What is the antibiotic prophylaxis for a patient on high-dose corticosteroids (steroids)?

From the Guidelines

Patients on high-dose steroids should be considered for antibiotic prophylaxis against Pneumocystis jirovecii pneumonia (PCP) if they are receiving daily doses of prednisolone >15-30 mg or equivalent for >2-4 weeks, especially in combination with immunosuppressants. The most commonly used prophylaxis scheme is trimethoprim/sulfamethoxazole (TMP-SMX) 480 mg/day (single-strength) or 960 mg three times a week 1. It is essential to weigh the risk-benefit ratio and consider individual patient factors, such as persistent lymphopenia, older age, and pre-existing lung disease, which may increase the risk of PCP infection 1. Alternative prophylactic medications, including atovaquone, dapsone, or nebulized pentamidine, may be considered, but their usage is limited by factors like cost or need for hospital administration 1.

Key considerations for antibiotic prophylaxis in patients on high-dose steroids include:

• The dose and duration of steroid therapy, with higher doses and longer durations increasing the risk of infection 1
• The use of immunosuppressants in combination with steroids, which may further increase the risk of PCP infection 1
• Individual patient factors, such as age, lung disease, and lymphopenia, which may affect the risk-benefit ratio of prophylaxis 1
• The potential for adverse events associated with TMP-SMX, such as nausea, headache, and rash, which may affect treatment decisions 1.

In general, antibiotic prophylaxis should be tailored to the individual patient's risk factors and medical history, rather than being routinely recommended for all patients on high-dose steroids 1.

From the FDA Drug Label

For Patients With Impaired Renal Function When renal function is impaired, a reduced dosage should be employed Prophylaxis Adults The recommended dosage for prophylaxis in adults is 1 sulfamethoxazole and trimethoprim DS (double strength) tablet daily12. The patient on high dose steroids may require antibiotic prophylaxis.

• The recommended dosage for prophylaxis in adults is 1 sulfamethoxazole and trimethoprim DS (double strength) tablet daily 2. However, the label does not explicitly address the use of antibiotics prophylaxis for patients on high dose steroids. Therefore, no conclusion can be drawn about the specific use of trimethoprim-sulfamethoxazole for antibiotic prophylaxis in patients on high dose steroids.

From the Research

Antibiotics Prophylaxis for Patients on High-Dose Steroids

• The use of antibiotics prophylaxis for patients on high-dose steroids is a topic of discussion in the medical community, with some studies suggesting its efficacy in preventing opportunistic infections 3, 4.
• A study published in the Journal of the National Comprehensive Cancer Network found that the incidence of opportunistic infections was low in patients on immune checkpoint inhibitors who required high-dose steroids, and questioned the necessity of PJP prophylaxis 5.
• Another study published in the Annals of the Rheumatic Diseases found that trimethoprim/sulfamethoxazole prophylaxis significantly reduced the incidence of pneumocystis pneumonia in patients with rheumatic diseases receiving high-dose steroids 3.
• A review of the literature on PJP prophylaxis in non-HIV patients on chronic steroids found that the role of prophylaxis in this population remains controversial 6.
• A practical approach to monitoring and prevention of infectious complications associated with systemic corticosteroids and other immunosuppressive agents suggests that PJP prophylaxis should be considered in patients on high-dose corticosteroids for >4 weeks or in patients chronically treated with moderate doses 4.
• A comprehensive literature review on complications of corticosteroid therapy found that prolonged, high-dose corticosteroid use is associated with increased risk of infections, including bacterial sepsis and tuberculosis reactivation 7.

Guidelines and Recommendations

• The NCCN Guidelines recommend prophylactic antibiotics for Pneumocystis jirovecii pneumonia for patients receiving prolonged high-dose steroids/immunosuppressive agents 5.
• The Infectious Diseases Society of America guidelines for the prevention and treatment of opportunistic infections in patients with HIV suggest that PJP prophylaxis should be considered in patients on high-dose corticosteroids 5.
• The American Society of Hematology recommends screening and antimicrobial prophylaxis against tuberculosis, hepatitis B, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia in patients on high-dose corticosteroids for >4 weeks or in patients chronically treated with moderate doses 4.