Can methylprednisolone (corticosteroid) be given during an infection?

Methylprednisolone During Infection: Selective Use Based on Clinical Context

Methylprednisolone should not be routinely administered during active infection unless there is a specific compelling indication, as it can exacerbate infections and increase mortality in certain scenarios. 1

Risks of Methylprednisolone During Infection

Methylprednisolone and other corticosteroids carry significant risks during infection:

• Immunosuppression effects:

  • Reduced resistance to new infections
  • Exacerbation of existing infections
  • Increased risk of disseminated infections
  • Reactivation of latent infections
  • Masking of infection signs 1

• Specific infection risks:

  • Bacterial infections (increased severity)
  • Fungal infections (exacerbation of systemic fungal infections)
  • Viral reactivation (especially hepatitis B, varicella, measles)
  • Tuberculosis reactivation
  • Parasitic infections (amebiasis, strongyloidiasis) 1, 2

Appropriate Use During Infection

Despite these risks, methylprednisolone may be indicated in specific infectious scenarios:

1. Severe Community-Acquired Pneumonia (SCAP):

   • Consider in patients with septic shock refractory to fluid resuscitation and vasopressors
   • Most beneficial when CRP >150 mg/L
   • Recommended dose: 0.5 mg/kg IV every 12 hours for 5 days 3

2. Rapidly Progressive or Exacerbating Interstitial Lung Disease (ILD):

   • High-dose IV methylprednisolone is recommended for patients with acute respiratory failure
   • Alternative etiologies like infections must be ruled out first 3

3. COVID-19:

   • Not recommended for routine use
   • Consider only in severe cases requiring mechanical ventilation or oxygen support
   • Not beneficial in patients without respiratory support 3
   • Caution: May increase risk of secondary infections 3, 4

Contraindications and Special Precautions

• Absolute contraindications:

  • Systemic fungal infections (unless treating drug reactions) 1
  • Viral hepatitis (harmful) 5
  • Cerebral malaria (harmful) 5

• Relative contraindications requiring special precautions:

  • Renal impairment (increased mortality risk in patients with elevated creatinine) 6
  • Viral pneumonia (increased mortality with influenza) 3
  • Tuberculosis (requires chemoprophylaxis during treatment) 1

Screening and Prophylaxis Recommendations

Before initiating methylprednisolone during or near infection:

1. Screen for:

   • Tuberculosis (latent or active)
   • Hepatitis B
   • Strongyloides stercoralis
   • Consider fungal infections 2

2. Prophylaxis considerations:

   • Pneumocystis jirovecii pneumonia prophylaxis for high-dose or prolonged therapy
   • Tuberculosis prophylaxis for patients with latent TB
   • Varicella prophylaxis with immune globulin for exposed non-immune patients 1, 2

Monitoring During Treatment

• Monitor for development of new infections
• Consider dose reduction or withdrawal if infection worsens
• Check blood pressure, glucose, and electrolytes regularly
• Watch for signs of secondary infections 7, 1

In summary, while methylprednisolone carries significant risks during infection, it may be appropriate in specific scenarios where the inflammatory response is causing more harm than the infection itself. The decision must be based on careful risk-benefit assessment with close monitoring for complications.