In a healthy adult or child with an uncomplicated viral infection such as the common cold, non‑severe influenza, viral gastroenteritis, or uncomplicated viral rash, should systemic glucocorticoids be administered, and under what circumstances are steroids indicated for viral illnesses?

Steroids for Viral Illness

Systemic glucocorticoids should NOT be administered to healthy adults or children with uncomplicated viral infections such as the common cold, non-severe influenza, viral gastroenteritis, or viral rashes. 1, 2

Evidence Against Routine Steroid Use in Uncomplicated Viral Illness

Bronchiolitis in Children

• Corticosteroid medications should not be used routinely in the management of bronchiolitis based on systematic reviews of nearly 1,200 children showing no statistically significant benefit in length of stay, clinical scores, or hospital admission rates. 1
• The American Academy of Pediatrics strongly recommends against routine use of steroids in viral respiratory infections, including bronchiolitis, viral wheezing, or post-viral rhinosinusitis. 2
• Available evidence demonstrates a preponderance of harm over benefit when steroids are used for uncomplicated viral bronchiolitis in children. 1

Influenza and Other Respiratory Viral Infections

• Observational studies evaluating glucocorticoid treatment in influenza demonstrate that this treatment is associated with increased mortality and higher incidence of nosocomial infection. 1, 3
• The American College of Physicians recommends avoiding steroids in most acute respiratory infections except for specific indications like COPD exacerbations, severe allergic reactions, or septic shock unrelated to viral pneumonia. 2

General Viral Infections

• Corticosteroids should not be used in the treatment of non-severe COVID-19 patients because they suppress the immune response and are associated with slow recovery, bacterial infections, hypokalemia, mucormycosis, and increased mortality risk. 4
• The American College of Chest Physicians recommends never using steroids for viral pneumonia or influenza-associated shock. 2

When Steroids ARE Indicated for Viral Illness

Severe COVID-19 with Respiratory Failure

• Glucocorticoids should be used as first-tier immunomodulatory treatment in pediatric patients with severe COVID-19 manifesting as ARDS, shock, or signs of hyperinflammation (elevated LDH, d-dimer, IL-6, CRP, ferritin, decreased lymphocyte count). 1
• Dexamethasone 6 mg daily reduced mortality by 35% in patients on mechanical ventilation and 20% in those requiring supplemental oxygen according to the RECOVERY trial. 5
• Dexamethasone 6 mg once daily (oral or intravenous) for up to 10 days should only be initiated if the patient requires supplemental oxygen, noninvasive ventilation, or mechanical ventilation. 5
• A meta-analysis of 7 randomized clinical trials demonstrated a reduction in mortality in COVID-19 patients treated with glucocorticoids who required respiratory support. 1

SARS with Respiratory Failure

• Corticosteroids are not indicated for routine care of patients with uncomplicated SARS. 1
• Pulse-dose steroid therapy could be used for patients with clinical deterioration manifest by persistent fever, worsening radiographic opacities, and hypoxemic respiratory failure. 1
• The decision to use corticosteroids should be based on careful evaluation of possible benefits compared with risks, as there is uncertainty surrounding effectiveness. 1

Adjunctive Use in Cellulitis/Erysipelas

• In a randomized, double-blind trial of 108 patients with uncomplicated erysipelas, an 8-day tapering course of prednisolone (starting at 30 mg) shortened median healing time, treatment time with IV antibiotics, and hospital stay by 1 day. 1
• Clinicians may consider systemic corticosteroids as an optional adjunct for treatment of uncomplicated cellulitis and erysipelas in selected adult patients to attenuate inflammatory reactions. 1

Critical Pitfalls to Avoid

Timing and Severity Assessment

• Corticosteroids given early in the course of infection or at high doses may delay viral clearance. 1
• In COVID-19 patients not requiring supplemental oxygen, the RECOVERY trial showed no benefit and potential harm from corticosteroids. 5
• Administration of systemic glucocorticoids to patients hospitalized with COVID-19 may increase mortality in those not receiving oxygen at randomization (RR 1.27; 95% CI 1.00-1.61). 6

Secondary Infections

• Steroids cause more infections, especially after invasive procedures (tracheal intubation, central venous catheter), with growth rates of 76.3% in patients with tracheal aspirate receiving steroids versus 54.2% without steroids. 7
• Glucocorticoid use in critically ill patients is associated with increased neuropathy and myopathy. 1
• Strict adherence to infection control measures during steroid treatment is essential to reduce infection risk. 7

Other Complications

• Known complications of glucocorticoids include gastrointestinal bleeding, peptic ulcer perforation, sigmoid diverticular perforation, anastomotic leakage, wound infection, and wound dehiscence. 1
• For SARS management, corticosteroid treatment was associated with psychosis, diabetes, and avascular necrosis. 1

Monitoring Requirements When Steroids Are Used

• Daily oxygen saturation and respiratory status should be tracked. 5
• Monitor for signs of secondary bacterial infection, which may require empiric antibiotics. 5
• Provide prophylactic anticoagulation, as critically ill COVID-19 patients have high thrombotic risk. 5
• Stress ulcer prophylaxis with H2 receptor inhibitors is recommended for critically ill patients. 1