Meta-Analysis

. 2025 May;51(5):917-929.

doi: 10.1007/s00134-025-07912-2. Epub 2025 May 5.

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

Tyler Pitre^#¹, Ellen Pauley^#^{2

3}, Dipayan Chaudhuri¹, Rohit Saha^{4

5}, Kristina E Rudd⁶, Jesús Villar^{7

8

9

10}, Lindsay R Berry¹¹, Elizabeth Lorenzi¹², Thomas Hills^{13

14}, Alistair Nichol^{15

16}, David A Harrison¹⁷, Simon Finfer^{18

19}, Jeremy Cohen²⁰, John Myburgh^{21

22

23}, Naomi Hammond^{24

25}, Domingo Martínez⁷, Cristina Fernández⁷, David Antcliffe²⁶, Anthony Gordon²⁶, André Scherag²⁷, Holger Bogatsch²⁸, Frank M Brunkhorst²⁹, Balasubramanian Venkatesh^{18

30}, Djillali Annane³¹, Danny McAuley^{2

3}, Derek C Angus⁶, Bram Rochwerg^#³², Manu Shankar-Hari^#³³

Affiliations

¹ Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
² Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
³ The Prince Charles Hospital, Rode Road, Chermside, Brisbane, Australia.
⁴ Critical Care Centre, King's College London, London, UK.
⁵ School of Immunology and Microbial Sciences, King's College London, London, UK.
⁶ Center for Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
⁷ CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
⁸ Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
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.
¹⁰ Universidad del Atlántico Medio (UNAM), Tafira Baja, Las Palmas, Spain.
¹¹ Berry Consultants LLC, Austin, USA.
¹² Berry Consultants, Austin, USA.
¹³ Department of Infectious Diseases, Te Whatu Ora Auckland, Auckland, New Zealand.
¹⁴ Medical Research Institute of New Zealand, Wellington, New Zealand.
¹⁵ University College Dublin Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland.
¹⁶ The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
¹⁷ Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK.
¹⁸ The George Institute for Global Health, University of New South Wales, Sydney, Australia.
¹⁹ School of Public Health, Faculty of Medicine, Imperial College London, London, England.
²⁰ The George Institute for Global Health, The Wesley Hospital, Brisbane, and The University of Queensland, Brisbane, Australia.
²¹ The George Institute for Global Health, Sydney, Australia.
²² Faculty of Medicine, University of New South Wales, Sydney, Australia.
²³ Intensive Care Unit, St George Hospital, Kogarah, Australia.
²⁴ Critical Care Program, Northern Sydney Local Health District, NHMRC Emerging Leader Fellow, Faculty of Medicine, UNSW Sydney, Sydney, Australia.
²⁵ Intensive Care National Audit and Research Centre (ICNARC), London, UK.
²⁶ Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK.
²⁷ Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany.
²⁸ Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany.
²⁹ Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
³⁰ Gold Coast University Hospital, Southport, Australia.
³¹ 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.
³² Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada. rochwerg@mcmaster.ca.
³³ Centre for Inflammation Research, Institute for Repair and Regeneration, Edinburgh, UK. manu.shankar-hari@ed.ac.uk.

^# Contributed equally.

PMID: 40323455
DOI: 10.1007/s00134-025-07912-2

Meta-Analysis

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

Tyler Pitre et al. Intensive Care Med. 2025 May.

. 2025 May;51(5):917-929.

doi: 10.1007/s00134-025-07912-2. Epub 2025 May 5.

Authors

Affiliations

¹ Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
² Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
³ The Prince Charles Hospital, Rode Road, Chermside, Brisbane, Australia.
⁴ Critical Care Centre, King's College London, London, UK.
⁵ School of Immunology and Microbial Sciences, King's College London, London, UK.
⁶ Center for Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
⁷ CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
⁸ Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
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.
¹⁰ Universidad del Atlántico Medio (UNAM), Tafira Baja, Las Palmas, Spain.
¹¹ Berry Consultants LLC, Austin, USA.
¹² Berry Consultants, Austin, USA.
¹³ Department of Infectious Diseases, Te Whatu Ora Auckland, Auckland, New Zealand.
¹⁴ Medical Research Institute of New Zealand, Wellington, New Zealand.
¹⁵ University College Dublin Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland.
¹⁶ The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
¹⁷ Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK.
¹⁸ The George Institute for Global Health, University of New South Wales, Sydney, Australia.
¹⁹ School of Public Health, Faculty of Medicine, Imperial College London, London, England.
²⁰ The George Institute for Global Health, The Wesley Hospital, Brisbane, and The University of Queensland, Brisbane, Australia.
²¹ The George Institute for Global Health, Sydney, Australia.
²² Faculty of Medicine, University of New South Wales, Sydney, Australia.
²³ Intensive Care Unit, St George Hospital, Kogarah, Australia.
²⁴ Critical Care Program, Northern Sydney Local Health District, NHMRC Emerging Leader Fellow, Faculty of Medicine, UNSW Sydney, Sydney, Australia.
²⁵ Intensive Care National Audit and Research Centre (ICNARC), London, UK.
²⁶ Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK.
²⁷ Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital-Friedrich Schiller University Jena, Jena, Germany.
²⁸ Institute for Medical Informatics, Statistics and Epidemiology (IMISE) and Clinical Trial Centre Leipzig, Leipzig, Germany.
²⁹ Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
³⁰ Gold Coast University Hospital, Southport, Australia.
³¹ 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.
³² Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada. rochwerg@mcmaster.ca.
³³ Centre for Inflammation Research, Institute for Repair and Regeneration, Edinburgh, UK. manu.shankar-hari@ed.ac.uk.

^# Contributed equally.

PMID: 40323455
DOI: 10.1007/s00134-025-07912-2

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.

Keywords: Community-acquired pneumonia; Corticosteroid; Meta-analysis; Mortality; Randomised controlled trial; Systematic review.

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Conflict of interest statement

Declarations. 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.

References

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

Affiliations

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

Authors

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Abstract

Conflict of interest statement

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