When are steroids indicated for influenza treatment to reduce mortality?

Steroids Should NOT Be Used in Influenza Pneumonia Due to Increased Mortality

Corticosteroids are contraindicated in influenza pneumonia and should be avoided, as they are associated with significantly increased mortality (OR 3.06,95% CI 1.58-5.92), higher rates of bacterial superinfection, and prolonged ICU stays. 1, 2

Guideline Recommendations Against Steroid Use

Major medical societies uniformly recommend against routine corticosteroid use in influenza:

• The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) suggest NOT using corticosteroids routinely in adults with severe influenza pneumonia (conditional recommendation, low-quality evidence) 1

• The Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) recommend avoiding corticosteroids in adults with influenza (conditional recommendation, very low-quality evidence) 1, 3

• The British Infection Society and British Thoracic Society recommend against corticosteroids in hospitalized influenza patients, focusing instead on antivirals, antibiotics for bacterial co-infection, and supportive care 1

• Studies on influenza have found corticosteroids exacerbate infection and increase mortality rates 4

Evidence of Harm from Corticosteroids

The data consistently demonstrates worse outcomes with steroid use:

• Meta-analysis of 13 observational studies (n=1,917 patients) showed mortality OR of 3.06 (95% CI 1.58-5.92) against corticosteroid use 2

• Analysis of four low-bias trials revealed consistent findings (OR 2.82,95% CI 1.61-4.92) with higher risk of superinfection 2

• Corticosteroids increase nosocomial infection risk (OR 3.16,95% CI 2.09-4.78) 5

• Duration of mechanical ventilation increases by 3.82 days (95% CI 1.49-6.15) with steroid use 5

• ICU length of stay increases by 4.78 days (95% CI 2.27-7.29) with corticosteroid treatment 5

Mechanism of Harm

Corticosteroids compromise critical antiviral defenses:

• Innate immunity is fundamental in defending against influenza virus, and corticosteroids compromise this essential immune response 1

• The immunosuppressive effect facilitates bacterial secondary infections 1, 2

• Corticosteroids may delay viral clearance and increase risk of secondary infection 2

Recommended Treatment Instead of Steroids

Focus on evidence-based antiviral and antibiotic therapy:

Antiviral Treatment

• Oseltamivir 75 mg orally twice daily for 5 days is the primary treatment 1
• Initiate within 48 hours of symptom onset for maximum benefit, though hospitalized severely ill patients may benefit even beyond 48 hours 1
• Dose reduction to 75 mg once daily required if creatinine clearance <30 mL/min 1

Antibiotic Coverage

• ALL patients with influenza pneumonia must receive antibiotics to cover bacterial co-infection or secondary infection 1, 3
• Cover S. pneumoniae, H. influenzae, M. catarrhalis, and Staphylococcus aureus 1, 3
• For non-severe pneumonia: oral co-amoxiclav or tetracycline 1
• For severe pneumonia: IV broad-spectrum β-lactamase stable antibiotic plus macrolide 1

Critical Exceptions: When Steroids MUST Be Continued

Do NOT abruptly stop steroids in these specific situations:

Patients on Chronic Corticosteroids

• Patients with chronic conditions requiring corticosteroids (severe asthma, COPD exacerbation) should CONTINUE their necessary steroid therapy 1, 2
• Patients on chronic corticosteroids who develop influenza should continue steroids but attempt dose reduction to the lowest effective level to avoid adrenal insufficiency 1, 2
• Abrupt cessation in patients taking >5 mg/day prednisone or equivalent can cause acute adrenal insufficiency 2

Patients with Rheumatic Diseases

• Continue glucocorticoids but reduce to the lowest possible dose to control underlying disease and prevent adrenal insufficiency 2
• In life-threatening or organ-threatening rheumatic disease manifestations, benefits of maintaining corticosteroids may outweigh risks even with influenza 2

Clinical Algorithm for Steroid Decision-Making

Follow this stepwise approach:

1. Confirm influenza diagnosis via rapid test or PCR 3

2. Assess current steroid use:

   • If NOT on chronic steroids → DO NOT START steroids 4, 1
   • If on chronic steroids → CONTINUE but reduce to minimum effective dose 1, 2

3. Initiate appropriate treatment:

   • Start oseltamivir immediately 1, 3
   • Add antibiotics for bacterial coverage 1, 3
   • Provide supportive care 1

4. Monitor for complications:

   • Watch for bacterial superinfection (occurs in 10.8% of cases) 6
   • Assess for respiratory failure 6

Common Pitfalls to Avoid

• Never start steroids empirically for presumed influenza pneumonia, even if patient appears severely ill 4
• Do not confuse with COVID-19 management where steroids have proven benefit; influenza is different 7
• Avoid abrupt steroid cessation in chronic users due to adrenal crisis risk 2
• Do not delay antivirals while waiting for confirmatory testing; start empirically if high clinical suspicion 1