Corticosteroid Use in Viral Infections

Introduction to Corticosteroid Use

Corticosteroids should not be routinely administered in viral infections, but reserved for specific clinical scenarios where benefits outweigh risks, as recommended by the World Health Organization and supported by evidence from the World Journal of Emergency Surgery and The Lancet Respiratory Medicine 1, 2

Corticosteroids work through anti-inflammatory and immunosuppressive effects, decreasing host inflammatory responses and inhibiting activation of inflammatory cells, according to the World Journal of Emergency Surgery 1

Corticosteroid use in viral infections comes with significant risks, including delayed viral clearance, secondary infections, impaired wound healing, and metabolic complications, as reported by The Lancet Respiratory Medicine 2
Historical evidence showed increased mortality, delayed viral clearance, and increased hospital stay with corticosteroid use, according to The Lancet Respiratory Medicine 2
Complications associated with corticosteroid use include avascular necrosis, psychosis, and diabetes, as reported by The Lancet Respiratory Medicine 2

For moderate-severe disease requiring oxygen, dexamethasone 6 mg daily for up to 10 days reduced 28-day mortality, as recommended by the World Journal of Emergency Surgery and supported by the European Respiratory Society 1, 3
Alternative regimens, such as methylprednisolone 1-2 mg/kg/day for approximately 3 days, may be used in certain clinical scenarios, according to the World Journal of Emergency Surgery 1
The American Thoracic Society recommends cautious use of corticosteroids in patients with viral infections, considering disease severity and underlying conditions 2

The following treatment guidelines are recommended:

Category	Description	Treatment
Mild	No oxygen requirement, no pneumonia	No corticosteroids, supportive care, and monitoring for disease progression [4, 3]
Moderate-severe	Oxygen requirement, pneumonia	Systemic dexamethasone 6 mg daily for up to 10 days [5, 3]
Critical	Respiratory failure, shock, or multi-organ dysfunction	Systemic dexamethasone 6 mg daily for 10 days, with caution due to potential harmful effects [3, 6]

Surgical patients should be aware of the increased risk for anastomotic leakage, wound infection, and wound dehiscence associated with corticosteroid use, as reported by the World Journal of Emergency Surgery 1
Immunocompromised patients should use corticosteroids with extreme caution due to the higher risk of secondary infections, as recommended by the Infectious Diseases Society of America 2
Patients with pre-existing respiratory conditions, such as asthma or COPD, should continue baseline inhaled corticosteroids at usual dose and add systemic dexamethasone if oxygen requirements develop, as recommended by the European Respiratory Society 3

Blood glucose should be monitored for steroid-induced hyperglycemia, and secondary infections should be vigilantly monitored, especially in patients with invasive devices, as recommended by the American Diabetes Association and the Centers for Disease Control and Prevention 1, 2
Viral load should be monitored when possible for delayed viral clearance, according to the World Health Organization 1
Supportive treatment includes oxygen therapy for hypoxemia, adequate hydration, and management of respiratory secretions, but not routine administration of corticosteroids, and may include bronchodilators in cases with evident bronchospasm 3
Patients on corticosteroids require vigilant monitoring for secondary infections, including bacterial, fungal, and viral infections, and hyperglycemia, as they may further suppress immunity (moderate quality evidence) 7