AS A CLINICAL PHARMACIST, you'll see more push to use steroids for patients hospitalized with community-acquired pneumonia (CAP). The thought is that inflammation in the lungs causes a lot of pneumonia symptoms. We've heard about this controversial topic for a while. Some small trials show a benefit, while others do not. To date, guidelines still don't recommend their use. But new evidence suggests hospitalized patients with CAP who get prednisone 50 mg daily for seven days are stable about 1.5 days sooner and can switch to PO antibiotics a day earlier. Plus patients may be able to be discharged one day sooner.
Consider using steroids for immunocompetent floor patients. But be aware that there's not enough evidence yet to use steroids in pneumonia patients treated in the community or in the ICU. Suggest giving adjunctive steroids for patients with CAP who have evidence of an exaggerated or dysregulated host inflammatory response, defined as sepsis or respiratory failure with an FiO2 requirement of > 50 percent PLUS one or more of the following features: (1) Metabolic acidosis with an arterial pH of < 7.3, (2) Lactate > 4 mmol/L, (3) C-reactive protein > 150 mg/L.
When using adjunctive steroids, treat for five days. For patients who are UNable to take oral medications, suggest use methylprednisolone 0.5 mg/kg IV every 12 hours. For patients who can take oral medications, suggest use prednisone 50 mg orally daily.
Avoid steroids in patients with CAP known to be caused by a viral pathogen such as influenza or a fungal pathogen such as Aspergillus. Continue to use calculators such as the Pneumonia Severity Index to help determine whether patients require hospital admission and whether they should go to the floor or the ICU. Make sure patients are monitored appropriately. One in 13 hospitalized patients on steroids may need corrective insulin for high blood glucose. Most patients won't be in the hospital for seven days, so keep in mind to give an Rx to complete the steroid course.
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