Adjunctive corticosteroid therapy for high-severity CAP in adults

Bergmann, 2023

Corticosteroid therapy is recommended for adults with high-severity CAP if there is a concurrent indication for use; for example:

• sepsis or septic shock – for regimens, refer to local sepsis protocols
• a COPD exacerbation – for regimens, see Systemic corticosteroids
• SARS-CoV-2 – for regimens, refer to local protocols or see Diagnosis and management of COVID-19 for links to resources on management of SARS-CoV-2.

For critically unwell adults with high-severity CAP who do not have any of the above indications, hydrocortisone is recommended in these guidelines because it is associated with a mortality benefitChaudhuri, 2024See, 2024Dequin, 2023. However, the evidence to guide the choice of corticosteroid, when to start, dosage and duration of therapy varies – seek expert advice and, if available, consult local protocolsBergmann, 2023.

Avoid the use of corticosteroids if the pathogen is likely to be influenza A or B, Mycobacterium tuberculosis or fungal.

For critically unwell adults with high-severity CAP who require high-flow oxygen or mechanical ventilation (invasive or noninvasive), add hydrocortisone to empirical therapy within 24 hours of diagnosisDequin, 2023Leung, 2025Metlay, 2019Saleem, 2023. While awaiting expert advice, or in the absence of local protocols, a suitable regimen isDequin, 2023Leung, 2025Venkatesh, 2018:

Some centres administer hydrocortisone as a continuous infusionDequin, 2023Venkatesh, 2018; however, the stability of the solution for 24 hours in temperatures more than 24ºC is not guaranteedMihovec, 2022Giles, 2016.