Is steroid administration typical for hospitalized patients with severe influenza?

Steroid Administration for Hospitalized Influenza Patients

No, steroids are NOT typically given for hospitalized influenza patients and should generally be avoided, as they are associated with increased mortality, higher rates of secondary infections, and worse clinical outcomes.

Current Guideline Recommendations

The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) recommend against routine corticosteroid use in adults with severe influenza pneumonia (conditional recommendation, low-quality evidence) 1. Similarly, the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) advise avoiding corticosteroids in adults with influenza (conditional recommendation, very low-quality evidence) 1.

The British Infection Society and British Thoracic Society pandemic influenza guidelines do not include corticosteroids in their treatment algorithms for hospitalized influenza patients, focusing instead on antivirals, antibiotics for bacterial co-infection, and supportive care 2.

Evidence of Harm from Corticosteroid Use

Mortality Risk

• Meta-analysis of 13 observational studies (n=1,917 patients) demonstrated an odds ratio of 3.06 (95% CI: 1.58-5.92) for mortality associated with corticosteroid use in influenza 1, 3.
• Analysis of four studies with low risk of bias showed consistent findings (OR: 2.82; 95% CI: 1.61-4.92) 3.
• A comprehensive meta-analysis of 19 studies with 4,916 patients found corticosteroid treatment significantly associated with mortality (OR 1.98,95% CI 1.62-2.43, p < 0.00001) 4.
• Updated Cochrane review including 30 studies showed adverse association with mortality (OR 3.90; 95% CI 2.31-6.60) 5.

Secondary Infections

• Corticosteroids significantly increase the risk of hospital-acquired infections (OR 3.16,95% CI 2.09-4.78, p < 0.00001) 4.
• Pooled analysis showed increased odds of nosocomial infection (OR 2.74; 95% CI 1.51-4.95) 5.
• Real-world data from Asian cohorts demonstrated that corticosteroids increased superinfection rates from 2.7% to 9.7% 6.

Prolonged Critical Illness

• Corticosteroid treatment is associated with longer duration of mechanical ventilation (weighted mean difference 3.82 days, 95% CI 1.49-6.15) 4.
• ICU length of stay is markedly longer with corticosteroid use (weighted mean difference 4.78 days, 95% CI 2.27-7.29) 4.

Mechanism of Harm

Corticosteroids compromise innate immunity, which is fundamental for defense against influenza virus 1. The immunosuppressive effects facilitate secondary bacterial infections and may delay viral clearance 3, 6. This is particularly concerning as bacterial superinfections (especially with Staphylococcus aureus and Streptococcus pneumoniae) are already a major cause of mortality in severe influenza 1.

Recommended Treatment Instead

Antiviral Therapy

• Oseltamivir 75 mg orally twice daily for 5 days is the primary treatment for hospitalized influenza patients 2, 1.
• Treatment should ideally begin within 48 hours of symptom onset, but hospitalized patients who are severely ill may benefit even when started beyond 48 hours 2, 1.
• Dose reduction to 75 mg once daily is required if creatinine clearance is <30 mL/min 2.

Antibiotic Coverage

• All patients with influenza pneumonia should receive antibiotics to cover bacterial co-infection or secondary infection 1.
• For non-severe pneumonia: oral co-amoxiclav or tetracycline 2.
• For severe pneumonia: intravenous combination of broad-spectrum β-lactamase stable antibiotic (co-amoxiclav or cefuroxime/cefotaxime) plus a macrolide (clarithromycin or erythromycin) 2.
• Coverage should include S. pneumoniae, H. influenzae, M. catarrhalis, and Staphylococcus aureus 1.

Important Exceptions and Caveats

When Corticosteroids May Be Continued

The guideline recommendations do not prohibit clinically appropriate corticosteroid use for other medical indications 1. Specifically:

• Patients with chronic conditions requiring corticosteroids (e.g., severe asthma, COPD exacerbation, adrenal insufficiency) should continue their necessary steroid therapy 2, 1.
• Patients with rheumatic diseases on chronic corticosteroids who develop influenza should continue their steroids but attempt dose reduction to the lowest effective level to avoid adrenal insufficiency 3.
• Abrupt discontinuation of chronic corticosteroids can cause acute adrenal crisis, which is life-threatening 3.
• Patients on refractory septic shock may receive corticosteroids per septic shock protocols, though this remains controversial in influenza 7.

Risk Factors to Consider

Patients already on chronic systemic steroids (≥20 mg prednisolone daily for >1 month, or ≥1 mg/kg/day in children <20 kg) are at higher risk for influenza complications and should be monitored closely 2.

Clinical Bottom Line

Corticosteroids should not be routinely administered to hospitalized influenza patients. The evidence consistently demonstrates harm across multiple outcomes including mortality, secondary infections, and prolonged critical illness 1, 3, 4, 5, 6. Standard treatment consists of oseltamivir, antibiotics for bacterial coverage, and supportive care 2, 1. Continue corticosteroids only when medically necessary for other indications, using the lowest effective dose 1, 3.