Can Budesonide Inhalation Be Continued During Bacterial Respiratory Infections in Asthma Patients?
Yes, patients with asthma should continue their budesonide inhalation therapy during bacterial respiratory infections, as inhaled corticosteroids are maintenance therapy for underlying airway inflammation and should not be discontinued. 1
Key Clinical Principles
Budesonide is not a bronchodilator and does not treat acute infections—it treats the underlying asthma inflammation that must be controlled regardless of concurrent infections. 1 The FDA label explicitly states that budesonide inhalation suspension is not indicated for rapid relief of acute bronchospasm or acute asthma episodes, but this does not mean it should be stopped during infections. 1
Evidence Supporting Continued Use
The 2020 National Asthma Education and Prevention Program guidelines specifically recommend starting or continuing inhaled corticosteroids during respiratory tract infections in asthmatic patients. 2 For children aged 0-4 years with recurrent wheezing, the guidelines conditionally recommend a short course of daily ICS (budesonide 1 mg twice daily for 7-10 days) at the onset of respiratory tract infection symptoms, which resulted in a 33% relative risk reduction in exacerbations requiring systemic corticosteroids. 2
A 2020 retrospective study of 98 hospitalized asthma patients found that budesonide inhalation suspension use was associated with shorter hospital stays (6.0 vs 8.5 days), faster symptom recovery (2.5 vs 5.0 days), and reduced costs—irrespective of the presence or absence of respiratory infection. 3
Clinical trials spanning over 20 years demonstrate that budesonide effectively controls asthma symptoms and is well-tolerated during respiratory infections. 4, 5
Important Distinction: Antibiotics vs. Inhaled Corticosteroids
The 1993 British Thoracic Society guidelines state that antibiotics should only be given if bacterial infection is present, but this recommendation applies to antibiotics—not to inhaled corticosteroids. 2 This is a critical distinction: antibiotics treat bacterial infections directly, while budesonide treats the underlying asthma inflammation that can worsen during any respiratory infection (viral or bacterial).
Three pediatric asthma guidelines explicitly discourage routine antibiotic use during asthma exacerbations unless bacterial infection is confirmed, but none recommend stopping inhaled corticosteroids. 2
Clinical Implementation
When to Continue Budesonide
- Maintain regular maintenance doses during bacterial respiratory infections. 1
- Consider increasing to higher doses or adding systemic corticosteroids if asthma control deteriorates, but do not stop the inhaled corticosteroid. 2, 1
- For children with recurrent infection-triggered wheezing, consider intensifying to budesonide 1 mg twice daily for 7-10 days at infection onset. 2
When to Add Antibiotics
Add antibiotics only when there is clear evidence of bacterial infection (purulent sputum, elevated inflammatory markers, radiographic consolidation), but continue the budesonide throughout. 2
Critical Safety Monitoring
- Patients on budesonide are more susceptible to serious infections like chickenpox and measles due to immunosuppression, requiring careful exposure avoidance and prophylaxis if exposed. 1
- Monitor for oral candidiasis (thrush) during infections, as the combination of inhaled corticosteroids and potential antibiotic use increases risk—instruct patients to rinse mouth after each inhalation. 1
- Watch for signs of systemic corticosteroid effects if patients require both inhaled budesonide and oral/IV corticosteroids for severe exacerbations during bacterial infections. 1
Common Pitfalls to Avoid
Do not discontinue budesonide when starting antibiotics for bacterial respiratory infections—this is the most common error. The inhaled corticosteroid controls airway inflammation, while antibiotics treat bacterial infection; both may be needed simultaneously. 2, 1
Do not confuse the recommendation against routine antibiotics in asthma exacerbations with a recommendation against inhaled corticosteroids. 2 These are separate therapeutic decisions addressing different pathophysiologic processes.
Ensure patients understand that budesonide is not treating the infection itself but preventing asthma worsening during the infection. 1 Patients may mistakenly stop their controller medication when starting antibiotics, thinking the antibiotic will "replace" their asthma medication.