Community acquired pneumonia (CAP) and steroids (steroid use in CAP)

There is evidence regarding positive outcomes from using oral steroid treatment in community acquired pneumonia (CAP):

• a systematic review regarding the use of steroids in hospitalized patients with CAP was undertaken (1)
  • this concluded:
    • for hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day
      
      
• a further systematic review concluded (2):
  • corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death
  • corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP
  • corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits
    
    
• considering both adult and paediatric patients (3)
  • a systematic review stated that the "take home message" was that
    • "..for adult patients with severe community-acquired pneumonia, corticosteroids reduce morbidity and mortality. For pediatric patients and adults with nonsevere community-acquired pneumonia, corticosteroids appear to reduce morbidity, but not mortality"
    • the authors stated that
      • current data suggest that corticosteroids reduce morbidity and mortality in severe community-acquired pneumonia
        • corticosteroids were also shown to be beneficial in patients with nonsevere community-acquired pneumonia who were admitted to the hospital
        • administration of corticosteroids was associated with an increased rate of hyperglycemia, without a difference in other adverse events
      • limitations of the review were highlighted:
        • studies included in the meta-analysis varied in the doses, days of total treatment, and type of corticosteroid administered
        • review included patients with a variety of medical conditions (eg, chronic obstructive pulmonary disease, diabetes), who may respond differently than patients without these comorbidities
        • many of the outcomes were limited by small sample sizes, with one study comprising nearly half of all of the included patients
        • sample sizes in the pediatric studies were very small
          
          
• a systematic review found (4):
  • corticosteroid therapy is associated with a lower incidence of progression to requiring mechanical ventilation among patients hospitalized with CAP
  • no association was found between corticosteroid therapy and mortality, treatment failure, or adverse events
    
    
• steroid therapy in adults who had been admitted to the intensive care unit (ICU) for severe CAP
  • among patients with severe community-acquired pneumonia being treated in the ICU, those who received hydrocortisone had a lower risk of death by day 28 than those who received placebo (5)
    
    
• a review (18 RCTs; n=4,661) found corticosteroids probably reduce mortality in more severe community-acquired pneumonia (RR 0.62 [95% CI 0.45 to 0.85]; moderate certainty) and probably reduce risk of requiring invasive mechanical ventilation and ICU admission (6)

In general, studies suggest that corticosteroids are relatively beneficial and safe in patients with CAP, with the greatest benefit in severe CAP. Currently, the routine use of corticosteroids is not recommended by clinical practice guidelines with the exception of CAP and refractory septic shock. (7)

Reference:

1. Siemieniuk RA et al. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis.Ann Intern Med. 2015 Oct 6;163(7):519-28
2. Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017 Dec 13;12:CD007720. doi: 10.1002/14651858.CD007720
3. Seagraves T, Gottieleb M. Are Corticosteroids Beneficial in the Treatment of Community-Acquired Pneumonia? Ann Emerg Med. 2018 Jun 21. pii: S0196-0644(18)30410-4
4. Saleem N, Kulkarni A, Snow TAC, et al. Effect of Corticosteroids on Mortality and Clinical Cure in Community-Acquired Pneumonia: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Control Trials. Chest. 2022 Sep:S0012-3692(22)03705-9.
5. Dequin P et al; for the CRICS-TriGGERSep Network. Hydrocortisone in Severe Community-Acquired Pneumonia. NEJM March 21, 2023.
6. Pitre, T., Abdali, D., Chaudhuri, D. et al. Corticosteroids in Community-Acquired Bacterial Pneumonia: a Systematic Review, Pairwise and Dose-Response Meta-Analysis. J GEN INTERN MED (2023). https://doi.org/10.1007/s11606-023-08203-6
7. Harris L, Crannage A. Corticosteroids in Community-Acquired Pneumonia: A Review of Current Literature. J Pharm Technol. 2021 June 37(3): 152–160