Clinicians have generally avoided prescribing corticosteroids for active infection because of their known immunosuppressive effects and concern about long-term complications. We conducted a review of the published randomized, double-blind trials comparing corticosteroids and placebo in infections. Except in some trials of viral infections, sore throat, and cerebral cysticercosis, all patients also received active antimicrobial agents in addition to placebo or corticosteroids. For patients with bacterial meningitis, tuberculous meningitis, tuberculous pericarditis, severe typhoid fever, tetanus, or pneumocystis pneumonia with moderate to severe hypoxemia, treatment with corticosteroids improved patient survival (group 1 infections). For patients with bacterial arthritis, corticosteroids were also beneficial and reduced long-term disability (group 2 infections). For about a dozen other infections, corticosteroids significantly relieved symptoms (group 3 infections), and clinicians should consider using them if symptoms are substantial. Corticosteroids were harmful in 2 infections, viral hepatitis and cerebral malaria (group 5 infections). We conclude that corticosteroids are beneficial and safe for a wide variety of infections, although courses longer than 3 weeks should be withheld from patients with concomitant human immunodeficiency virus infection and low CD4 counts.
Dose and duration of corticosteroid treatment. In the studies reviewed, there was great heterogeneity in the initial corticosteroid dose (A, milligrams of prednisone equivalents, standardized to a 70-kg person)
and duration of treatment (B, days). The values presented represent the average dose and duration from Tables 1, 2, 3, and 4. Because the scale in both parts of the figure is logarithmic, actual heterogeneity is greater than it first appears. The initial daily dose was 40- to 60-mg prednisone equivalents for 50% of infections (most bacterial infections, pulmonary and pericardial tuberculosis) and 100- to 250-mg prednisone equivalents for another 38% of infections (bacterial meningitis, bacterial arthritis, pneumocystis pneumonia, and other forms of tuberculosis). Most viral and bacterial infections responded to 4 to 14 days of treatment, and most tuberculous infections, to 5 to 12 weeks. RSV indicates respiratory syncytial virus.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Internal Medicine editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 32
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Users' Guides to the Medical Literature
Consider an RCT of corticosteroids in patients with an acute exacerbation of chronic obstructive...
The Rational Clinical Examination
Evidence Summary and Review 5
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.