The role of corticosteroids in severe viral pneumonia: lessons from COVID-19 and influenza
et al., Pneumonia, doi:10.1186/s41479-025-00192-w, Feb 2026
Review of corticosteroid use in influenza and COVID-19 severe pneumonia. In influenza, the weight of evidence associates corticosteroid therapy with increased mortality, delayed viral clearance, and higher rates of secondary infection. In COVID-19, the RECOVERY trial established low-dose dexamethasone as standard of care in severe and critical disease, with the greatest mortality benefit seen in mechanically ventilated patients.
However, authors present evidence that this benefit does not extend to all hospitalized patients. In the RECOVERY trial itself, patients not receiving respiratory support at randomization showed no mortality reduction. Several studies found that corticosteroids given to non-ventilated patients or those with low inflammatory profiles were associated with increased mortality, severe ARDS, or septic shock. Data on patients receiving high-flow or simple oxygen remain inconclusive. The authors also note that timing matters: benefit was greater when treatment began after seven or more days of symptoms rather than early in the disease course, and that higher doses and longer durations did not improve survival. Authors conclude that corticosteroid therapy is context-dependent, and that a personalized approach guided by real-time inflammatory and virological monitoring is needed to optimize outcomes.
Gordon et al., 5 Feb 2026, China, peer-reviewed, 2 authors, study period 11 March, 2020 - 13 April, 2020.
Contact: ramirez_pau@gva.es.
Abstract: ## REVIEW
The role of corticosteroids in severe viral pneumonia: lessons from COVID-19 and influenza
Monica Gordon 1 and Paula Ramirez 1*
Abstract
Background Corticosteroids have long been used as immunomodulatory agents in viral respiratory infections, but their role in influenza and COVID-19 remains controversial. While both diseases share overlapping pathogenic mechanisms involving hyperinflammation and immune dysregulation, clinical evidence suggests divergent outcomes in response to corticosteroid therapy.
Objective This review critically examines the evidence regarding corticosteroid use in influenza and COVID-19, focusing on their impact on mortality, disease progression, and secondary infections.
Methods A narrative review was conducted including randomized controlled trials, meta-analyses, and major observational studies published between 2000 and 2025. Data were analyzed comparatively for influenza (seasonal and pandemic strains) and SARS-CoV-2 infection.
Results In influenza, most studies associate corticosteroid administration-particularly at high doses or prolonged courses-with increased mortality, delayed viral clearance, and higher rates of secondary bacterial pneumonia. Conversely, in COVID-19, randomized trials such as RECOVERY demonstrated that low-to-moderate doses of dexamethasone significantly reduce mortality in patients requiring oxygen or mechanical ventilation, without clear benefit in mild disease. These opposing outcomes highlight the importance of timing, dosing, and patient selection, reflecting distinct immunopathological trajectories between the two infections.
Conclusions Corticosteroid therapy exerts context-dependent effects in viral pneumonia. While detrimental in most cases of influenza, it is beneficial in severe COVID-19 when guided by systemic inflammation. Future strategies should focus on personalized and real-time immune monitoring to tailor immunomodulatory interventions to each patient's inflammatory and virological status.
*Correspondence: Paula Ramirez ramirez\_pau@gva.es 1 Critical Care Department, Hospital Universitario y Politécnico la Fe,
Valencia, Spain
Open Access
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