When are corticosteroids (CS) recommended for flu treatment?

Corticosteroids in Flu Treatment

Corticosteroids should NOT be administered for the treatment of seasonal influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons (such as pre-existing adrenal insufficiency or refractory septic shock). 1

Primary Recommendation

The Infectious Diseases Society of America (IDSA) explicitly states that clinicians should not administer corticosteroid adjunctive therapy for adults or children with suspected or confirmed seasonal influenza (A-III recommendation). 1 This recommendation applies across all severity levels, including:

• Uncomplicated influenza 1
• Influenza-associated pneumonia 1
• Respiratory failure 1
• Acute respiratory distress syndrome (ARDS) 1

Evidence Supporting This Recommendation

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 2
• Analysis of four low-bias trials showed consistent findings (OR: 2.82; 95% CI: 1.61-4.92) 2
• A multicenter study of 241 patients with influenza-associated ARDS found that early corticosteroid treatment (≥200 mg hydrocortisone equivalent within 3 days) was independently associated with increased hospital mortality [adjusted OR 5.02 (95% CI: 2.39-10.54)] 3
• Higher doses and earlier treatment correlated with higher mortality 3

Infectious Complications:

• Corticosteroids significantly increase the risk of nosocomial infections (OR 3.16,95% CI: 2.09-4.78) 4
• Increased odds of subsequent bacteremia [adjusted OR 2.37 (95% CI: 1.01-5.56)] 3
• Secondary bacterial infections are more common with corticosteroid use 2

Prolonged Disease Course:

• Mechanical ventilation duration increased by 3.82 days (95% CI: 1.49-6.15) 4
• ICU stay prolonged by 4.78 days (95% CI: 2.27-7.29) 4

Critical Exceptions: When Corticosteroids May Be Continued

Patients on Chronic Corticosteroid Therapy:

• If a patient with rheumatic disease develops symptomatic influenza, continue glucocorticoids but reduce to the lowest possible dose to control the underlying disease and prevent adrenal insufficiency 2
• Never abruptly discontinue corticosteroids in patients receiving >5 mg/day prednisone equivalent due to risk of acute adrenal crisis 2
• Gradual tapering is required for patients on long-term corticosteroid therapy 2

Life-Threatening Underlying Conditions:

• In patients with severe organ-threatening or life-threatening rheumatic disease manifestations, the benefits of maintaining corticosteroids may outweigh risks even with concurrent influenza 2

Refractory Septic Shock:

• Corticosteroids may be considered for septic shock refractory to vasopressors and fluid resuscitation, but this is for shock management, not influenza treatment per se 5

Mechanism of Harm

The immunosuppressive effects of corticosteroids:

• Facilitate secondary bacterial infections 6
• Compromise innate immune responses necessary to combat influenza virus 6
• May delay viral clearance 1, 7

Proper Management Algorithm for Influenza

Instead of corticosteroids, focus on:

1. Immediate antiviral therapy with neuraminidase inhibitors (oseltamivir, zanamivir, or peramivir) as soon as possible, regardless of time since symptom onset in severe cases 1, 8

2. Empiric antibacterial coverage for patients presenting with severe disease (extensive pneumonia, respiratory failure, hypotension) to cover coinfection with S. pneumoniae, H. influenzae, M. catarrhalis, and S. aureus 1, 6

3. Investigate bacterial coinfection in patients who deteriorate after initial improvement or fail to improve after 3-5 days of antiviral treatment 1, 8

Common Pitfall to Avoid

Do not extrapolate evidence from COVID-19 corticosteroid benefits to influenza—the evidence for these two viral pneumonias differs dramatically. While corticosteroids show benefit in severe COVID-19, they consistently demonstrate harm in influenza. 5, 7