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.
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