Intensive Care Med https://doi.org/10.1007/s00134-023-07182-w CORRESPONDENCE Guidelines for management of severe community acquire pneumonia: baseless and confusing suggestion Soumya Sankar Nath * , Nandhini Nachimuthu and Deepti Sharma © 2023 Springer-Verlag GmbH Germany, part of Springer Nature We read with interest the guidelines for managing severe community-acquired pneumonia (sCAP) published in Intensive Care Medicine [1]. Te guidelines suggested that in sCAP with shock, methylprednisolone (MPS) be advised at the dose of 0.5 mg/kg twice a day for fve days [1]. Te frst randomized controlled trial (RCT) cited used MPS for 21 days in de-escalating doses and found no signifcant diferences in 60-day mortality between the group that received MPS and that did not [2]. Tere were also no diferences in the secondary outcomes like vaso- pressor-dependent shock, development of acute respira- tory distress syndrome (ARDS), mechanical ventilation (MV) free days, duration of intensive care unit (ICU), or hospital stay. Subset analysis revealed a three-day reduc- tion in the median duration of MV, but a small sample size and other factors marred this fnding. Te authors pointed out that 40 mg of MPS was insufcient to achieve the serum level required to provide an adequate anti- infammatory response. Another RCT, the authors relied upon compared a continuous infusion of 300 mg of hydrocortisone for seven days with a placebo [3]. Tey reported signifcant improvement in PaO 2 /FiO 2 (P/F) ratio, chest radiograph score, and a signifcant reduction in C-reactive protein (CRP) levels, sequential organ failure assessment score, and duration of MV. However, there was no signifcant diference in mortality among the groups. A meta-analysis of 10 RCTs reported decreased all- cause mortality in patients who received conventional antimicrobials and corticosteroids compared to those who received conventional antimicrobials alone [4]. Te optimal dose and duration of corticosteroids were ambiguous, as dose and duration varied in the studies. However, the sub-group analysis failed to show any sta- tistically signifcant diference in all-cause mortality in the short course (≤ 5 days) corticosteroid-treated group compared to the conventional antimicrobial alone group. A multicentric double-blind study examined MPS (0.5 mg/kg twice daily for seven days) in patients with sCAP and high infammatory response (CRP lev- els > 150 mg/dl) [5]. Although MPS reduced the risk of treatment failure (defned as the development of shock, the need for invasive MV in those not on MV, death, and radiographic deterioration), it failed to show any difer- ence in in-hospital mortality [5]. Tus, of the cited studies, only two used MPS, one for fve days and the other for 21 days. All other studies quoted used hydrocortisone in varying doses. So, there is a lack of evidence to suggest MPS (both the studies quoted failed to show any mortality beneft) at the dose of 0.5 mg/kg (the authors of the RCT expressed doubts regarding its adequacy) for fve days (systematic review and meta-analysis failed to show any mortality beneft) in patients of sCAP with shock. Moreover, none of the stud- ies or meta-analyses compared the role of MPS, or for that matter, any corticosteroid, in patients of sCAP with shock. Further, sCAP with shock is just a subset of sep- tic shock. Te surviving sepsis guidelines 2021 advocated hydrocortisone (200 mg/day) in all patients with septic shock [6]. Tus, the present guidelines run contrary to the sepsis guidelines and are bound to create confusion among the intensivists. *Correspondence: soumyanath@rediffmail.com Department of Anaesthesiology and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India This comment refers to the article available online at https://doi.org/10. 1007/s00134-023-07033-8