Acute severe community-acquired pneumonia: corticosteroid adjunct therapy

Also known as Corticosteroids in CAP · Hydrocortisone for severe pneumonia · CAPE COD trial

Corticosteroids as adjunct therapy in SEVERE CAP: immunomodulation of excessive inflammation. Evidence: CAPE COD trial (2023, NEJM) — hydrocortisone 200 mg/day IV for 4-7 days (with protocol tapering) reduced 28-day mortality in ICU severe CAP (6.2% vs 11.9%). Torres 2015 (JAMA) — methylprednisolone 0.5 mg/kg q12h for 5 days reduced treatment failure in severe CAP with CRP over 150 mg/L. Meta-analyses: reduced mortality in severe CAP, less need for mechanical ventilation, less ARDS, shorter time to clinical stability, at the cost of hyperglycaemia. Not supported: non-severe CAP, influenza (observational harm signal), fungal pneumonia. Separate indications: Pneumocystis pneumonia (consensus-endorsed adjunct) and COVID-19 (dexamethasone 6 mg daily up to 10 days, RECOVERY).

low22 referencesUpdated 26 July 202612 min readVerification in progress

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8 MCQs

Meet the patient

A 68-year-old man arrives in ICU with severe community-acquired pneumonia. CURB-65 is 4, CRP 220 mg/L, PaO2/FiO2 180. He needs noradrenaline for septic shock and has bilateral infiltrates on chest X-ray. The team is debating adjunct corticosteroids.^[3]

The question that decides his next week is the question that decides every severe CAP: does this patient have the severe, ICU-level phenotype that benefits, or the non-severe phenotype in which steroids show no mortality gain? Torres required CRP over 150 mg/L at admission; CAPE COD and Confalonieri enrolled ICU-admitted severe CAP; the Blum and Meijvis trials studied ward-level CAP and found speed-of-recovery benefits without a survival signal. Severity-and-inflammation reasoning is the central viva insight.^[3]^[4]^[8]

References22Show

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