Glucocorticoid Treatment for Hospital-Acquired and Ventilator-Associated Pneumonia

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.