Efficacy of higher-dose versus lower-dose corticosteroids in community-acquired pneumonia: a systematic review and network meta-analysis

Adjunctive corticosteroids improve outcomes in hospitalized patients with community-acquired pneumonia (CAP), but whether higher-dose regimens provide additional benefit over lower-dose regimens remains uncertain.

We searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) up to January 25, 2026. Interventions were standardized to protocol-assigned dexamethasone-equivalent doses: high (≥ 7.5 mg/d) and low (< 7.5 mg/d). A frequentist network meta-analysis was performed. The primary outcome was short-term all-cause mortality. Confidence in network meta-analysis estimates was assessed using the Confidence in Network Meta-Analysis (CINeMA) framework.

32 RCTs involving 9,746 participants were included. Compared with placebo or usual care, higher-dose corticosteroids were associated with lower short-term mortality (Risk Ratio [RR], 0.83; 95% Confidence Interval [CI], 0.74-0.92), as were lower-dose corticosteroids (RR, 0.84; 95% CI, 0.75-0.95). The indirect comparison showed no clear difference between higher- and lower-dose regimens (RR, 0.98; 95% CI, 0.83-1.16). In severe patients with CAP, the corresponding indirect estimate was RR 1.01 (95% CI, 0.77-1.33). Most secondary active-dose comparisons were imprecise and showed no consistent advantage of either strategy.

Compared with placebo or usual care, lower-dose corticosteroids (moderate confidence) and higher-dose corticosteroids (low confidence) were both associated with lower short-term mortality. The indirect higher-versus-lower dose comparison showed no clear mortality difference between dose categories; confidence in this comparison was low. Future research should prioritize large, head-to-head RCTs designed to evaluate whether selected inflammatory phenotypes benefit from higher-dose corticosteroids.