A 78-year-old female presents with dyspnea, and her workup is concerning for community-acquired pneumonia (CAP). Despite your best interventions, her oxygenation and work of breathing are worsening, so you call Respiratory Therapy to initiate high-flow nasal cannula. Meanwhile, you’re left thinking, “Would steroids help turn her around? But what are the guidelines - are steroids best used for CAP or sepsis or both? What kind of CAP? When and how much?”
A 2024 focused update produced by a panel of international experts provided new evidence-based guidelines on the use of corticosteroids in hospitalized adults and children with sepsis, acute respiratory distress syndrome (ARDS), and CAP.
Why did people start using steroids for sepsis, ARDS, and CAP in the first place?
Dysregulated inflammatory response is common in acutely ill patients during hospitalization, and corticosteroids have been hypothesized to be beneficial due to their anti-inflammatory mechanisms.
The Society of Critical Care Medicine (SCCM) put together a panel of international experts to provide updated evidence-based recommendations addressing the use of corticosteroids in the management of acutely ill patients requiring hospitalization, specifically in sepsis, ARDS, and CAP. The panel identified five actionable Patient, Intervention, Comparator, Outcomes (PICO) questions related to the use of corticosteroids in critical illness. It then conducted systematic literature reviews to identify studies relevant to each of the five PICO questions. The panelists developed recommendations using the GRADE Evidence-to Decision framework and designated their recommendations as strong (using the phrase “we recommend”) and as conditional (using the phrase “we suggest”). Consensus was defined as an 80% agreement among at least 75% of panel members.
The Recommendations
Corticosteroids in Sepsis and Septic Shock:
Recommendation:
1A) We “suggest” administering corticosteroids to adult patients with septic shock (conditional recommendation, low certainty).
1B) We “recommend against” administration of high dose/short duration corticosteroids (> 400 mg/d hydrocortisone equivalent for < 3 d) for adult patients with septic shock (strong recommendation, moderate certainty).
Rationale:
Corticosteroid use may reduce hospital mortality and long-term mortality (from 60 d to 1 yr) (relative risk [RR] 0.94; 95% CI, 0.89–1.00, low certainty) and probably reduces ICU mortality and short-term mortality (14–30 d) (RR 0.93; 95% CI, 0.88–0.98, moderate certainty) in patients with sepsis or septic shock. Corticosteroids offered small to moderate desirable effects in patients with septic shock. The 2017 guidelines recommended the use of corticosteroids in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy. The 2024 update decided that the evidence shows that corticosteroids are beneficial in patients with septic shock requiring vasopressors, regardless of dose. However, there was no consensus or recommendation for specific steroid dosing.
Corticosteroids in Acute Respiratory Distress Syndrome:
Recommendation:
2A) We “suggest” administering corticosteroids to adult critically ill patients with ARDS (conditional recommendation, moderate certainty).
Rationale:
Corticosteroid use probably reduces 28-day mortality (RR 0.82; 95% CI, 0.72–0.95, moderate certainty) in critically ill patients with ARDS. Patients who received a longer course of corticosteroids (> 7 d) had higher rates of survival than those who received a shorter course (7 d or less) (p = 0.04, moderate credibility). Corticosteroids offered moderate desirable effects. The 2017 guidelines recommended giving steroids within 14 days of the diagnosis of moderate to severe ARDS (Pao2/Fio2 ratio of < 200). The 2024 guidelines decided to remove the qualifier based on Pao2/Fio2 ratio. There was no demonstrated differential effect based on corticosteroid timing or type or dosage and the panel did not recommend specific steroid dosing regimens.
Corticosteroids in Community-Acquired Pneumonia:
Recommendation:
3A) We “recommend” administering corticosteroids to adult patients hospitalized with severe bacterial CAP (strong recommendation, moderate certainty).
3B) We “make no recommendation” for administering corticosteroids for adult patients hospitalized with less severe bacterial CAP.
Rationale:
In patients with severe CAP, corticosteroids probably reduce hospital mortality (RR 0.62; 95% CI, 0.45–0.85; moderate certainty). In all hospitalized patients with CAP (severe and less severe), corticosteroids probably reduce the need for invasive mechanical ventilation (moderate certainty). There was a large desirable treatment effect of corticosteroid use for patients with severe CAP with less magnitude of benefit in less severe CAP. Severe CAP was defined differently between RCTs, see paper for variable definitions of severe CAP.
Takeaway Points:
Sepsis/Septic shock: In the ED, consider administering corticosteroids to patients with septic shock on vasopressors regardless of pressor dose.
ARDS: In the ED, consider administering corticosteroids to patients with severe pneumonia or sepsis, however ARDS from other causes may not benefit from steroids.
CAP: If the patient has severe pneumonia, is hypoxic, or will be admitted to the ICU, consider administering corticosteroids. (The Cook County ICU team recommends giving 50mg q6h.)
Authored by Taylor Wahrenbrock, MD and Kathryn McGregor, MD, and Eric Leser, MD.
References and Further Reading Suggestions from ICU Colleagues:
Chaudhuri D, Nei AM, Rochwerg B, et al. 2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia. Crit Care Med. 2024;52(5):e219-e233. doi:10.1097/CCM.0000000000006172
CAPE COD Trial for CAP: Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in Severe Community-Acquired Pneumonia. N Engl J Med. 2023;388(21):1931-1941. doi:10.1056/NEJMoa2215145
Inclusion criteria for Severe CAP : "The severity of pneumonia was defined by the presence of at least one of four criteria: the initiation of mechanical ventilation (invasive or noninvasive) with a positive end-expiratory pressure level of at least 5 cm of water; the initiation of the administration of oxygen through a high-flow nasal cannula with a ratio of the partial pressure of arterial oxygen to the inspired fraction of oxygen (Pao2:Fio2) of less than 300, with a Fio2 of 50% or more; for patients wearing a nonrebreathing mask, an estimated Pao2:Fio2 ratio of less than 300, according to prespecified charts; or a score of more than 130 on the Pulmonary Severity Index, which classifies patients with community-acquired pneumonia into five groups according to increasing severity, with a score of more than 130 defining group V, which is associated with the highest mortality."
APROCCHSS Trial for Septic Shock: Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med. 2018;378(9):809-818. doi:10.1056/NEJMoa1705716
ADRENAL Trail for Septic Shock: Venkatesh B, Finfer S, Cohen J, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med. 2018;378(9):797-808. doi:10.1056/NEJMoa1705835
In this trial, the researchers gave hydrocortisone at a dose of 200 mg IV per day. Our ICU gives 50 mg q6h IV for the same dose.
Do not give steroids for HAP.