Corticosteroids as adjunctive treatment in community-acquired pneumonia

Community-acquired Pneumonia (CAP) is the first leading infectious cause of death in developed countries. The mortality rate in severe CAP is very high and has not changed in recent years, despite advances in antimicrobial therapy and supportive measures. Several studies have identified an excessive host inflammatory response as a marker of poor prognosis in CAP. Corticosteroids are anti-inflammatory and immunosupressive agents widely used in modern medicine. Chronic use of corticosteroids has been related to immunosuppression and higher incidence of pneumonia due to opportunistic and high resistant bacteria. However, the use of corticosteroids as adjunctive therapy in CAP may be beneficial due to their anti-inflammatory effect. Experimental pneumonia studies showed that corticosteroid administration was associated with a reduction in circulating and pulmonary cytokine levels, an improvement in histopathological severity scores and a decreased bacterial burden. Several randomized controlled trials (RCT) testing the usefulness of corticosteroids in CAP have been performed in the recent years with conflicting results. However, two recent meta-analyses found improved mortality in the subgroup with severe CAP and/or receiving >5 days of glucocorticoid treatment. Dosage, duration of treatment and side effects are two important aspects not well determined yet. This review discusses the association of corticosteroids as adjunctive therapy and its association with clinical outcomes and side effects in patients with CAP.