Adjunctive corticosteroids in non-HIV immunocompromised patients with Pneumocystis jirovecii pneumonia: a systematic review and meta-analysis
Abstract
Background: Pneumocystis jirovecii pneumonia (PJP) in non-HIV immunocompromised adults carries 30%–60% mortality. Adjunctive corticosteroids are standard in HIV-PJP but remain contested in non-HIV PJP. Objectives: To determine whether adjunctive corticosteroids reduce mortality and invasive mechanical ventilation (IMV) in non-HIV PJP, and whether effect estimates differ between randomized and observational study designs. Design: Systematic review and meta-analysis. Data sources and methods: Six databases and two trial registers were searched from inception to February 7, 2026. Randomized and observational studies comparing adjunctive corticosteroids versus no corticosteroids or placebo in non-HIV adults with PJP were eligible. Random-effects meta-analyses (restricted maximum likelihood) of two co-primary outcomes included subgroup, sensitivity, E-value, and Grading of Recommendations Assessment analyses. Results: Twenty-eight studies were included (one randomized controlled trial (RCT), 27 observational; ∼ 5300 patients): 22 contributed corticosteroid-versus-no-corticosteroid comparisons and six contributed dose-comparison data only. Evidence was discordant by design (interaction p=0.006 ): the RCT showed lower IMV (hazard ratio (HR) 0.36, 95% CI 0.14–0.90) and lower 90-day mortality (HR 0.59, 0.37–0.93); regression-adjusted observational studies suggested harm (odds ratio (OR) 1.56, 1.10–2.22); propensity-based estimates were null-compatible. Pre-specified mortality pools…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 5,300 participants or records.
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