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- Presentation
Infection Prevention and Screening Strategies for Steroid Use
Description
The talk reviews infection prevention when using systemic steroids, emphasizing that corticosteroids suppress both innate and adaptive immunity and increase risk for viral, bacterial, fungal, and opportunistic infections. A major focus is Pneumocystis jirovecii pneumonia (PJP): risk rises around prednisone 20 mg/day for at least 4 weeks, but prophylaxis is generally most justified when steroids are combined with additional risk factors such as cytotoxic drugs, transplant, malignancy, interstitial lung disease, or other immunosuppressants. In dermatology patients, prophylaxis is usually considered in higher-risk scenarios like granulomatosis with polyangiitis, lupus, pemphigus on multi-agent therapy, pyoderma gangrenosum with combination immunosuppression, or similar situations. Preferred prophylaxis is trimethoprim-sulfamethoxazole (often double-strength Monday, Wednesday, Friday), with dapsone or atovaquone as alternatives; prophylaxis should continue until immunosuppression resolves. The lecture also recommends infection screening before anticipated prolonged moderate-to-high dose steroids (roughly 15–20 mg/day for several weeks): test for tuberculosis with IGRA/QuantiFERON, obtain hepatitis B and C serologies, and HIV testing. Positive TB screening should prompt chest imaging and treatment for latent TB if indicated. Vaccination review is also essential: inactivated vaccines can generally be given during steroid therapy, though may be less effective, but live vaccines should be avoided during high-dose chronic steroids and ideally administered 2–4 weeks beforehand. Key vaccines to verify include influenza, pneumococcal, COVID-19, and Shingrix. Overall, the message is to anticipate steroid duration/dose, screen for latent infections, optimize vaccines, and consider PJP prophylaxis when steroids are paired with other risk factors.
View moreConclusions
- Clinically meaningful infection risk from corticosteroids rises mainly when prednisone-equivalent doses reach about 20 mg/day for at least 4 weeks, especially if other immunosuppressive factors are present.
- For Pneumocystis jirovecii pneumonia, steroid use alone usually is not enough to justify prophylaxis; a second risk factor such as transplant, malignancy, interstitial lung disease, or additional immunosuppressive therapy is typically needed.
- Trimethoprim-sulfamethoxazole is the preferred PCP prophylaxis regimen when prophylaxis is warranted, with alternative agents reserved for intolerance or contraindication.
- In dermatology patients, PCP prophylaxis is uncommon overall and should be targeted to higher-risk combinations rather than used routinely for every patient on steroids.
- Before prolonged moderate-to-high dose steroid therapy, patients should be screened for latent or chronic infections such as tuberculosis, hepatitis B, hepatitis C, and HIV.
- Patients expected to receive 15 to 20 mg/day prednisone-equivalent for more than a month should generally receive TB testing with follow-up evaluation if positive.
- High-dose steroids can promote reactivation or worsening of hepatitis B, hepatitis C, and HIV-related infection, supporting pre-treatment screening.
- Vaccination review should be part of the pre-steroid workup, with emphasis on influenza, pneumococcal, COVID-19, and Shingrix status.
- Most inactivated vaccines can still be given during steroid therapy, but their immune response may be weaker.
- Live vaccines should be avoided during high-dose steroid treatment and, when needed, given several weeks before immunosuppression begins.
- The overall best-practice approach is to anticipate steroid-associated infectious complications, screen and vaccinate proactively, and add PCP prophylaxis only when steroid dose and added risk factors make the benefit clear.
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