxis 3
Monitor for steroid-related complications including hyperglycemia and increased risk of secondary infections 2

Caution should be exercised in the setting of viral pneumonia, since meta-analyses in influenza patients show increased mortality with corticosteroid use 1
The Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) guidelines give a strong conditional recommendation against routine use of adjunctive steroids in patients treated for community-acquired pneumonia (CAP) 1
However, adjunctive glucocorticoids may be beneficial in severe CAP patients with septic shock refractory to fluid resuscitation and vasopressor use, especially with elevated CRP >150 mg/L 1