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Corticosteroids for adult patients hospitalised with non-viral community-acquired pneumonia: a systematic review and meta-analysis

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Abstract

Purpose

International clinical practice guidelines addressing corticosteroid treatment for patients hospitalised with non-viral community-acquired pneumonia (CAP) are inconsistent.

Methods

We conducted a systematic review of randomized controlled trials (RCTs) evaluating the use of corticosteroids in hospitalised adult patients with suspected or probable CAP. We performed random effects pairwise, Bayesian, and dose–response meta-analyses using the restricted maximum likelihood (REML) heterogeneity estimator. We assessed certainty of evidence using GRADE methodology.

Results

We identified 30 eligible RCTs, including a total of 7519 patients. The prednisone-equivalent doses ranged between 29 mg/day and 100 mg/day. Corticosteroids probably reduced short-term (28–30 days) mortality (RR 0.82 [95% CI 0.74–0.91]; moderate certainty) while the reduction in longer term (60–90 day) mortality is less certain (RR 0.89 [95% CI 0.76–1.03]; low certainty). Corticosteroids reduced the need for invasive mechanical ventilation (IMV) (RR 0.63 [95% CI 0.48–0.82]; high certainty) and may reduce duration of ICU stay (MD 1.53 days fewer [95% CI 0.31–2.75 days fewer]; low certainty), and hospital stay (MD 2.30 days fewer [95% CI 0.81–3.81 days fewer]; low certainty). Corticosteroids probably increased hyperglycaemia requiring intervention (RR 1.32 [95% CI 1.12–1.56]; moderate certainty) but probably have no effect on secondary infections (RR 0.97 [95% CI 0.85–1.11]; moderate certainty).

Conclusion

Corticosteroids probably reduced short-term mortality and reduce the need for invasive mechanical ventilation in hospitalised patients with CAP.

PROSPERO registration number

CRD42024521536.

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Author information

Author notes

  1. Tyler Pitre and Ellen Pauley have contributed equally to this work.

  2. Bram Rochwerg and Manu Shankar-Hari share joint senior authorship.

Authors and Affiliations

  1. Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada

    Tyler Pitre & Dipayan Chaudhuri

  2. Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, UK

    Ellen Pauley & Danny McAuley

  3. The Prince Charles Hospital, Rode Road, Chermside, Brisbane, Australia

    Ellen Pauley & Danny McAuley

  4. Critical Care Centre, King’s College London, London, UK

    Rohit Saha

  5. School of Immunology and Microbial Sciences, King’s College London, London, UK

    Rohit Saha

  6. Center for Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA

    Kristina E. Rudd & Derek C. Angus

  7. CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain

    Jesús Villar, Domingo Martínez & Cristina Fernández

  8. Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Canada

    Jesús Villar

  9. Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit at Hospital Universitario Dr. Negrín, Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Las Palmas, Spain

    Jesús Villar

  10. Universidad del Atlántico Medio (UNAM), Tafira Baja, Las Palmas, Spain

    Jesús Villar

  11. Berry Consultants LLC, Austin, USA

    Lindsay R. Berry

  12. Berry Consultants, Austin, USA

    Elizabeth Lorenzi

  13. Department of Infectious Diseases, Te Whatu Ora Auckland, Auckland, New Zealand

    Thomas Hills

  14. Medical Research Institute of New Zealand, Wellington, New Zealand

    Thomas Hills

  15. University College Dublin Clinical Research Centre at St Vincent’s University Hospital, Dublin, Ireland

    Alistair Nichol

  16. The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia

    Alistair Nichol

  17. Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK

    David A. Harrison

  18. The George Institute for Global Health, University of New South Wales, Sydney, Australia

    Simon Finfer & Balasubramanian Venkatesh

  19. School of Public Health, Faculty of Medicine, Imperial College London, London, England

    Simon Finfer

  20. The George Institute for Global Health, The Wesley Hospital, Brisbane, and The University of Queensland, Brisbane, Australia

    Jeremy Cohen

  21. Critical Care Program, Northern Sydney Local Health District, NHMRC Emerging Leader Fellow, Faculty of Medicine, UNSW Sydney, Sydney, Australia

    Naomi Hammond

  22. Intensive Care National Audit and Research Centre (ICNARC), London, UK

    Naomi Hammond

  23. Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK

    David Antcliffe & Anthony Gordon

  24. Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany

    André Scherag

  25. Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany

    Holger Bogatsch

  26. Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany

    Frank M. Brunkhorst

  27. Gold Coast University Hospital, Southport, Australia

    Balasubramanian Venkatesh

  28. IHU PROMETHEUS, Comprehensive Sepsis Centre, General Intensive Care Unit, Raymond Poincaré Hospital (APHP); School of Medicine Simone Veil, University Versailles, University Paris Saclay, Paris, France

    Djillali Annane

  29. Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada

    Bram Rochwerg

  30. Centre for Inflammation Research, Institute for Repair and Regeneration, Edinburgh, UK

    Manu Shankar-Hari

  31. The George Institute for Global Health, Sydney, Australia

    John Myburgh

  32. Faculty of Medicine, University of New South Wales, Sydney, Australia

    John Myburgh

  33. Intensive Care Unit, St George Hospital, Kogarah, Australia

    John Myburgh

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  1. Tyler Pitre
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  2. Ellen Pauley
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Corresponding authors

Correspondence to Bram Rochwerg or Manu Shankar-Hari.

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Conflicts of interest

Anthony C. Gordon reports NIHR Health Technology Assessment and Imperial BRC grants to his institution,consultancy payments from AstraZeneca, Beckman Coulter and VVB Bio, a Fresenius Kabi speaker fee, and a leadership role with the NIHR National Research Collaboration Programme (institutional payments) . David A. Harrison declares institutional research grants from the UK NIHR (REMAP-CAP) and the EU ECRAID-Base consortium .Balasubramanian Venkatesh holds an NHMRC Investigator Fellowship and institutional grants from Baxter and Endpoint Health . Jeremy Cohen is chief investigator on an MRFF grant (funds to UNSW) and is Treasurer of the College of Intensive Care Medicine (unpaid) . Lindsay Berry is an employee of Berry Consultants, specialising in adaptive and platform trial statistics . David Antcliffe reports NIHR EME and DSE awards paid to his institution . Kevin Gibbs receives NIH, PCORI and US DoD grants (institutional), travel support to Critical Care Reviews 2024 and serves on a Vanderbilt DSMB . Naomi Hammond holds an NHMRC Emerging Leadership grant and consultancy fees from Revimmune Inc. to her institution . Thomas E. Hills has project-specific funding from the Health Research Council of New Zealand and Te Niwha Infectious Diseases Research Platform . Kristina E. Rudd is supported by an NIH/NIGMS K23 award . Djillali Annane receives institutional grants from the Agence Nationale de la Recherche, French Ministry of Health and Plan d’Investissement d’Avenir . John A. Myburgh holds an NHMRC Leadership Fellowship . Daniel F.McAuley lists multiple investigator-initiated institutional grants from NIHR, Innovate UK, MRC, Wellcome Trust and others, plus an industry-sponsored Novavax study . Jesús Villar receives competitive research funding from Instituto de Salud Carlos III and European programmes for ARDS projects . Bram Rochwerg acknowledges NIHR grant support to his institution for REMAP-CAP . All remaining authors—Dipayan Chaudhuri, Domingo Martínez Baño, Holger Bogatsch, Frank M. Brunkhorst, Tyler Pitre, André Scherag, Rohit Saha, Winnie Liu, Ellen Pauley and Alistair Nichol—declare no competing interests.

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Pitre, T., Pauley, E., Chaudhuri, D. et al. Corticosteroids for adult patients hospitalised with non-viral community-acquired pneumonia: a systematic review and meta-analysis. Intensive Care Med 51, 917–929 (2025). https://doi.org/10.1007/s00134-025-07912-2

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