Does prednisolone use increase the risk of sepsis in a patient with a recent history of antibiotic exposure and a traumatic tendon rupture?

Prednisolone and Sepsis Risk in Patients with Traumatic Tendon Rupture

The question appears to conflate two distinct concerns: prednisolone does NOT increase sepsis risk in the context of traumatic tendon rupture with recent antibiotic exposure, but it DOES dramatically increase the risk of further tendon complications, particularly if fluoroquinolone antibiotics were used.

The Core Issue: Tendon Rupture Risk, Not Sepsis

The provided evidence addresses tendon complications, not sepsis. Concomitant corticosteroid use with fluoroquinolones increases the risk of Achilles tendon rupture to an odds ratio of 43.2, meaning 1 in 979 patients will experience rupture 1. This represents the primary morbidity concern in this clinical scenario.

Risk Stratification for Tendon Complications

If the patient received fluoroquinolone antibiotics:

• The risk of additional tendon rupture escalates dramatically with prednisolone use (OR 43.2 for Achilles tendon rupture) 1
• This risk is highest in patients over 60 years (1 rupture per 1,638 treated patients vs. 1 per 5,958 in general population) 1
• Bilateral involvement occurs in more than half of cases, so the contralateral tendon is also at risk 2

If non-fluoroquinolone antibiotics were used:

• Oral corticosteroids still increase tendon rupture risk (OR 1.4) 3
• Injected corticosteroids carry higher risk (OR 2.2) 3
• The absolute risk is substantially lower than with fluoroquinolone combination 3

Clinical Decision Algorithm

For patients with traumatic tendon rupture and recent antibiotic exposure:

1. Identify the antibiotic class used - fluoroquinolones (ciprofloxacin, levofloxacin) carry the highest risk when combined with corticosteroids [@1-3@]

2. If fluoroquinolones were used within 90 days:

   • Strongly avoid systemic corticosteroids due to 43-fold increased rupture risk 1
   • Consider alternative anti-inflammatory strategies
   • The risk window extends 90 days post-fluoroquinolone exposure 1

3. If non-fluoroquinolone antibiotics were used:

   • Corticosteroids carry moderate risk (OR 1.4) but may be used with caution if clinically necessary 3
   • Monitor closely for contralateral tendon symptoms 2

4. Consider magnesium supplementation if corticosteroids are deemed essential, as fluoroquinolones chelate magnesium affecting collagen synthesis 2, 4

Critical Pitfalls to Avoid

• Do not assume the traumatic rupture is purely mechanical - 50% of fluoroquinolone-associated tendon disorders occur during sports or physical activity, suggesting the drug weakens the tendon making it susceptible to "traumatic" rupture 2

• Symptoms can appear as late as 6 months after fluoroquinolone discontinuation, so recent exposure history is critical 2

• Only 26% of patients fully recover from fluoroquinolone-associated tendon disorders, with 74% reporting persistent pain and disability 2

• Other tendons beyond the Achilles are at risk, including patellar, rotator cuff, and hand/foot tendons 2

Regarding Sepsis Risk

The evidence provided does not support an increased sepsis risk from prednisolone in this clinical context. The primary concern is additional tendon rupture and impaired healing, which directly impacts morbidity and quality of life. Corticosteroids may theoretically increase infection risk through immunosuppression, but this is not the documented complication pattern in tendon rupture patients with recent antibiotic exposure.