BACKGROUND: The benefit-risk profile of systemic corticosteroids in non-COVID-19 pneumonia and acute respiratory distress syndrome (ARDS) remains debated.
PURPOSE: To assess corticosteroid effects on mortality and infection-related complications in adults with severe pneumonia or ARDS.
DATA SOURCES: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform through September 2025.
STUDY SELECTION: Randomized controlled trials comparing systemic corticosteroids with placebo and usual care. Primary analysis: severe pneumonia or ARDS with corticosteroids 3 mg/kg-1 of body weight per day-1 or less (prednisone-equivalent) for 15 days or less, initiated within 7 days.
DATA EXTRACTION: Paired reviewers; consensus for disagreements.
DATA SYNTHESIS: From 16 831 screened records, 20 studies (15 severe pneumonia, 5 ARDS) including 3459 participants met criteria. Low-dose, short-course corticosteroids probably reduce short-term mortality in severe pneumonia (15 studies, 2445 participants; risk ratio [RR], 0.73 [95% CI, 0.57 to 0.93]; I2 = 14%; moderate certainty) and ARDS (5 studies, 1014 participants; RR, 0.77 [CI, 0.61 to 0.99]; I2 = 23%; moderate certainty). Corticosteroids may reduce secondary shock in severe pneumonia (9 studies, 1690 participants; RR, 0.49 [CI, 0.26 to 0.92]; I2 = 55%; low certainty). They probably result in little to no difference in hospital-acquired infections (severe pneumonia: 7 studies, 1665 participants; RR, 0.99 [CI, 0.82 to 1.20]; I2 = 0%; moderate certainty; ARDS: 4 studies, 677 participants; RR, 0.97 [CI, 0.59 to 1.59]; I2 = 0%; low certainty) or secondary pneumonia (severe pneumonia: 4 studies, 1011 participants; RR, 0.96 [CI, 0.66 to 1.39]; I2 = 0%; ARDS: 4 studies, 677 participants; RR, 0.88 [CI, 0.43 to 1.79]; I2 = 0%; both low certainty). Evidence is very uncertain for catheter-related and bloodstream infections. Long-term mortality evidence is very uncertain for severe pneumonia.
LIMITATION: Heterogeneous pneumonia severity classification limiting subgroup precision.
CONCLUSION: In severe pneumonia and ARDS, adjunct corticosteroids probably reduce short-term mortality. In severe pneumonia, they may reduce secondary shock. In both conditions, corticosteroids may have little or no effect on hospital-acquired infections.
PRIMARY FUNDING SOURCE: None. (PROSPERO: CRD42024536301).
| Specialty | Score |
|---|---|
| Hospital Doctor/Hospitalists | |
| Internal Medicine | |
| Infectious Disease | |
| Respirology/Pulmonology | |
| Intensivist/Critical Care |
Old news with the same high level of uncertainty: Which patient population is the best target for benefit? What type of steroid should be used? What is the optimal dose of steroids and for how long?
This very rigorous and comprehensive meta-analysis provides robust underpinning for the new U.S. and European guidelines: adjunctive low-dose, short-course corticosteroids reduce mortality in both severe pneumonia and ARDS, with no increased risk of adverse effects, which strongly supports their adoption in clinical practice.
Well done review but many reviews are already available with the same information.
Steroids are already used in severe pneumonia therapy. This paper has significant variability in pneumonia classification that makes the results difficult to interpret.
This is a useful up-to-date meta-analysis suggesting that short-course low-dose systemic corticosteroids probably reduce short-term mortality in non-COVID severe pneumonia and ARDS with little apparent increase in hospital-acquired infections. Heterogeneity, uncertain long-term harms, and some low-certainty outcomes, however, mean clinicians should apply the results cautiously and researchers should pursue more standardized and longer studies with a subgroup focus.
This systematic review synthesizes a large number of studies with heterogeneous patients and treatments to inform clinicians of the potential benefits (and harms) of corticosteroids in ARDS and severe pneumonia. This is important because studies have not consistently been conclusive, and the long history of corticosteroid trials makes it difficult for clinicians to know the evidence in totality. This makes corticosteroids potentially one of the most underused treatments in these conditions (while potentially being overused in other conditions).
, McMaster University