Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain
among the most frequent complications in critically ill patients. Despite the implementation
of modern preventive strategies and the widespread use of broad-spectrum antibiotics,
both the incidence and treatment failure rates remain high. However, no adjunctive
therapy is currently recommended. Glucocorticoids have recently attracted renewed
interest as potential immunomodulatory agents in this setting. By reducing excessive
inflammation and promoting the resolution of the immune response, they may help limit
lung injury and improve clinical outcomes. This hypothesis is supported by findings
from related conditions such as community-acquired pneumonia, acute respiratory distress
syndrome, and severe COVID-19, where corticosteroids have demonstrated benefits in
selected populations. However, evidence specific to HAP and VAP remains limited. A
few randomized trials have evaluated corticosteroids for prevention, particularly
in trauma patients, where findings suggest a potential benefit and highlight the relevance
of this strategy in select populations. More recently, individualized approaches based
on inflammatory biomarkers have shown promise in identifying patients who are more
likely to benefit from corticosteroid therapy. Two randomized controlled trials, currently
ongoing to evaluate their role as adjunctive treatment in established HAP and VAP,
will help define the efficacy and tolerance of steroids. Given the heterogeneity of
immune responses in critically ill patients, a “one-size-fits-all” approach is unlikely
to be effective. Identifying inflammatory sub-phenotypes using clinical and biological
markers (such as C-reactive protein or interleukin-6) may help guide a more personalized
use of immunomodulatory therapies. Alterations in the lung microbiome could also influence
host response and treatment efficacy. Altogether, corticosteroids represent a promising
but still understudied adjunctive strategy for HAP and VAP. Future research should
aim to refine patient selection and optimize treatment strategies within a precision
medicine framework.
Keywords
pneumonia - steroids - immunity
