What is the appropriate use of steroids, such as prednisolone, in patients with Lower Respiratory Tract Infections (LRTI), particularly those with a history of respiratory conditions like asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Steroid Use in Lower Respiratory Tract Infections

Oral corticosteroids should NOT be used for acute lower respiratory tract infections in adults without asthma or COPD, as they do not reduce symptom duration or severity and provide no clinical benefit. 1

Evidence Against Routine Steroid Use in LRTI

The landmark 2017 JAMA trial definitively demonstrated that prednisolone 40 mg daily for 5 days in adults with acute LRTI (without asthma) showed:

• No difference in cough duration: 5 days in both prednisolone and placebo groups (HR 1.11,95% CI 0.89-1.39, p=0.36) 1
• No clinically meaningful difference in symptom severity: mean difference of only -0.20 points on a 0-6 scale (95% CI -0.40 to 0.00, p=0.05), well below the minimal clinically important difference of 1.66 units 1
• No effect on antibiotic use or other secondary outcomes 1

This finding held true even in patients with clinically unrecognised asthma identified by wheeze and nocturnal symptoms, where prednisolone showed no benefit (cough duration difference 0.24 days, 95% CI -1.23 to 2.88 days; symptom severity difference -0.14,95% CI -0.78 to 0.49) 2

When Steroids ARE Indicated in Respiratory Infections

Asthma Exacerbations with LRTI

Systemic corticosteroids are essential for acute asthma exacerbations, regardless of concurrent LRTI. 3

• Administer prednisone 40-60 mg orally or hydrocortisone 200 mg IV within the first hour of presentation 3
• The Infectious Diseases Society of America recommends antibiotics only when there is strong evidence of bacterial infection (radiographic pneumonia, purulent sputum with fever, clinical sinusitis) 3
• For community-acquired LRTI requiring antibiotics, aminopenicillin for 5-7 days is first-line 3

COPD Exacerbations

Prednisolone is indicated for COPD exacerbations but does NOT prevent LRTI. 4

• Inhaled steroids in COPD patients actually increase the risk of LRTI/CAP rather than prevent it 4, 5
• While inhaled steroids may decrease acute exacerbations in COPD subgroups, they do not decrease LRTI risk 4

Severe Community-Acquired Pneumonia

Low-dose corticosteroids reduce mortality in severe CAP requiring ICU admission. 6

• Hydrocortisone ≤400 mg daily for ≤8 days was associated with lower 30-day mortality (10% vs 16%) in a meta-analysis of 1,689 ICU patients with severe bacterial CAP 6
• The American College of Physicians recommends low-dose corticosteroids for severe CAP with high inflammatory markers or septic shock, using 5-7 days of treatment 5
• Methylprednisolone 0.5 mg/kg IV every 12 hours or prednisone 50 mg daily for 5-7 days for severe CAP with high inflammatory response 5

Septic Shock from Pneumonia

Hydrocortisone 50 mg IV every 6 hours plus fludrocortisone 50 μg daily for 7 days in septic shock from pneumonia decreased mortality (39% vs 51%) 6

Critical Contraindication

Corticosteroids are absolutely contraindicated in influenza pneumonia due to increased mortality. 5

Common Pitfalls to Avoid

Inappropriate Prescribing Patterns

Despite lack of evidence, steroid use in ARTI is alarmingly common:

• 11.8% of patients with ARTI received systemic steroids in a nationwide US study of nearly 10 million patients 7
• There was high geographical variability with adjusted OR of 14.48 for parenteral steroids in southern versus northeastern US 7
• An increasing trend from 2007 to 2016 (aOR 1.93 comparing 2016 to 2007) suggests worsening inappropriate prescribing 7

Key Clinical Errors

• Do not prescribe steroids for uncomplicated LRTI based on discolored sputum alone, as this reflects inflammation, not bacterial infection 8
• Do not use the IPCAG wheeze questions to target oral corticosteroid treatment in patients with ALRTI, as even those with unrecognised asthma showed no benefit 2
• Do not extrapolate COPD exacerbation guidelines to simple LRTI without underlying chronic lung disease 1

Adverse Effects to Monitor

When steroids are appropriately indicated, monitor for:

• Hyperglycemia (occurs in nearly twice as many steroid-treated patients, RR 1.49) 5, 9
• Gastrointestinal bleeding 6
• Neuropsychiatric disorders 6
• Muscle weakness 6
• Hypernatremia 6
• Secondary infections including sinusitis 6, 9

FDA-Approved Indications for Prednisolone

The FDA label for prednisolone includes respiratory indications for:

• Asthma (as distinct from allergic asthma) 10
• Acute exacerbations of COPD 10
• Symptomatic sarcoidosis, idiopathic eosinophilic pneumonias, hypersensitivity pneumonitis, idiopathic pulmonary fibrosis 10
• Pneumocystis carinii pneumonia with hypoxemia in HIV+ individuals under appropriate antibiotic treatment 10

Notably, simple acute lower respiratory tract infection is NOT an FDA-approved indication for prednisolone 10