Treatment of Infection: Role of Corticosteroids

I have recently seen several patients who were treated for infections by emergency department physicians and who were given oral corticosteroids along with antibiotics. My understanding of the action of corticosteroids is that they suppress the immune system. If this is true, why would they be given to someone who already has an infection?

---- June M. Hite, MSN, CFNP, PhD
     Brownwood, Tex

Although it is true that corticosteroids suppress both cellular and humoral immunity, they also can offer potential benefits in the treatment of an acute infectious disease. Some of the pathology that occurs in an infectious disease consists of damage to the host's tissue caused by the body's own immune response to the infection. In some cases, this phenomenon is exacerbated by antibiotics--presumably through their lysis of organisms, which further stimulates the host immune response.

A number of trials specifically assessed the role of corticosteroids in limiting this immune-mediated destruction. Some settings in which corticosteroids have been found to be beneficial are select cases of Pneumocystis pneumonia^1-3 and bacterial meningitis.⁴ In most instances, the first dose of corticosteroids precedes or coincides with the administration of antimicrobials to limit the immune response to antibiotic-associated lysis of microorganisms.

There has also been renewed interest in the phenomenon of relative adrenal insufficiency associated with sepsis. When this occurs, the administration of exogenous steroids is associated with improved outcomes in some patients.⁵

Even though the indiscriminate administration of corticosteroids is associated with a host of side effects, including immune suppression, their administration to select patients with infection may actually improve outcomes.

---- André N. Sofair, MD MPH
     Assistant Professor of Medicine, Epidemiology, and Public Health
     Yale University School of Medicine
     New Haven, Conn

References:

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Gagnon S, Boota AM, Fischl MA, et al. Corticosteroids as adjunctive therapy for severe

Pneumocystis carinii

pneumonia in the acquired immunodeficiency syndrome. A double-blind, placebo-controlled trial.

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. 1990;323:1444-1450.

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Bozzette SA, Sattler FR, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for

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pneumonia in the acquired immunodeficiency syndrome. California Collaborative Treatment Group.

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Gallant JE, Chaisson RE, Moore RD. The effect of adjunctive corticosteroids for the treatment of

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van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids in acute bacterial meningitis.

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Nguyen HB, Rivers EP, Abrahamian FM, et al; Emergency Department Sepsis Education Program and Strategies to Improve Survival (ED-SEPSIS) Working Group. Severe sepsis and septic shock: review of the literature and emergency department management guidelines.

Ann Emerg Med

. 2006;48:28-54.