How can infections be prevented and managed in patients on chronic corticosteroid (corticosteroid) therapy?

Prevention and Management of Infections in Patients on Chronic Corticosteroid Therapy

Patients on chronic corticosteroid therapy require systematic infection prevention strategies including screening, prophylaxis, vaccination, and vigilant monitoring to reduce infection-related morbidity and mortality.

Infection Risk with Corticosteroids

Corticosteroids suppress the immune system through multiple mechanisms, increasing susceptibility to various pathogens:

• FDA labeling warns that corticosteroids increase infection risk with viral, bacterial, fungal, protozoan, and helminthic pathogens 1
• Infection risk is dose and duration-dependent, with significant risk at prednisone-equivalent doses >15-30 mg daily for ≥4-8 weeks 2
• The relative risk of infection is approximately 1.6 times higher in patients on systemic corticosteroids compared to controls 3
• Infection risk is particularly high in patients with neurologic diseases (RR 2.8) and also elevated in intestinal and renal diseases 3

Recommended Screening Before Initiating Therapy

Before starting chronic corticosteroid therapy, screen for:

1. Latent tuberculosis: Tuberculin skin test or interferon-gamma release assay 1
2. Hepatitis B: HBsAg, anti-HBc, and anti-HBs 1
3. Strongyloides in patients from endemic areas or with unexplained diarrhea 1
4. Baseline vaccination status: Ensure up-to-date immunizations before initiating therapy 2

Infection Prevention Strategies

Antimicrobial Prophylaxis

• Pneumocystis jirovecii pneumonia (PCP):

  • Recommended for patients receiving prednisone equivalent ≥20 mg/day for ≥4 weeks 4
  • First-line: Trimethoprim/sulfamethoxazole (TMP/SMX)
  • Alternatives: Atovaquone, dapsone, or aerosolized pentamidine for TMP/SMX-intolerant patients 4

• Tuberculosis prophylaxis:

  • For patients with latent TB or tuberculin reactivity 1
  • Continue chemoprophylaxis during prolonged corticosteroid therapy

• Hepatitis B reactivation prevention:

  • Antiviral therapy for HBsAg-positive patients 1
  • Monitor HBV DNA and liver enzymes during therapy

• Fungal infections:

  • Universal prophylaxis not routinely recommended 4
  • Consider in high-risk patients (e.g., those with severe alcoholic hepatitis, ICU admission, or MELD score ≥24) 4
  • Invasive aspergillosis risk is 16% in severe alcoholic hepatitis patients on corticosteroids 4

Vaccination Recommendations

• Complete age-appropriate vaccinations before initiating corticosteroids when possible 2
• Live vaccines are contraindicated during immunosuppressive corticosteroid therapy 1
• Inactivated vaccines may be administered but with potentially diminished response 1
• Consider varicella zoster immune globulin for non-immune patients exposed to chickenpox 1
• Consider immunoglobulin prophylaxis for measles exposure 1

Monitoring During Therapy

• Regular clinical assessment for signs and symptoms of infection
• Systematic screening for infection before initiating therapy, repeatedly during treatment, and during follow-up 4
• Respiratory infections: Monitor closely as these represent 40% of infections during/after corticosteroid treatment 4
• Urinary tract infections: Account for approximately 32% of baseline infections in susceptible patients 5
• Invasive fungal infections: Consider galactomannan testing (cut-off ≥0.5, sensitivity 89%, specificity 84%) in high-risk patients 4

Management of Infections During Corticosteroid Therapy

1. Early identification and treatment of infections is critical
2. Consider dose reduction or temporary discontinuation of corticosteroids during severe infections 2
3. Continue antibiotics when initiating corticosteroids in patients with controlled infections 4
4. Maintain antibiotic therapy throughout corticosteroid treatment for patients with baseline infections 4

Special Considerations

• Alcoholic hepatitis patients: Higher risk of infections (28-day cumulative incidence ~20%) 4
• Transplant recipients: Require more intensive monitoring and prophylaxis 5
• Intra-articular injections: Associated with modest infection risk (IRR 1.10), highest in first 30 days and in patients ≥65 years old 6
• Beneficial use of corticosteroids: Despite infection risks, corticosteroids improve survival in specific infectious conditions including bacterial meningitis, tuberculous meningitis, severe typhoid fever, and PCP with hypoxemia 7

Common Pitfalls to Avoid

• Failing to screen for latent infections before initiating therapy
• Discontinuing antibiotics prematurely when starting corticosteroids in patients with controlled infections
• Overlooking fungal infections: Consider invasive aspergillosis in patients with persistent fever despite antibiotics
• Ignoring vaccination status: Complete vaccinations before starting corticosteroids whenever possible
• Missing early signs of infection: Corticosteroids may mask inflammatory signs and symptoms

By implementing these preventive strategies and maintaining vigilant monitoring, clinicians can significantly reduce the infection-related morbidity and mortality associated with chronic corticosteroid therapy.