Corticosteroid Use and Bacterial Infections
Mechanism and Risk
- Corticosteroids can induce defects in lymphocyte signaling, which can enhance infection susceptibility, according to the Journal of Hepatology 1
- The risk of infection-related complications increases with combination with other immunosuppressive medications, as reported in the Journal of Crohn's and Colitis 2
Evidence from Specific Clinical Scenarios
- In patients with severe alcoholic hepatitis treated with prednisolone, serious infections were more frequent compared to those not given prednisolone (10% vs. 6%), as found in the Journal of Hepatology 1
- Development of infection was associated with increased 90-day mortality only in patients treated with prednisolone, independent of baseline disease severity, according to the Journal of Hepatology 1
- Bacterial infections represent approximately 90% of infectious episodes in patients with severe alcoholic hepatitis, as reported in the Journal of Hepatology 1
- During or after corticosteroid treatment, there's a notable shift toward respiratory infections (40% of all episodes), as found in the Journal of Hepatology 3
- Topical corticosteroids may have both beneficial and harmful effects in bacterial keratitis, according to Ophthalmology 4
- Potential disadvantages of topical corticosteroids in bacterial keratitis include recurrence of infection, local immunosuppression, and inhibition of collagen synthesis, as reported in Ophthalmology 5
- For most bacterial infections (except Nocardia), the risk may be low when appropriate antibiotics are used concurrently, according to Ophthalmology 5
- Corticosteroids should be avoided in presumed bacterial ulcers until the organism has been identified and the infection is responding to antibiotics, as recommended in Ophthalmology 5
Special Considerations
- Corticosteroids increase risk of fungal infections, particularly invasive aspergillosis, as reported in the Journal of Hepatology 1
- In patients with severe alcoholic hepatitis treated with corticosteroids, invasive aspergillosis incidence was 16% during a three-month follow-up, according to the Journal of Hepatology 1
- Pneumocystis pneumonia (PCP) has been reported in patients on corticosteroid treatment with very high mortality rates, as found in the Journal of Hepatology 1
Clinical Approach
- Screen carefully for infection before initiating corticosteroid therapy, as recommended in the Journal of Hepatology 1
- Continue monitoring for infection during treatment and follow-up period, according to the Journal of Hepatology 1
- If infection is present at baseline, ensure it is well-treated and "controlled" before starting steroids, as suggested in the Journal of Hepatology 3
- Consider concurrent antibiotic therapy - in patients with baseline infection who received prednisolone, continued antibiotic therapy was associated with significantly reduced mortality (13% vs. 52%), as reported in the Journal of Hepatology 3
- Use the minimum amount of corticosteroid required to achieve the desired clinical effect, as recommended in Ophthalmology 5
- Consider prophylactic antibiotics in high-risk patients, according to the Journal of Hepatology 3
Steroid Administration in Active Infection
Critical Decision Framework
- The European Society of Intensive Care Medicine recommends avoiding high-dose steroids (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) in active infection, as they increase hospital-acquired infections, hyperglycemia, and gastrointestinal bleeding without mortality benefit 6
Practical Management Algorithm
- The American College of Gastroenterology suggests stopping azathioprine/mercaptopurine therapy and JAK inhibitors in IBD patients with infection, and not restarting treatment until negative PCR-SARS-CoV-2 test (if available) 7
- The World Journal of Emergency Surgery reports that corticosteroids significantly increase surgical complications, including anastomotic leakage, wound infection and dehiscence, gastrointestinal bleeding, and peptic ulcer perforation 8