Steroid Use in Influenza: Not Recommended
No, it is not safe to routinely give steroids to someone with influenza—current guidelines explicitly recommend against corticosteroid use in influenza infection due to increased mortality, higher rates of secondary bacterial infections, and delayed viral clearance. 1, 2
Primary Guideline Recommendations
The Infectious Diseases Society of America (IDSA) provides an A-III recommendation that clinicians should not administer corticosteroid adjunctive therapy for adults or children with suspected or confirmed seasonal influenza, unless clinically indicated for other reasons such as pre-existing conditions requiring steroids. 2
Both the American Thoracic Society (ATS) and IDSA suggest not using corticosteroids routinely in adults with severe influenza pneumonia (conditional recommendation, low-quality evidence). 1
The British Infection Society and British Thoracic Society similarly recommend against corticosteroid use in hospitalized influenza patients. 1
Evidence of Harm
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 with OR of 2.82 (95% CI: 1.61-4.92). 2
- A comprehensive meta-analysis of 19 studies with 4,916 patients found corticosteroids significantly associated with mortality (OR 1.98,95% CI 1.62-2.43). 3
Secondary Infections
- Corticosteroid treatment is associated with a 3.16-fold increased risk of nosocomial infections (OR 3.16,95% CI 2.09-4.78). 3
- Pooled analysis showed increased odds of hospital-acquired infection (OR 2.74,95% CI 1.51-4.95). 4
Prolonged Critical Illness
- Duration of mechanical ventilation is significantly longer (weighted mean difference 3.82 days, 95% CI 1.49-6.15). 3
- ICU stay duration is markedly prolonged (weighted mean difference 4.78 days, 95% CI 2.27-7.29). 3
Mechanism of Harm
Corticosteroids compromise innate immunity, which is fundamental in defending against influenza virus. 1
The immunosuppressive effects facilitate secondary bacterial infections and may delay viral clearance. 1, 2
Recommended Treatment Instead
Antiviral Therapy
- Oseltamivir 75 mg orally twice daily for 5 days is the primary treatment for influenza. 1
- Treatment should begin as soon as possible, ideally within 48 hours of symptom onset, though hospitalized patients may benefit even when started later. 1, 2
Antibiotic Coverage
- All patients with influenza pneumonia should receive antibiotics to cover bacterial co-infection or secondary infection. 1
- Coverage should include S. pneumoniae, H. influenzae, M. catarrhalis, and Staphylococcus aureus. 1
Critical Exceptions: When Steroids Should Be Continued
Pre-existing Steroid-Dependent Conditions
- Patients with chronic conditions requiring corticosteroids (severe asthma, COPD exacerbation, rheumatic diseases) should continue their necessary steroid therapy. 1, 2
- In patients with rheumatic diseases who develop influenza, continue glucocorticoids but reduce to the lowest effective dose to control the underlying disease and avoid adrenal insufficiency. 2
Avoiding Adrenal Crisis
- Never abruptly discontinue steroids in patients on chronic therapy (>5 mg/day prednisone or equivalent) due to risk of acute adrenal insufficiency. 2
- Gradual dose reduction is essential rather than abrupt cessation. 2
Common Pitfalls to Avoid
Do not use steroids empirically for influenza symptoms or pneumonia, even in severe cases, as this contradicts current evidence showing harm. 1, 2
Do not confuse COVID-19 evidence with influenza—while steroids benefit severe COVID-19, they are harmful in influenza. 5
Do not withhold steroids from patients with legitimate indications (asthma exacerbation, adrenal insufficiency) simply because they have concurrent influenza. 1, 2
Monitor patients already on chronic steroids closely as they are at higher risk for influenza complications. 1