Systemic Corticosteroids, Mortality, and Infections in Pneumonia and Acute Respiratory Distress Syndrome : A Systematic Review and Meta-analysis.

Summary

Across 20 RCTs (n=3459), adjunct systemic corticosteroids—particularly low-dose, short-course regimens—probably reduce short-term mortality in severe non-COVID pneumonia and ARDS, with little to no increase in hospital-acquired infections. In severe pneumonia, secondary shock may also be reduced.

Key Findings

• Across 20 RCTs (n=3459), systemic corticosteroids probably reduce short-term mortality in severe pneumonia (RR 0.73, 95% CI 0.57–0.93).
• Adjunct steroids in severe pneumonia may reduce secondary shock.
• Corticosteroids likely have little or no effect on hospital-acquired infections in severe pneumonia and ARDS.

Clinical Implications

Consider adjunct low-dose, short-course systemic corticosteroids in adults with severe community-acquired pneumonia and ARDS, with monitoring for hyperglycemia and secondary infections.

Limitations

• Pneumonia severity classifications and steroid regimens were heterogeneous, limiting subgroup precision and dose-response inference.
• Limited number and size of ARDS trials reduces certainty for ARDS-specific effects.

Future Directions

Head-to-head trials to define optimal dosing/timing across ARDS phenotypes and severe pneumonia subgroups; standardized severity criteria to refine treatment effect estimates.