Fujishima Seitaro
Center for Preventive Medicine, Keio University School of Medicine, 1-3-1 Azabudai, Minato-ku, Tokyo, 106-0041, Japan.
J Intensive Care. 2025 Jul 1;13(1):37. doi: 10.1186/s40560-025-00809-8.
Despite advances in treatment and the expansion of standard care, pneumonia remains a major cause of mortality. It frequently leads to complications such as septic shock and acute respiratory distress syndrome (ARDS), both of which carry high fatality rates. Although antimicrobial therapy is the cornerstone of treatment, additional supportive care and adjunctive therapies, such as corticosteroids, are often required, especially in severe community-acquired pneumonia (CAP).Recent updates to major guidelines on CAP, sepsis, ARDS, and critical illness-related corticosteroid insufficiency generally support corticosteroid use in severe CAP. However, the REMAP-CAP randomized controlled trial, published in 2025, failed to demonstrate significant benefit, potentially influencing future recommendations. Currently, corticosteroid therapy should be individualized based on CAP severity, particularly the degree of hypoxemia and respiratory failure. In eligible patients, early initiation and flexible duration of corticosteroid use based on clinical response may be appropriate. For nonbacterial pneumonia, strong evidence supporting corticosteroid use exists only for COVID-19 and Pneumocystis jirovecii pneumonia in HIV-infected individuals. Conversely, observational data do not support corticosteroid use for influenza or fungal infections. In CAP complicated by septic shock or ARDS, corticosteroid use is endorsed by recent guidelines; however, the recommended timing, dosage, and duration vary. Although combination therapy with hydrocortisone and fludrocortisone is a potential option, further direct evidence is needed. Biomarkers such as C-reactive protein and, in the near future, insights into corticosteroid-related immune repair mechanisms in COVID-19 may aid in identifying corticosteroid-responsive phenotypes.
尽管治疗方法有所进步且标准护理有所扩展，但肺炎仍然是主要的死亡原因。它经常导致诸如感染性休克和急性呼吸窘迫综合征（ARDS）等并发症，这两种并发症的死亡率都很高。虽然抗菌治疗是治疗的基石，但通常还需要额外的支持性护理和辅助治疗，如皮质类固醇，尤其是在重症社区获得性肺炎（CAP）中。近期关于CAP、脓毒症、ARDS以及与危重症相关的皮质类固醇功能不全的主要指南更新普遍支持在重症CAP中使用皮质类固醇。然而，2025年发表的REMAP-CAP随机对照试验未能证明其有显著益处，这可能会影响未来的推荐。目前，皮质类固醇治疗应根据CAP的严重程度个体化，特别是低氧血症和呼吸衰竭的程度。对于符合条件的患者，根据临床反应早期开始并灵活确定皮质类固醇的使用疗程可能是合适的。对于非细菌性肺炎，仅在HIV感染个体的新冠肺炎和耶氏肺孢子菌肺炎中存在支持使用皮质类固醇的有力证据。相反，观察数据不支持在流感或真菌感染中使用皮质类固醇。在并发感染性休克或ARDS的CAP中，近期指南认可使用皮质类固醇；然而，推荐的时机、剂量和疗程各不相同。虽然氢化可的松和氟氢可的松联合治疗是一种可能的选择，但还需要进一步的直接证据。生物标志物如C反应蛋白，以及在不久的将来，对新冠肺炎中皮质类固醇相关免疫修复机制的深入了解，可能有助于识别对皮质类固醇有反应的表型。
