Can steroids be administered to a patient with an active infection?

Can Steroids Be Given With Active Infection?

Steroids can be administered during active infection in specific clinical scenarios when the infection is adequately treated with appropriate antimicrobials, but this requires careful patient selection, infection control, dose limitation, and vigilant monitoring. 1, 2, 3

Critical Decision Framework

When Steroids Are Beneficial Despite Active Infection

Group 1: Infections Where Steroids Improve Survival (when combined with appropriate antimicrobials):

• Bacterial meningitis 3
• Tuberculous meningitis 3
• Tuberculous pericarditis 3
• Severe typhoid fever 3
• Tetanus 3
• Pneumocystis pneumonia with moderate to severe hypoxemia 3, 4
• Severe community-acquired bacterial pneumonia (reduces 30-day mortality from 16% to 10%) 4
• Severe COVID-19 requiring oxygen or mechanical ventilation (dexamethasone 6 mg daily reduces 28-day mortality from 26% to 23%) 4

Group 2: Infections Where Steroids Reduce Long-Term Disability:

• Bacterial arthritis 3

Absolute Contraindications - Never Give Steroids

Group 5: Infections Where Steroids Are Harmful:

• Viral hepatitis 3
• Cerebral malaria 2, 3
• Influenza pneumonia (increases mortality with OR 3.06) 5

Infections Requiring Extreme Caution

High-Risk Scenarios Requiring Infection Control First:

• Active tuberculosis without adequate treatment 2
• Systemic fungal infections (avoid unless needed for drug reactions) 2
• Active amebiasis 2
• Strongyloides infestation (risk of hyperinfection syndrome and fatal gram-negative septicemia) 2
• Hepatitis B carriers (risk of reactivation) 2

Practical Management Algorithm

Step 1: Screen for Contraindicated Infections

• Rule out cerebral malaria, viral hepatitis, and influenza before initiating steroids 2, 3
• Screen for latent tuberculosis, hepatitis B, Strongyloides, and systemic fungal infections 2, 6

Step 2: Ensure Adequate Antimicrobial Coverage

If infection is present at baseline, it must be well-treated and "controlled" before starting steroids 1

• In patients with baseline infection receiving prednisolone, continued antibiotic therapy reduced mortality from 52% to 13% 1
• For tuberculosis: provide chemoprophylaxis during prolonged steroid therapy 2
• For varicella exposure: consider varicella zoster immune globulin prophylaxis 2
• For measles exposure: consider immunoglobulin prophylaxis 2

Step 3: Use Appropriate Steroid Dosing

Do NOT use high-dose steroids (hydrocortisone ≥300 mg/day or prednisolone ≥75 mg/day) in active infection 7

• High-dose steroids increase hospital-acquired infections, hyperglycemia, and gastrointestinal bleeding without mortality benefit 7
• For severe pneumonia: limit to methylprednisolone 1-2 mg/kg/day (or equivalent) for 3-5 days 5
• For COVID-19: dexamethasone 6 mg daily for up to 10 days 5, 4

Step 4: Implement Prophylaxis for High-Risk Patients

PCP Prophylaxis: Required for patients receiving ≥20 mg methylprednisolone equivalent for ≥4 weeks 5, 6

GI Prophylaxis: Proton pump inhibitor for all patients receiving steroids for grade 2-4 conditions 5

Bone Protection: Calcium and vitamin D supplementation with prolonged use 5

Special Clinical Scenarios

COVID-19 Patients

Do stop/reduce corticosteroids whenever possible in COVID-19 patients 7

• Do NOT continue prednisone at doses above 20 mg/day 7
• Steroid use at COVID-19 presentation was associated with 19% ICU admission rate and 11% death rate 7
• However, for severe COVID-19 requiring oxygen, dexamethasone 6 mg daily is beneficial 4

IBD Patients With Infection

• Stop azathioprine/mercaptopurine therapy 7
• Stop JAK inhibitors 7
• Do not restart treatment until negative PCR-SARS-CoV-2 test (if available) 7

Surgical Patients

Corticosteroids significantly increase surgical complications 7:

• Increased risk of anastomotic leakage 7
• Increased wound infection and dehiscence 7
• Risk of gastrointestinal bleeding and peptic ulcer perforation 7
• Risk of sigmoid diverticular perforation 7

Infection Risk Stratification

Dose and Duration-Dependent Risk

The risk of infection increases with:

• Doses >20 mg prednisone equivalent daily 1, 6
• Duration >4 weeks of continuous therapy 6
• Combination with other immunosuppressive agents 1

Infection Types to Monitor

During or after corticosteroid treatment, expect shift toward 1:

• Respiratory infections (40% of all episodes) 1
• Bacterial infections (90% of infectious episodes) 1
• Invasive aspergillosis (16% incidence in high-risk populations during 3-month follow-up) 1
• Pneumocystis pneumonia (very high mortality rates) 1

Critical Monitoring Requirements

During Treatment

• Monitor for development of new infections continuously 2, 6
• Screen for secondary bacterial superinfection 5
• Monitor glucose levels (hyperglycemia risk increases with RR 1.49) 5
• Discontinue immunosuppressive agent during acute infection episodes 6

Common Pitfalls to Avoid

1. Starting steroids before adequate fluid resuscitation in septic shock 7
2. Using steroids in presumed bacterial ulcers before organism identification and antibiotic response 1
3. Failing to provide antimicrobial prophylaxis in high-risk patients 1, 6
4. Continuing high-dose steroids (>20 mg/day prednisone) during active viral infection 7
5. Ignoring the need for infection screening before initiating immunosuppressive treatment 5