Efficacy and safety of high-dose versus low-dose corticosteroid therapy in severe patients with HIV-associated Pneumocystis jirovecii pneumonia

Corticosteroid therapy is currently recommended by clinical guidelines for severe patients with HIV-associated Pneumocystis jirovecii pneumonia (PJP). However, the optimal corticosteroid dose remains unclear. This study aimed to evaluate the clinical efficacy and safety of high-dose versus low-dose corticosteroid therapy in severe patients with HIV-Associated PJP. We retrospectively collected hospitalized patients with severe HIV-associated PJP. According to the prespecified daily corticosteroid dose-to-body-weight ratio recorded in the study database, patients were categorized into a lower-dose group (<1 mg/kg/day) and a higher-dose group (≥1 mg/kg/day). The 28-day and 90-day all-cause mortality rates, length of hospital stay, duration and rate of mechanical ventilation, change in the PaO2/FiO2 ratio, and corticosteroid-related adverse events were compared between groups. Propensity score matching (PSM) was performed using clinically relevant baseline covariates, and post-matching balance was assessed using standardized mean differences (SMDs). Before PSM, baseline imbalances were observed between the low-dose and high-dose groups. After clinically driven 1:1 PSM, 116 patients were included in the matched cohort (58 per group). The 28-day and 90-day all-cause mortality rates did not differ significantly between the lower-dose and higher-dose groups (25.9% vs. 24.1%, log-rank p = 0.827; 39.7% vs. 39.7%, log-rank p = 0.961, respectively). No statistically significant between-group differences were observed in mechanical ventilation rate or duration, length of hospital stay, improvement in PaO2/FiO2, or corticosteroid-related adverse events, including hyperglycemia and secondary infection. A parsimonious propensity-score sensitivity analysis excluding APACHE II and total SOFA yielded qualitatively similar conclusions for 28-day and 90-day survival. In patients with severe HIV-associated PJP receiving adjunctive corticosteroids, the higher-dose regimen was not associated with improved 28-day or 90-day survival after propensity score matching. No statistically significant overall differences were identified in the prespecified secondary outcomes or recorded adverse events. Because this retrospective study was not designed as an equivalence or noninferiority study, the absence of statistically significant differences should not be interpreted as proof that the two dosing strategies are equivalent. These findings should be interpreted cautiously given the limited matched sample size, residual confounding, and potential sensitivity to propensity-score model specification.