Adjunctive Corticosteroids and Mortality in Non-HIV Patients with Pneumocystis jirovecii Pneumonia: A Systematic Review and Meta-Analysis

BACKGROUND: The role of adjunctive corticosteroids in non-HIV PJP remains controversial. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing adjunctive corticosteroids plus standard antimicrobial therapy versus standard therapy alone in HIV-negative adults with PJP. We searched PubMed, Embase, Web of Science, and Cochrane Library from inception to December 19, 2025. The primary outcome was all-cause mortality. We performed meta-analyses using random-effects models, subgroup analyses by mortality timing, and sensitivity analyses. RESULTS: Twenty studies (one RCT, 19 observational studies) involving 3,816 patients were included. Among 2,899 patients receiving corticosteroids, 756 died (26.1%), compared to 246 deaths among 917 controls (26.8%). The pooled analysis showed no significant association between adjunctive corticosteroids and all-cause mortality (odds ratio [OR] 1.10, 95% confidence interval [CI]: 0.86-1.41; P = 0.43; I² = 21%). Subgroup analyses for short-term (≤30-day) mortality (OR 1.13, 95% CI: 0.78-1.63) and long-term (>30-day) mortality (OR 1.36, 95% CI: 0.79-2.32) also demonstrated no significant benefit. Results were robust in sensitivity analyses. CONCLUSIONS: Adjunctive corticosteroids were not associated with reduced mortality in non-HIV PJP. However, the overall certainty of evidence was very low. Based on current evidence, routine corticosteroid use is not supported, and these findings should be interpreted with caution. Future high-quality randomized trials are needed.