Corticosteroids for community-acquired pneumonia in non-ICU patients presenting to the emergency department: a systematic review and meta-analysis

Hanin A. Alhodathi; Hend M. Hussein; Shamael M. Alali; Zainab A. Hasan; Abdullah M. Al. Hussain; Almohanad A. Sait; Hassan A. Alali; Janah M. Almahdi; Jawad A. Alomaishi; Elaf S. Alzahrani; Abdullah Y. A. Alharbi; Alaa A. Alsaegh

doi:10.18203/2394-6040.ijcmph20263221

Authors

Hanin A. Alhodathi Suliman Alrajhi University, Saudi Arabia https://orcid.org/0009-0009-4540-3966
Hend M. Hussein Department of Basic Science, Al -Rayan National College of Medicine, Al-Rayan National Colleges, Al Madinah Al Munawwarah, Saudi Arabia https://orcid.org/0009-0008-8766-6695
Shamael M. Alali Al -Rayan National College of Medicine, Al-Rayan National Colleges, Al Madinah Al Munawwarah, Saudi Arabia https://orcid.org/0009-0007-4902-9065
Zainab A. Hasan Ain Shams University, Cairo, Egypt https://orcid.org/0009-0000-5934-1713
Abdullah M. Al. Hussain mam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Almohanad A. Sait King Abdulaziz University, Jeddah, Saudi Arabia https://orcid.org/0009-0007-2497-5522
Hassan A. Alali King Faisal University, Al Ahsa, Saudi Arabia
Janah M. Almahdi Alexandria University, Alexandria, Egypt https://orcid.org/0009-0000-5612-8941
Jawad A. Alomaishi King Faisal University, Al Ahsa, Saudi Arabia https://orcid.org/0009-0005-8616-7091
Elaf S. Alzahrani King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia https://orcid.org/0009-0005-0077-0966
Abdullah Y. A. Alharbi University of Jeddah, Jeddah, Saudi Arabia https://orcid.org/0009-0000-6521-0410
Alaa A. Alsaegh King Abdulaziz University, Jeddah, Saudi Arabia

DOI:

https://doi.org/10.18203/2394-6040.ijcmph20263221

Keywords:

Community-acquired pneumonia, Corticosteroids, Emergency department, Systematic review and meta-analysis, Clinical outcomes

Abstract

Community-acquired pneumonia (CAP) is among the most common infectious indications for emergency department attendance and hospitalization and carries a heavy mortality burden despite advances in antimicrobial therapy. Because a dysregulated host inflammatory response independently drives clinical deterioration, corticosteroids have been proposed as adjunctive treatment, but their benefit in non-ICU patients presenting to the emergency department remains unclear. A systematic search of PubMed, Web of Science, and EMBASE was conducted to identify randomized controlled trials evaluating systemic corticosteroids versus placebo or standard care in adults with CAP managed outside the ICU. The primary outcome was all-cause mortality; secondary outcomes included time to clinical stability, length of hospital stays, ICU admission, and adverse events. Twelve RCTs were included. Pooled analysis showed no significant difference in mortality between the corticosteroid and control groups (RR=0.98, 95% CI: 0.87–1.10, p=0.71; I²=0%). Neither time to clinical stability nor length of hospital stay differed significantly between groups, though both outcomes showed substantial heterogeneity. Corticosteroid use was associated with a significantly higher risk of hospital readmission (RR=1.35, 95% CI: 1.11–1.64, p<0.001) and hyperglycemia (RR=1.69, 95% CI: 1.49–1.92, p<0.001). Early corticosteroid therapy in non-ICU adults with CAP does not reduce mortality or meaningfully accelerate clinical recovery, while consistently increasing the risks of hyperglycemia and hospital readmission. Routine use in this population cannot be recommended on current evidence, and future trials should incorporate biomarker-guided designs to identify inflammatory phenotypes most likely to benefit from corticosteroid therapy.

Author Biographies

Abdullah M. Al. Hussain, mam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Hassan A. Alali, King Faisal University, Al Ahsa, Saudi Arabia

Janah M. Almahdi, Alexandria University, Alexandria, Egypt

References

Wunderink RG, Waterer GW. Community-acquired pneumonia. N Engl J Med. 2014;370:543-51.

Corrales-Medina VF, Musher DM, Shachkina S, Chirinos JA. Acute pneumonia and the cardiovascular system. Lancet. 2013;381:496-505.

Confalonieri M, Urbino R, Potena A, Piattella M, Parigi P, Puccio G. Hydrocortisone infusion for severe community-acquired pneumonia: A preliminary randomized study. Am J Respir Crit Care Med. 2005;171:242-8.

Stern A, Skalsky K, Avni T, Leventhal E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017;12:CD007720.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.

Dequin PF, Meziani F, Quenot JP, Clere-Jehl R, Kamel T, Resiere D. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388:1931-41.

Briel M, Spoorenberg SMC, Snijders D, Torres A, Fernández-Serrano S, Meduri GU. Corticosteroids in patients hospitalized with community-acquired pneumonia: Systematic review and individual patient data metaanalysis. Clin Infect Dis. 2018;66:346-54.

Lucinde RK, Gathuri H, Mwaniki P, Orindi B, Otieno EO, Mwakio S. A pragmatic trial of glucocorticoids for community-acquired pneumonia. N Engl J Med. 2025;393:2187-97.

Lloyd M, Karahalios A, Janus E, Skinner EH, Haines T, De Silva A. Effectiveness of a bundled intervention including adjunctive corticosteroids on outcomes of hospitalized patients with community-acquired pneumonia: A stepped-wedge randomized clinical trial. JAMA Intern Med. 2019;179:1052-60.

Wittermans E, Vestjens SMT, Spoorenberg SMC, Blok WL, Grutters JC, Janssen R. Adjunctive treatment with oral dexamethasone in non-ICU patients hospitalised with community-acquired pneumonia: A randomised clinical trial. Eur Respir J. 2021;58:2002535.

Blum CA, Nigro N, Briel M, Schuetz P, Ullmer E, Suter-Widmer I. Adjunct prednisone therapy for patients with community-acquired pneumonia: A multicentre, double-blind, randomised, placebo-controlled trial. Lancet. 2015;385:1511-8.

Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: A systematic review and meta-analysis. Ann Intern Med. 2015;163:519-28.

Popovic M, Blum CA, Nigro N, Mueller B, Schuetz P, Christ-Crain M. Benefit of adjunct corticosteroids for community-acquired pneumonia in diabetic patients. Diabetologia. 2016;59:2552-60.

Snijders D, Daniels JM, de Graaff CS, van der Werf TS, Boersma WG: Efficacy of corticosteroids in community-acquired pneumonia: A randomized double-blinded clinical trial. Am J Respir Crit Care Med. 2010;181:975-82.

Blum CA, Roethlisberger EA, Cesana-Nigro N, Winzeler B, Rodondi N, Blum MR. Adjunct prednisone in community-acquired pneumonia: 180-day outcome of a multicentre, double-blind, randomized, placebo-controlled trial. BMC Pulm Med. 2023;23:500.

Torres A, Sibila O, Ferrer M, Polverino E, Menendez R, Mensa J. Effect of corticosteroids on treatment failure among hospitalized patients with severe community-acquired pneumonia and high inflammatory response: A randomized clinical trial. JAMA. 2015;313:677-86.

Wirz SA, Blum CA, Schuetz P, Albrich WC, Akpinar F, Felder L. Pathogen- and antibiotic-specific effects of prednisone in community-acquired pneumonia. Eur Respir J. 2016;48:1680-90.