Questioning the Role of Corticosteroids Treating Pneumonia

Optimizing the management of community-acquired pneumonia (CAP) still remains a goal of organizations like the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS).1 This is primarily due to the fact that CAP is common and has been associated with a significant amount of morbidity and mortality. Pneumonia is a leading cause of hospital admissions and healthcare resource consumption worldwide.2 As of 2017, pneumonia in addition to influenza, remains the eighth leading cause of death in the United States.

While antibiotics are the mainstay for treatment, the role of corticosteroids for adjunctive treatment of CAP has long remained controversial. The 2007 IDSA/ATS Guidelines on the management of CAP briefly mention that there may be some benefit to the use of corticosteroid therapy in patients with severe CAP who are not in shock, but refrain from making a clear recommendation of their use due to a lack of strong evidence.1 Severe CAP is defined as CAP requiring supportive measures in an intensive care unit (ICU).3 Corticosteroids are well known to be the cause of a variety of potentially severe adverse effects that often prevents clinicians from utilizing them. However, corticosteroids may reduce the inflammatory response that occurs in CAP. Therefore, many clinicians remain curious about the role of corticosteroids in CAP compelling the emergence of new evidence.

A recent systematic review and meta-analysis evaluated the benefits and harms of adjunctive corticosteroids in CAP from 6 different trials.4 The review found no difference in the rate of mortality at 30 days in the corticosteroid group compared to placebo (5.0% vs 5.9%, p=0.24). Additionally, the time to clinical stability and hospital length of stay was reduced by one day in the corticosteroid group (p<0.001). However, the corticosteroid group did experience higher rates of hyperglycemia (22% vs. 12%; p<0.001) and rehospitalization (5.0% vs. 2.7%; p=0.04). Only studies which included severe CAP patients in the meta-analysis found significant benefit with steroid utilization, whereas, studies that evaluated non-severe patients did not.

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