Pneumonia led to more than 1 million emergency department visits in the United States in 2022, and mortality from pneumonia remains high at approximately 12.2 deaths per 100,000 people.1 Community-acquired pneumonia (CAP) in particular is categorized into severe or nonsevere based on the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) CAP severity criteria.2 The role of using steroids in CAP treatment has been debated for a long time.
Most notably, in the early 2010s, randomized controlled trials did not show improved outcomes in patients with nonsevere CAP.3–4 However, there were encouraging signs to support the use of steroids in patients with severe CAP.4 A few years later, a large randomized controlled trial showed faster recovery in patients with CAP who received seven days of prednisone without a true mortality benefit.5 A subsequent large meta-analysis showed improved morbidity and mortality in severe CAP with a number needed to treat of only 18 patients.6 This same meta-analysis also demonstrated improved morbidity but not mortality in nonsevere CAP cases.6 Fast-forward to 2023, when the CAPE COD trial demonstrated improved mortality in patients admitted to the ICU with severe pneumonia who received hydrocortisone within 24 hours of admission.7
Today, steroids are being increasingly administered in ICUs in patients with severe pneumonia—an approach that would have seemed unlikely just a few years ago. However, the question remains of whether there is any role for following the same (or at least a similar) strategy in less severe cases of pneumonia. Could a practice like this potentially prevent worsening pneumonias and improve morbidity and mortality?
A recently published randomized trial (SONIA) in The New England Journal of Medicine evaluated the role of adjunctive corticosteroids in CAP and demonstrated a reduction in 30-day mortality among patients treated with a 10-day course of low-dose oral steroids.8 Notably, the majority of enrolled patients were not critically ill and did not require ICU-level care, suggesting applicability to nonsevere CAP.
While these findings are compelling, they should be interpreted with caution. The study population differs from those typically encountered in higher-resource settings, and the trial was conducted in an environment with limited access to intensive care. As such, additional studies are needed before broadly recommending corticosteroids for patients with nonsevere CAP. It is also important to mention that the IDSA/ATS 2019 clinical practice guideline recommends against using steroids in nonsevere CAP.2 Per the guidelines, this is a strong recommendation based on a high quality of evidence.2
Finally, it is crucial to highlight that steroids will need to be used with caution in viral pneumonias (with the notable exception of severe COVID-19 pneumonias) owing to the possible increased risk of secondary infections and mortality.9–10 Another important consideration is the potential harm of corticosteroids in fungal pneumonias, where their use has been associated with dissemination and worse clinical outcomes. A notable exception is moderate to severe Pneumocystis jirovecii pneumonia in patients with advanced HIV infection, where adjunctive corticosteroids improve outcomes.11
Given these risks, careful patient selection remains essential. While emerging data suggest a potential expanding role for corticosteroids in CAP, particularly in severe disease, it remains uncertain whether this approach should extend to nonsevere or outpatient settings. More evidence is needed before considering routine use alongside standard antibiotic therapy.
References
1. Centers for Disease Control and Prevention. FastStats: pneumonia. National Center for Health Statistics. Reviewed February 20, 2026.
2. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. doi:10.1164/rccm.201908-1581ST
3. Snijders D, Daniels JM, de Graaff CS, et al. Efficacy of corticosteroids in community-acquired pneumonia: a randomized double-blinded clinical trial. Am J Respir Crit Care Med. 2010;181(9):975-82. doi:10.1164/rccm.200905-0808OC
4. Fernández-Serrano S, Dorca J, Garcia-Vidal C, et al. Effect of corticosteroids on the clinical course of community-acquired pneumonia: a randomized controlled trial. Crit Care. 2011;15(2):R96. doi:10.1186/cc10103
5. Blum C, Nigro N, Briel M, et al. Adjunct prednisone therapy for patients with community-acquired pneumonia: a multicenter, double-blind, randomized, placebo-controlled trial. Lancet. 2015;385(9977):1511-1518. doi:10.1016/S0140-6736(14)62447-8
6. Stern A, Skalsky K, Avni T, et al. Corticosteroids for pneumonia. Cochrane Database Syst Rev. 2017;12(12):CD007720. doi:10.1002/14651858.CD007720.pub3
7. Dequin PF, Meziani F, Quenot JP, et al; CRICS-TriGGERSep Network. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med. 2023;388(21):1931-1941. doi:10.1056/NEJMoa2215145
8. Lucinde RK, Gathuri H, Mwaniki P, et al. A pragmatic trial of glucocorticoids for community-acquired pneumonia. N Engl J Med. 2025;393(22):2187-2197. doi:10.1056/NEJMoa2507100
9. Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. 2021;384(8):693-704. doi:10.1056/NEJMoa2021436
10. Lansbury LE, Rodrigo C, Leonardi-Bee J, et al. Corticosteroids as adjunctive therapy in the treatment of influenza: an updated cochrane systematic review and meta-analysis. Crit Care Med. 2020;48(2):e98-e106. doi:10.1097/CCM.0000000000004093
11. Bozzette SA, Sattler FR, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group. N Engl J Med. 1990;323(21):1451-1457. doi:10.1056/NEJM199011223232104
