Can taking steroids (corticosteroids) worsen a bacterial illness?

Can Steroids Worsen Bacterial Infections?

Yes, corticosteroids can worsen bacterial infections by suppressing the immune system, increasing the risk of infection with any pathogen, and potentially exacerbating existing bacterial infections. 1

Mechanism and Risk

Corticosteroids affect the immune system in several ways that can impact bacterial infections:

• Suppress the immune system, reducing resistance to new infections and exacerbating existing ones 1
• Induce defects in lymphocyte signaling, which can enhance infection susceptibility 2
• Mask signs of infection, potentially delaying diagnosis and appropriate treatment 1
• Increase risk of disseminated infections and reactivation of latent infections 1

The risk of infection-related complications increases with:

• Higher corticosteroid dosages - high and very high doses are associated with significantly greater risk of bacteremia compared to no or low-dose treatment 3
• Longer duration of therapy 4
• Combination with other immunosuppressive medications 2

Evidence from Specific Clinical Scenarios

Alcoholic Hepatitis

• In patients with severe alcoholic hepatitis treated with prednisolone, serious infections were more frequent compared to those not given prednisolone (10% vs. 6%) 2
• Development of infection was associated with increased 90-day mortality only in patients treated with prednisolone, independent of baseline disease severity 2
• Bacterial infections represent approximately 90% of infectious episodes in this setting 2
• During or after corticosteroid treatment, there's a notable shift toward respiratory infections (40% of all episodes) 2

Bacterial Keratitis (Eye Infections)

• Topical corticosteroids may have both beneficial and harmful effects in bacterial keratitis 2
• Potential disadvantages include recurrence of infection, local immunosuppression, and inhibition of collagen synthesis 2
• For most bacterial infections (except Nocardia), the risk may be low when appropriate antibiotics are used concurrently 2
• Corticosteroids should be avoided in presumed bacterial ulcers until the organism has been identified and the infection is responding to antibiotics 2

COVID-19 and Secondary Bacterial Infections

• High-dose corticosteroid treatment in COVID-19 patients is associated with increased risk of bacteremia (OR 6.18) compared to no corticosteroid treatment 3
• Very high corticosteroid doses show even greater risk (OR 8.12) 3
• These associations persist after adjusting for factors like comorbidities and mechanical ventilation 3

Special Considerations

Fungal and Opportunistic Infections

• Corticosteroids increase risk of fungal infections, particularly invasive aspergillosis 2
• In patients with severe alcoholic hepatitis treated with corticosteroids, invasive aspergillosis incidence was 16% during a three-month follow-up 2
• Pneumocystis pneumonia (PCP) has been reported in patients on corticosteroid treatment with very high mortality rates 2

Tuberculosis

• Corticosteroids can reactivate latent tuberculosis 1
• Patients with latent tuberculosis or tuberculin reactivity should be closely monitored for reactivation during prednisone therapy 1
• During prolonged prednisone therapy, chemoprophylaxis should be considered for these patients 1

Clinical Approach

When considering corticosteroid use in patients with bacterial infections:

• Screen carefully for infection before initiating corticosteroid therapy 2
• Continue monitoring for infection during treatment and follow-up period 2
• If infection is present at baseline, ensure it is well-treated and "controlled" before starting steroids 2
• Consider concurrent antibiotic therapy - in patients with baseline infection who received prednisolone, continued antibiotic therapy was associated with significantly reduced mortality (13% vs. 52%) 2
• Use the minimum amount of corticosteroid required to achieve the desired clinical effect 2
• Consider prophylactic antibiotics in high-risk patients 2

Conclusion

While corticosteroids are beneficial in certain infectious conditions when used with appropriate antimicrobial therapy, they generally increase the risk of bacterial infections and can worsen outcomes. The decision to use corticosteroids in patients with bacterial infections should carefully weigh the potential benefits against the increased risk of infection-related complications.