The primary limitations in evaluating the results of this systematic review are that many of the included trials did not report subgroup analyses based on pneumonia severity, and there was low certainty of evidence for several outcomes. Additionally, these results cannot provide conclusive insights into the consistency of steroid effectiveness across different etiologies of CAP; further studies are necessary to address this question.
It remains uncertain whether the effects of corticosteroids are consistent across different causes of bacterial pneumonia (e.g., Streptococcus pneumoniae vs. other pathogens). Future studies should investigate these microbiologic subgroups to clarify this potential variation in treatment response.
When comparing different corticosteroids' impact on mortality in patients with severe CAP, hydrocortisone appears to have an edge over other corticosteroids (low to moderate certainty). In addition, hydrocortisone did not have the same superiority when other outcomes were analyzed. This finding has limited impact on the findings of this systematic review as hydrocortisone is generally the corticosteroid of choice in ICU for patients with severe CAP and sepsis. This choice is because of hydrocortisone's high relative mineralocorticoid activity. Further research is needed to confirm whether non-hydrocortisone corticosteroids improves mortality in this context.
Although the systematic review reports the findings with specific levels of evidence—a methodologic strength of this systematic review—most conclusions are based on low-certainty evidence, underscoring the need for further research to clarify these questions. Only two conclusions, namely, the reduction in mortality in patients with severe CAP and the risk of hyperglycemia as a side effect, were derived from moderate-certainty evidence.
Different trials used varying criteria to define “severe” pneumonia, making it challenging to generalize findings. This variability limits the ability to apply results consistently across patient populations. There is no standardized dosing or treatment duration for corticosteroids across trials, which introduces inconsistencies in the reported effects and complicates determining the optimal approach. Most trials have relatively short follow-up periods, limiting information on the long-term effects of corticosteroid use, such as potential complications.
To summarize, the existing evidence supports the use of corticosteroids (namely, hydrocortisone) for hospitalized patients with severe CAP. This recommendation is based on the potential benefits in reduction of mortality, the need for mechanical ventilation and ICU admission, and shortening the duration of hospitalization, reduction in health care costs, and low risk for adverse events. Therefore, we have assigned a color recommendation of green (benefits > harms) to this treatment. This recommendation is in line with the recent recommendation by the Society of Critical Care Medicine, which in their 2024 updates issued a “strong” recommendation for use in hospitalized patient with severe “CAP.” Other societies employ a more cautious tone. While they highlight that corticosteroids may benefit a subset of patients, specifically those with severe CAP or those in septic shock, they caution against their widespread use due to risks of side effects and mixed evidence on efficacy.
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