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- Presentation
Infection Prevention and Screening Guidelines for Steroid Use
Description
The talk reviewed infection prevention and screening for patients receiving systemic steroids, emphasizing that risk rises around prednisone 20 mg/day or equivalent for four or more weeks, especially when combined with other immunosuppressive factors. For Pneumocystis jirovecii pneumonia, prophylaxis should be considered when high-dose steroids are paired with additional risks such as cyclophosphamide, rituximab, transplant, hematologic malignancy, interstitial lung disease, or certain severe dermatologic/rheumatologic diseases; trimethoprim-sulfamethoxazole is the usual first-line prophylaxis, with dapsone or atovaquone as alternatives. Before starting prolonged moderate-to-high dose steroids, patients should be screened for tuberculosis, hepatitis B and C, and HIV, similar to pre-biologic screening. TB evaluation begins with IGRA/Quantiferon and follows positive tests with chest imaging and further workup, with latent TB treated when indicated. The speaker also reviewed vaccination guidance: inactivated vaccines are safe though possibly less effective during immunosuppression, while live vaccines should be avoided once patients are on significant steroids and ideally given 2 to 4 weeks beforehand. Priority vaccines include influenza, pneumococcal, COVID-19, and Shingrix, with special attention to zoster risk in immunosuppressed patients. Additional discussion touched on practical issues such as timing of screening versus urgent steroid initiation, rare consideration of Strongyloides based on geography or travel history, and the importance of warning patients about steroid mood effects even with short courses.
View moreConclusions
- Glucocorticoids substantially increase infection risk by suppressing both innate and adaptive immunity, so prevention planning should begin before or at steroid initiation.
- A practical threshold for heightened infectious concern is about prednisone 20 mg/day or equivalent for four or more weeks, especially when additional immunosuppressive factors are present.
- Routine Pneumocystis jirovecii pneumonia prophylaxis is usually not needed for most dermatology patients on steroids alone, but should be considered when high-dose steroids are combined with other major risk factors such as cytotoxic therapy, transplant, hematologic malignancy, interstitial lung disease, or GPA.
- When PJP prophylaxis is warranted, trimethoprim-sulfamethoxazole is the preferred regimen, with dapsone or atovaquone as alternatives.
- Patients expected to receive moderate-to-high dose steroids for weeks should be screened for latent or chronic infections such as tuberculosis, hepatitis B, hepatitis C, and HIV before treatment when feasible.
- TB testing is particularly relevant when prolonged prednisone is planned, because corticosteroids can increase the risk of progression from latent to active tuberculosis.
- Vaccination status should be reviewed in patients likely to need prolonged steroid therapy, and needed catch-up vaccines should ideally be given before immunosuppression begins.
- Inactivated vaccines can still be given during steroid therapy, although immune response may be reduced.
- Live vaccines should generally be avoided during significant steroid immunosuppression and, when needed, given well before steroids are started.
- Varicella-zoster risk is increased with glucocorticoid use, so zoster vaccination with Shingrix is an important preventive step for eligible patients.
- The overall approach is to combine risk stratification, targeted screening, and vaccination rather than giving universal infection prophylaxis to every patient on steroids.
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