Level 2: Mid-level evidence

Corticosteroids are sometimes recommended for patients with sepsis, but their efficacy in adults hospitalized with community-acquired pneumonia is unclear. Most trials have been small and yielded inconsistent results, with some trials showing improvement and others showing worsening in the clinical course of the disease.

A recent Cochrane review of four trials that included 235 adults with pneumonia, suggested that hydrocortisone may reduce the need for mechanical ventilation but found no significant mortality benefit with either hydrocortisone or prednisolone as adjunctive pneumonia treatment (Chen Y et al.Cochrane Database Syst Rev. 2011;3:CD007720).

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In another trial that involved 213 hospitalized patients with pneumonia, oral prednisolone was associated with increased treatment failure (defined as escalation in care) at >72 hours after admission (19.2% vs. 9.2%, P=0.04, number needed to harm=10), again with no significant differences in mortality or in seven-day clinical cure rates (Snijder D et al. Am J Respir Crit Care Med. 2010;181:975-982). Prednisone was associated with a trend toward lower 30-day clinical cure rates (66.3% vs. 77.1%, P=0.08).

In the largest trial to date, 304 patients with community-acquired pneumonia were randomized to dexamethasone 5 mg IV vs. placebo once daily for four days (Lancet. 2011;377: 2023-2030). All patients received IV antibiotics within four hours of hospital admission. Dexamethasone was associated with a significant one-day reduction in median hospital stay (6.5 days vs. 7.5 days, P=0.048), but there were no significant differences in in-hospital mortality (5% vs. 5%), 30-day mortality (6% vs. 7%), intensive-care admissions (5% vs. 7%), hospital readmissions (5% vs. 5%), or empyema or pleural effusion (5% vs. 3%).

There was a significant increase in the risk of hyperglycemia in the dexamethasone group (44% vs. 23%, P<0.0001, NNH=4). Considering the inconsistent evidence of these trials, the benefits of corticosteroids in adults hospitalized with community-acquired pneumonia remains uncertain.