How should chronic corticosteroid (steroid) therapy be adjusted to minimize the risk of developing a wound infection?

From the Guidelines

Chronic steroids should be carefully tapered rather than abruptly discontinued when there is concern for developing wound infection, with a focus on maintaining the baseline dose during the perioperative period and considering a stress-dose increase during the acute phase of infection management, as recommended by the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline 1. When adjusting chronic steroids in patients at risk of wound infection, it is crucial to balance the need to minimize immunosuppression with the risk of adrenal crisis.

• For patients on long-term steroid therapy (such as prednisone >5 mg daily for more than 3 weeks), maintaining their baseline dose during the perioperative period is recommended, rather than administering perioperative supra-physiologic glucocorticoid doses (so-called “stress dosing”) 1.
• However, in cases where stress dosing is necessary, patients on chronic prednisone might receive hydrocortisone 50-100 mg IV every 8 hours during the initial infection treatment, then return to their maintenance dose as the infection resolves.
• If the infection is severe, working with an endocrinologist to develop a gradual tapering schedule, typically reducing by 2.5-5 mg of prednisone every 1-2 weeks as the infection comes under control, is advisable.
• The ECCO-ESCP consensus on surgery for Crohn's disease also highlights the importance of weaning steroids if possible, as prednisolone 20 mg daily or equivalent for more than 6 weeks before surgery is a significant risk factor for surgical complications, including wound infections 1.
• Optimizing infection management with appropriate antibiotics, wound care, nutritional support, and glycemic control is essential, as steroids can mask infection signs and impair wound healing through their immunosuppressive and anti-inflammatory effects.
• Regular monitoring of the wound, inflammatory markers, and the patient's clinical status is necessary to balance infection control with the patient's need for steroid therapy.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection The rate of infectious complications increases with increasing corticosteroid dosages. Monitor for the development of infection and consider prednisone tablets withdrawal or dosage reduction as needed.

The adjustment of chronic steroids with concern for developing wound infection should be done by monitoring for the development of infection and considering prednisone tablets withdrawal or dosage reduction as needed 2. It is essential to weigh the benefit-risk ratio for each patient in whom corticoid therapy is being considered 2.

• Key considerations:
  • Increased risk of infection with higher corticosteroid dosages
  • Monitor for signs of infection
  • Consider dosage reduction or withdrawal if infection develops
• Clinical decision:
  • Use the lowest effective dose of prednisone to minimize the risk of infection
  • Closely monitor patients for signs of infection, particularly those with a history of latent infections or compromised immune systems.

From the Research

Adjusting Chronic Steroids to Prevent Wound Infection

• Chronic steroid use can increase the risk of infection, including wound infection, due to its immune-modulating properties 3, 4.
• The risk of infection is dose-dependent and length-of-treatment dependent, with higher doses and longer treatment durations increasing the risk 4.
• To minimize the risk of infection, steroids should be used at the lowest effective dose for the shortest possible time 5.
• When tapering steroids, a moderate-to-high dose can be tapered rapidly to near-physiological doses, while watching for signs of disease reactivation 5.
• Once close to the physiological dose, tapering should be slower and at longer intervals to allow for recovery of the hypothalamic-pituitary-adrenal (HPA) axis 5.

Screening and Prophylaxis for Infections

• Screening and antimicrobial prophylaxis against certain infections, such as tuberculosis, hepatitis B, and Pneumocystis jirovecii pneumonia (PJP), may be indicated in patients on high-dose corticosteroids for >4 weeks or on moderate doses for ≥8 weeks 4.
• PJP prophylaxis should be considered with combination therapy of cyclophosphamide and corticosteroids until a prednisone-equivalent dose ≤ 5 mg/d is reached 4.
• Adherence to an age-based immunization schedule is recommended for all patients on immunosuppressive agents, including corticosteroids 4.

Comparative Safety of Systemic Immunomodulatory Medications

• The comparative safety of systemic immunomodulatory medications, including corticosteroids, has been evaluated in patients with atopic dermatitis, with cyclosporine and methotrexate showing the lowest 6-month risks of serious infections 6.
• Prednisone, azathioprine, and mycophenolate were associated with increased risks of serious infections compared to methotrexate 6.

Tapering Regimens in Rheumatic Disease

• A systematic review of corticosteroid tapering regimens in rheumatic disease found limited evidence to guide tapering strategies, with most guidelines relying on expert opinion and small case series 7.
• The review highlighted the need for additional research to develop evidence-based tapering recommendations 7.