What is the recommended time interval between a cortisone (corticosteroid) injection and starting antibiotics (antibacterial medication)?

Timing Between Cortisone Injection and Antibiotics

Patients should wait at least 2-3 days after receiving a cortisone injection before starting antibiotics to maintain optimal effectiveness of both treatments. 1

Evidence-Based Recommendations

For Bacterial Infections:

• Antibiotics should preferentially be administered prior to starting corticosteroid treatment or as soon as possible thereafter, without delaying treatment initiation 1
• When treating bacterial keratitis, topical corticosteroid therapy may be added to the treatment regimen following at least 2-3 days of progressive improvement with topical antibiotic treatment 1
• For bacterial keratitis, a subgroup analysis found that adding topical corticosteroids within 2-3 days of antibiotic therapy (rather than after 4 or more days) resulted in better visual outcomes 1

For Systemic Infections:

• Studies should be performed prior to beginning antibiotic treatment or as soon as possible thereafter 1
• When treating severe infections like bacterial meningitis or tuberculosis, concurrent administration of corticosteroids with antibiotics has shown improved survival outcomes 2
• For patients with alcohol-related liver disease receiving prednisolone, there was a significant reduction in 90-day mortality when antibiotic therapy was continued rather than stopped before initiating prednisolone 1

Clinical Considerations

Risk of Infection After Corticosteroid Use:

• Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection 3
• High-dose oral glucocorticoids do not significantly affect diagnostic accuracy within the first few days after treatment onset in certain inflammatory conditions 1
• After approximately 10 days of glucocorticoid treatment, a significant reduction in inflammatory markers occurs, potentially masking infection 1

Specific Clinical Scenarios:

• For orthopedic procedures, corticosteroid injections within 2 weeks before total knee arthroplasty increased the risk of postoperative infection, but delaying surgery more than 4 weeks did not provide additional infection risk reduction 4
• In bacterial keratitis, corticosteroids should be avoided if Nocardia or fungal infection is suspected due to risk of worsening the infection 1, 5
• For patients with herpes simplex virus infections, antiviral therapy should be maintained throughout the period of corticosteroid use to prevent viral reactivation 5

Monitoring and Follow-up

• Patients receiving both treatments should be monitored closely for signs of infection
• For ocular conditions, patients should be examined within 1-2 days after initiation of topical corticosteroid therapy 1
• Intraocular pressure must be monitored to prevent complications such as glaucoma 5
• Careful screening for infection is recommended before initiating corticosteroid therapy, repeatedly during treatment, and during the follow-up period 1

Common Pitfalls to Avoid

• Avoid starting corticosteroids without ruling out fungal infections, particularly in ocular conditions 1
• Do not discontinue antibiotics before starting corticosteroids in severe infections, as this can increase mortality 1
• Be aware that corticosteroids can mask signs of infection, potentially leading to delayed diagnosis
• Recognize that chronic topical immunotherapy increases the risk of infectious crystalline keratopathy 1

By following these guidelines, clinicians can optimize the effectiveness of both cortisone injections and antibiotic therapy while minimizing the risk of complications.