Bacterial Infections Where Steroids Are Indicated
Corticosteroids are beneficial and improve outcomes in bacterial meningitis (particularly S. pneumoniae), tuberculous meningitis, tuberculous pericarditis, severe typhoid fever, tetanus, and bacterial keratitis (with specific timing and pathogen considerations), while they should be avoided in Nocardia infections and used cautiously only after infection control is established. 1
Group 1: Infections Where Steroids Improve Survival
Bacterial Meningitis
- Streptococcus pneumoniae meningitis: Corticosteroids reduce mortality (RR 0.84) and should be administered as adjuvant therapy alongside antibiotics 2
- Haemophilus influenzae meningitis: Corticosteroids significantly reduce severe hearing loss (RR 0.34) in children 2
- Overall, corticosteroids reduce severe hearing loss (RR 0.67), any hearing loss (RR 0.74), and neurological sequelae (RR 0.83) in bacterial meningitis 2
- Critical caveat: Benefits are demonstrated primarily in high-income countries; no beneficial effect was found in low-income countries 2
Tuberculous Infections
- Tuberculous meningitis: Corticosteroids improve patient survival when added to antimicrobial therapy 1
- Tuberculous pericarditis: Corticosteroids improve survival outcomes 1
Other Life-Threatening Bacterial Infections
- Severe typhoid fever: Corticosteroids improve survival 1
- Tetanus: Corticosteroids improve patient survival 1
Group 2: Infections Where Steroids Reduce Long-Term Disability
Bacterial Arthritis (Septic Arthritis)
- Corticosteroids reduce long-term disability and joint damage when combined with appropriate antibiotics 1, 3
Group 3: Bacterial Keratitis - Conditional Use with Strict Timing
When Steroids May Be Beneficial
- Pseudomonas keratitis: Subgroup analysis showed potential benefit 4
- Severe bacterial keratitis: Cases with deep stromal involvement, infiltrates >2mm, or vision of counting fingers or worse may benefit 4
- Timing is critical: Adding topical corticosteroids within 2-3 days of antibiotic therapy (rather than after 4+ days) resulted in 1-line better visual acuity at 3 months 4
Conservative Approach Algorithm for Bacterial Keratitis
- Avoid corticosteroids initially until the organism is identified, epithelial defect is healing, and/or ulcer is consolidating 4
- Rule out Nocardia and fungal infection before considering steroids 4
- Wait for at least 2-3 days of progressive improvement with topical antibiotic treatment 4
- Use minimum effective dose to control inflammation 4
- Monitor IOP and examine patient within 1-2 days after initiating steroids 4
Absolute Contraindication in Keratitis
- Nocardia keratitis: Corticosteroid treatment results in poor visual outcomes and should be avoided 4, 5
Critical Safety Principles Across All Bacterial Infections
Pre-Treatment Screening
- Screen carefully for infection before initiating corticosteroid therapy 5
- If infection is present at baseline, ensure it is well-treated and "controlled" before starting steroids 5
Concurrent Antibiotic Therapy is Mandatory
- In patients with baseline infection who received corticosteroids, continued antibiotic therapy was associated with significantly reduced mortality (13% vs 52%) 5
- All beneficial uses of corticosteroids in bacterial infections require concurrent appropriate antimicrobial therapy 1
Duration Considerations
- Courses longer than 3 weeks should be withheld from patients with concomitant HIV infection and low CD4 counts 1
- Risk of infection increases with dose and duration of steroid therapy 6
Common Pitfalls to Avoid
Infections Where Steroids Are Harmful
- Viral hepatitis: Corticosteroids are harmful and should not be used 1
- Cerebral malaria: Corticosteroids are harmful 1
- Nocardia infections: Poor outcomes with corticosteroid use 4, 5
Monitoring Requirements
- Continue monitoring for infection during treatment and follow-up period 5
- Watch for shift toward respiratory infections (40% of episodes) during or after corticosteroid treatment 5
- Monitor for fungal superinfection, particularly invasive aspergillosis 5