When are steroid shots contraindicated in patients with upper respiratory infections?

Contraindications for Steroid Shots in Upper Respiratory Infections

Steroid shots are contraindicated in patients with uncomplicated upper respiratory infections as they provide no proven benefit and may cause significant harm through immunosuppression and delayed viral clearance. 1

General Contraindications

• Active viral infections: Steroids should be avoided in patients with uncomplicated viral upper respiratory infections 1
• Bacterial infections without appropriate antibiotic coverage: Steroids may mask symptoms while allowing infection to worsen
• Systemic fungal infections: Steroids can worsen fungal spread
• Influenza infection: Steroids may increase mortality in influenza pneumonia 2

Evidence-Based Rationale

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against using systemic steroids for hoarseness and acute laryngitis, despite this being a common practice 1. Their guideline states:

• No studies support the use of corticosteroids as empiric therapy for hoarseness
• Potential for significant adverse events outweighs any theoretical benefit
• Side effects can occur with even short-term use

Specific Clinical Scenarios

1. Uncomplicated URIs

• Recommendation: Steroids should not be routinely prescribed 1
• Rationale: Self-limited condition that resolves in 7-10 days with supportive care
• Risk: Potential for delayed viral clearance and immunosuppression

2. Severe Respiratory Infections

• Recommendation: Consider steroids only in specific severe cases with respiratory failure
• Rationale: In SARS patients with increasing oxygen requirements (PaO2 < 10 kPa or O2 sats < 90%), moderate doses of steroid may be considered 1
• Dosing: Prednisolone 30-40 mg/day or IV equivalent only in severe cases 1

3. Special Populations

Patients on High-Dose Steroids

• Patients taking prednisone equivalent ≥20 mg daily should defer non-live attenuated vaccinations (except influenza) until steroids are tapered to <20 mg daily 1
• This suggests increased infection risk in patients on high-dose steroids

Patients with Asthma/COPD

• While inhaled steroids are appropriate for management of underlying respiratory conditions, systemic steroids should not be routinely given for viral URI symptoms 1
• Inhaled steroids do not appear to increase risk of pulmonary infections 3

Risk-Benefit Analysis

Risks of Steroid Administration During URIs:

• Potential for prolonged viral shedding 4
• Possible blunting of immune response 5
• Masking of symptoms while infection progresses
• Systemic side effects (hyperglycemia, hypertension, mood changes)

Limited Evidence for Benefit:

• No convincing evidence of improved outcomes in uncomplicated URIs
• May worsen outcomes in influenza infections 2

Clinical Decision Algorithm

1. Assess URI severity:

   • Mild to moderate symptoms without respiratory distress → avoid steroids
   • Severe symptoms with respiratory failure → consider steroids only if specific indications present

2. Check for specific indications where steroids might be considered:

   • Severe COPD exacerbation with URI
   • Croup in pediatric patients
   • Severe allergic component with URI

3. Evaluate contraindications:

   • Active viral infection without specific indication → avoid steroids
   • Uncontrolled diabetes → avoid or use with extreme caution
   • Immunocompromised state → generally avoid

4. If steroids deemed necessary:

   • Use lowest effective dose for shortest duration
   • Ensure appropriate antimicrobial coverage if bacterial infection suspected
   • Monitor for adverse effects

Remember that the routine use of steroids for uncomplicated upper respiratory infections is not supported by evidence and should be avoided to prevent unnecessary harm to patients.