The 2024 Sepsis Guidelines: A Shift in Corticosteroid Use with a Focus on ARDS and CAP

By SWA

The 2024 update to the international sepsis guidelines marks a significant evolution in the approach to corticosteroid therapy, particularly in critically ill patients with Acute Respiratory Distress Syndrome (ARDS) and Community-Acquired Pneumonia (CAP).

These updates reflect new evidence supporting broader and earlier steroid use in select high-risk populations. Below, we explore the changes and their implications, with an integrated look at how septic shock factors into the clinical picture.

ARDS (Acute Respiratory Distress Syndrome)

What changed?

In the 2017 guidelines, corticosteroids were only conditionally recommended for patients with early, moderate to severe ARDS. This cautious approach was based on mixed clinical data and concerns about potential side effects like secondary infections or prolonged viral shedding.

What’s new in 2024?

The 2024 update now broadens this recommendation to include all severities of ARDS—mild, moderate, or severe. This remains a conditional recommendation, meaning clinical judgment is still essential, but the scope of patients who may benefit from corticosteroids has expanded significantly.

Why it matters:

  • ARDS is a common and severe complication of sepsis, especially in pneumonia-related cases.

  • Corticosteroids can suppress the excessive inflammatory response, improving oxygenation and reducing ventilator duration.

  • The change reflects new clinical trial evidence suggesting that early corticosteroid use may benefit a broader range of ARDS patients, not just those with more advanced disease.

CAP (Community-Acquired Pneumonia)

What changed?

In 2017, corticosteroid use in hospitalized CAP patients received only a conditional recommendation, primarily for patients at risk of treatment failure or those with high inflammatory markers.

What’s new in 2024?

The new guidelines elevate this to a strong recommendation—corticosteroids are now recommended for patients with severe CAP, based on robust evidence of clinical benefit.

Why it matters:

  • Severe CAP can escalate to septic shock or ARDS, especially in older or comorbid patients.

  • Recent studies (e.g., ESCAPe and CAPE COD trials) demonstrated that early corticosteroid use in severe CAP can reduce mortality, decrease progression to mechanical ventilation, and shorten ICU stays.

  • This shift underscores greater confidence in the benefit-risk ratio of corticosteroids in this population.

Defining Septic Shock and Its Classifications

Understanding how corticosteroid therapy integrates into sepsis care requires a clear definition of septic shock, and recognition of its many forms.

What is Septic Shock?

Septic shock is a severe subset of sepsis defined by:

  • Persistent hypotension requiring vasopressors to maintain MAP ≥65 mmHg, and

  • Serum lactate >2 mmol/L, despite adequate fluid resuscitation.

It reflects a dysregulated host response to infection, leading to circulatory, cellular, and metabolic dysfunction—often fatal if not rapidly treated.

Types of Septic Shock

Septic shock can present in different ways depending on hemodynamics, infection source, causative organism, or patient population.

1. By Hemodynamic Profile:

  • Hyperdynamic (early): ↑ cardiac output, ↓ systemic vascular resistance (warm extremities, bounding pulses)

  • Hypodynamic (late): ↓ cardiac output, ↑ SVR (cold extremities, weak pulses)

2. By Source of Infection:

  • Pulmonary (e.g., pneumonia → ARDS)

  • Abdominal (e.g., peritonitis, perforation)

  • Urinary (e.g., pyelonephritis, urosepsis)

  • Skin/Soft Tissue (e.g., cellulitis, necrotizing fasciitis)

  • CNS (e.g., meningitis)

  • Device-related (e.g., central line infections)

3. By Causative Organism:

  • Gram-negative (e.g., E. coli, Pseudomonas)

  • Gram-positive (e.g., Streptococcus pneumoniae, Staphylococcus aureus)

  • Fungal (e.g., Candida spp.)

  • Viral (e.g., Influenza, COVID-19)

4. By Patient Population:

  • Immunocompetent vs. immunocompromised

  • Pediatric, neonatal, or geriatric patients

  • Post-surgical or trauma-associated sepsis

How It All Connects: ARDS, CAP, and Septic Shock

Many cases of severe CAP can rapidly evolve into septic shock and ARDS, particularly in vulnerable populations. For example:

  • A patient with severe pneumococcal pneumonia may develop ARDS within 24–48 hours.

  • This may progress to septic shock, requiring vasopressors and ventilatory support.

In such scenarios, the 2024 guidelines support the early use of corticosteroids—not just to manage inflammation in ARDS, but also to improve outcomes in severe CAP and septic shock.

Summary of Key Updates

Area2017 Guidelines2024 Guidelines
Septic ShockCorticosteroids only if unresponsive to fluids/pressorsBroader conditional use recommended
ARDSConditional use in early moderate-to-severe ARDSConditional use in all severities of ARDS
Severe CAPConditional use in hospitalized patients with CAPStrong recommendation in severe CAP

Clinical Implication

These updates call for earlier consideration of corticosteroids in critically ill patients—particularly those with:

  • Mild to severe ARDS

  • Severe CAP, especially with signs of impending shock

  • Sepsis or septic shock, where inflammation is driving organ dysfunction

As always, treatment must be individualized—but the trend is clearly toward earlier intervention in the right patients.

Reference:
Corticosteroids for Sepsis, Acute Respiratory Distress Syndrome, or Community-Acquired Pneumonia

https://jamanetwork.com/journals/jama/fullarticle/2828913?guestAccessKey=3023e195-bf49-457e-a546-1e990c03aeea&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=mostreadwidget&utm_term=041125&adv=

© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742 ISBN: 0-9703195-0-9

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