What is the role of oral prednisolone (corticosteroid) in patients with viral Lower Respiratory Tract Infections (LRTI)?

Oral Prednisolone in Viral Lower Respiratory Tract Infections

Oral prednisolone should NOT be used for viral lower respiratory tract infections in adults without asthma, as it does not reduce symptom duration or severity and provides no clinical benefit. 1

Evidence Against Routine Use in Viral LRTI

The highest quality evidence comes from a 2017 multicenter randomized controlled trial of 398 adults with acute lower respiratory tract infection without asthma. This study definitively showed:

• Cough duration was identical between prednisolone and placebo groups (median 5 days in both groups; adjusted HR 1.11,95% CI 0.89-1.39, P=0.36) 1
• Symptom severity showed no clinically meaningful difference (mean difference -0.20 points on 0-6 scale, which falls far short of the 1.66-point minimal clinically important difference) 1
• No benefit was observed for duration of other LRTI symptoms, abnormal peak flow duration, or antibiotic use 1

Even in patients with clinically unrecognized asthma (identified by wheeze and nocturnal symptoms), prednisolone provided no benefit for viral LRTI, with identical median cough duration of 3 days in both groups 2

Critical Exception: Asthma Exacerbations

The only indication for prednisolone in viral LRTI is when the patient has underlying asthma with an acute exacerbation, regardless of concurrent viral infection:

• Administer prednisone 40-60 mg orally or hydrocortisone 200 mg IV within the first hour of presentation for acute asthma exacerbations 3
• This recommendation applies even when viral LRTI triggers the asthma exacerbation 3
• The steroid treats the asthma exacerbation itself, not the viral infection 3

Pediatric Population: Age-Dependent Considerations

The evidence in children shows conflicting results based on age:

• In children aged 6-35 months with viral respiratory distress, a 3-day course of prednisolone (2 mg/kg/day) reduced hospital length of stay by 1 day (2 vs 3 days, P=0.060) and shortened symptom duration (1 vs 2 days, P<0.001) 4
• However, in preschool children aged 10-60 months with mild-to-moderate viral wheezing, prednisolone showed no benefit over placebo for hospitalization duration (11.0 vs 13.9 hours, P>0.05) or any secondary outcomes 5

Absolute Contraindications

Corticosteroids are absolutely contraindicated in influenza pneumonia due to increased mortality 6

• The FDA warns that corticosteroids increase susceptibility to viral infections and may mask signs of infection 7
• Chickenpox and measles can have more serious or fatal courses in patients on corticosteroids 7

COPD Exacerbations: Different Context

While prednisolone is indicated for COPD exacerbations, this represents bacterial or mixed infections rather than purely viral LRTI:

• Inhaled steroids in COPD patients actually increase the risk of LRTI/CAP rather than prevent it 8, 9
• The European Respiratory Society does not recommend inhaled steroids or long-acting β2-agonists for LRTI prevention 8

Common Pitfalls to Avoid

• Do not prescribe prednisolone for discolored sputum alone, as this reflects inflammation, not bacterial infection requiring steroids 6
• Do not extrapolate asthma treatment guidelines to non-asthmatic viral LRTI - the pathophysiology is fundamentally different 1
• Do not use the IPCAG screening questions (wheeze plus nocturnal symptoms) to justify prednisolone in LRTI, as this approach has been proven ineffective 2

Monitoring If Steroids Are Appropriately Indicated

When prednisolone is used for legitimate indications (asthma exacerbations, COPD exacerbations):

• Monitor for hyperglycemia, which occurs in nearly twice as many steroid-treated patients (RR 1.49) 6
• Watch for signs of immunosuppression and secondary infections 7
• Be aware of HPA axis suppression with prolonged use 7