Studies evaluating corticosteroids as adjunctive therapy for community-acquired pneumonia (CAP) have produced mixed results, leaving clinicians uncertain about their role in routine practice. Steroids theoretically improve pneumonia outcomes by modulating the immune response and reducing inflammation, which can contribute to lung injury and organ failure in severe cases. However, clinical trials have yielded inconsistent findings, with some studies showing mortality benefits while others demonstrate no advantage or even potential harm. This variability has complicated efforts to establish clear guidelines for steroid use in CAP, particularly as study populations, disease severity, and treatment settings have varied widely across trials.

To help close the knowledge gap, researchers conducted the SONIA trial, a pragmatic, open-label, randomized, controlled trial enrolling 2,180 adult patients hospitalized with CAP across 18 public hospitals in Kenya. Notably, these facilities have limited or no access to intensive care units, and patients often present later in their disease course. Participants were randomized to receive either standard care alone or standard care plus low-dose oral glucocorticoids (dexamethasone 6 mg, hydrocortisone 160 mg, methylprednisolone 30 mg, prednisolone 50 mg, or prednisone 50 mg daily) for 10 days. The primary outcome was death from any cause at 30 days after enrollment. At the end of the trial, mortality was 22.6% in the glucocorticoid group compared with 26.0% in the standard-care group (hazard ratio, 0.84; 95% confidence interval, 0.73 to 0.97; P=0.02). These results support the 2023 CAPE COD trial (N=800), which showed reduced mortality with IV hydrocortisone in ICU patients with CAP (6.2% vs 11.9% at 28 days, P=0.006).

While steroids appear to be beneficial in severe CAP, their effects in milder disease are unproven. The Infectious Diseases Society of America (IDSA) recommends against their routine use in all pneumonia cases, citing insufficient evidence of benefit in non-severe cases and concerns about potential adverse effects, including hyperglycemia, gastrointestinal bleeding, and secondary infections. Current evidence suggests that if steroids are to be used, they should be reserved for patients with severe CAP requiring ICU-level care, where the inflammatory response is most pronounced, and the potential benefit outweighs the risks. For patients with mild to moderate CAP managed in outpatient or general ward settings, routine corticosteroid use is not supported by current evidence and should be avoided.

• SONIA study - Steroids vs Usual Care for CAP in a Low-Resource Setting, NEJM (2025)
• CAPE COD study - Hydrocortisone in Severe Community-Acquired Pneumonia, NEJM (2023)
• Pneumonia review