Biomarker-concordant Steroid use in Hospitalized Patients with Community-acquired Pneumonia: A Prospective Cohort Study

Introduction The neutrophil-lymphocyte ratio (NLR) is an emerging inflammatory biomarker in community-acquired pneumonia (CAP) with potential prognostic implications. Biomarker-concordant corticosteroid dosing strategies based on other inflammatory markers have been found to be associated with improved clinical outcomes. The NLR is a readily available and affordable biomarker and could help guide corticosteroid use in CAP. Our goal is to evaluate the association between NLR-concordant corticosteroid prescription and patient outcomes. Methods Single-center prospective cohort study of adults with CAP who were admitted to the Mayo Clinic in Rochester, Minnesota, between December 10, 2023, and March 11, 2025. Patients with available NLR within 24 hours of admission were evaluated. Those who received steroids after 24 hours of admission, stayed in the hospital shorter than 24 hours, and were not yet discharged were excluded. Steroid use was classified as 'biomarker-concordant' if given when NLR > 12 or withheld when NLR <= 12, and 'biomarker-discordant' otherwise. All-cause mortality was the primary outcome. Results Of 545 admissions with CAP, 465 were included. Steroid use was biomarker-discordant in 222 (47.7%) patients and biomarker-concordant in 243 (52.3%) patients. Systemic corticosteroid use within 24 hours was more common in the discordant group (127 (57.2%) versus 77 (31.7%)). After adjusting for the pneumonia severity index, there were no significant differences in clinical outcomes between groups including in-hospital mortality (odds ratio [95% C.I.] = 1.120 [0.463, 2.706]), 30 – day mortality (hazard ratio [95% C.I.] = 1.423 [0.747, 2.710]), oxygen-free days (estimate [95% C.I.] = 0.61 [–0.655, 1.879), or hospital-free days (estimate [95% C.I.] 0.222 [–0.943, 1.386]) between biomarker-discordant versus concordant corticosteroid use. Discussion Despite growing interest in biomarker-guided corticosteroid strategies, NLR-based concordance was not associated with clinical outcomes in this cohort, suggesting that its role may be limited to risk stratification rather than treatment guidance. Conclusions In this observational cohort of hospitalized CAP patients, a biomarker-concordant corticosteroid treatment strategy based on the NLR was not associated with improved clinical outcomes.