Clinical review: a systematic review of corticosteroid use in infections

The impact of inappropriate steroid exposure before the diagnosis of Kawasaki disease

BACKGROUND

Kawasaki disease (KD) is a systemic inflammatory disease characterized by vasculitis. In South Korea, some pediatric doctors empirically prescribe steroids to control febrile pediatric patients. This study aimed to evaluate the clinical characteristics of patients with KD after steroid exposure.

METHODS

This was a single-center, retrospective, observational study. This study included patients (aged ≤15 years) between January 2020 and July 2022. We compared two groups, one group exposed to steroids and the other group who were not, using the Student's t-test or analysis of variance; otherwise, the Mann-Whitney U test or Kruskal-Wallis test was conducted. Statistical significance was set at p < 0.05.

RESULTS

In total, 190 patients with KD were enrolled; of these, 64 (33.7 %) had a history of steroid exposure, and 126 (66.3 %) had no history of steroid exposure. In the steroid exposure group, prolonged fever duration (6.72 ± 1.72 versus 5.61 ± 1.19, p-value = <0.001), a lower proportion of complete KD (29.69 % vs. 88.10 %, p-value = <0.001), and a significantly lower level of C-reactive protein were observed. However, no significant correlations were observed between the Transthoracic Echocardiography (TTE) results (coronary artery aneurysm, existence of pericardial effusion) and prognostic factors (days of hospitalization, the number of intravenous immunoglobulin administrations, and Kobayashi score) between the two groups.

CONCLUSIONS

Patients with KD and previous steroid exposure may exhibit an incomplete KD phenotype with prolonged fever. Although previous steroid exposure does not affect the prognosis of KD, including coronary artery aneurysms, it may mask the classic features of KD, resulting in a delayed diagnosis.

Enteric Fever-Associated Hemophagocytic Lymphohistiocytosis: A Systematic Review of Clinical Characteristics and Outcomes

Enteric fever is a major contributor to rising health care costs in developing countries. Associated disease-related complications and drug resistance further compound this problem. Hemophagocytic lymphohistiocytosis (HLH) is an uncommon complication of enteric fever with high morbidity and mortality. This systematic review aimed to evaluate the clinical characteristics and treatment outcomes in enteric fever-associated HLH syndrome. We searched major electronic databases (PubMed, Google Scholar, and Scopus) to identify the cases of enteric fever associated with HLH from inception until June 2023. Prespecified data regarding clinical presentation, outcomes, and HLH therapy were collected. A total of 53 cases of enteric fever with HLH were included in the final analysis. The mean age of patients was 20 years, and the proportions of female and pediatric patients were 52.8% and 45.3%, respectively. The mean duration of illness was 10.4 days. A total of 39.6% of patients had enteric fever-associated complications; coagulopathy and encephalopathy were the most common (23.1% and 13.5%). The overall mortality rate was 9.4% in HLH. A total of 51% of patients received HLH-specific therapy (corticosteroids in 41.5% and intravenous immunoglobulin in 20.8% of patients). On multivariate analysis, high ferritin levels (≥5,000 ng/mL) were significantly associated with mortality (hazard ratio, 3.01; 95% CI = 0.62-14.12, P = 0.041). Enteric fever with secondary HLH is associated with high mortality. This review reveals the potential role of ferritin in disease prognosis. In cases with significantly elevated ferritin levels, the role of immunosuppressants or combination antibiotics should be explored.

Simultaneous control of infection and inflammation with keratin-derived antibacterial peptides targeting TLRs and co-receptors

Controlling infection-driven inflammation is a major clinical dilemma because of limited therapeutic options and possible adverse effects on microbial clearance. Compounding this difficulty is the continued emergence of drug-resistant bacteria, where experimental strategies aiming to augment inflammatory responses for enhanced microbial killing are not applicable treatment options for infections of vulnerable organs. As with corneal infections, severe or prolonged inflammation jeopardizes corneal transparency, leading to devastating vision loss. We hypothesized that keratin 6a-derived antimicrobial peptides (KAMPs) may be a two-pronged remedy capable of tackling bacterial infection and inflammation at once. We used murine peritoneal neutrophils and macrophages, together with an in vivo model of sterile corneal inflammation, to find that nontoxic and prohealing KAMPs with natural 10- and 18-amino acid sequences suppressed lipoteichoic acid (LTA)- and lipopolysaccharide (LPS)-induced NFκB and IRF3 activation, proinflammatory cytokine production, and phagocyte recruitment independently of their bactericidal function. Mechanistically, KAMPs not only competed with bacterial ligands for cell surface Toll-like receptor (TLR) and co-receptors (MD2, CD14, and TLR2) but also reduced cell surface availability of TLR2 and TLR4 through promotion of receptor endocytosis. Topical KAMP treatment effectively alleviated experimental bacterial keratitis, as evidenced by substantial reductions of corneal opacification, inflammatory cell infiltration, and bacterial burden. These findings reveal the TLR-targeting activities of KAMPs and demonstrate their therapeutic potential as a multifunctional drug for managing infectious inflammatory disease.

Corticosteroids Use and Incidence of Severe Infections in People Living with HIV Compared to a Matched Population

Background:

People living with HIV (PLWH) have been shown to have an increased risk of autoimmune diseases. Corticosteroids are the cornerstone of autoimmune diseases treatment, but their use is associated with an increased risk of infections. It is unclear how HIV status affects the risk of infection associated with corticosteroids use.

Methods:

We conducted a retrospective cohort study from 1991 to 2011, using a medico-administrative database from Quebec. Medical billing codes were used to identify PLWH, and we matched them on age, sex, and index date with up to 4 HIV-negative controls. The exposure of interest was the use of corticosteroids, defined as a systemic corticosteroid dispensation lasting at least 20 days. The outcome of interest was hospitalization for severe infection. Crude and adjusted incidence rates ratios of infection were obtained using a random effect Poisson model, and results were stratified by HIV status.

Results:

In total, 4798 PLWH were matched to 17 644 HIV-negative controls, among which 1083 (22.6%) PLWH and 1854 (10.5%) HIV-negative controls received at least one course of corticosteroid. The mean duration of corticosteroids use was 4 ± 4.4 months in PLWH and 1.6 ± 5.5 months in HIV-negative controls. The incidence rate ratio (IRR) for infections associated with corticosteroids use was 2.49[1.71–3.60] in PLWH and 1.32[0.71–2.47] in HIV-negative controls (P value for interaction 0.18). The most frequent infections were pulmonary infections (50.4%), followed by urinary tract infections (26%) and opportunistic infections (10.5%).

Conclusion:

Although our interaction term did not reach significance, the increased risk of infection associated with corticosteroids use was more pronounced in PLWH. However, further research with contemporary data is warranted to confirm if the risk associated with corticosteroids use remains high in PLWH with well-controlled HIV infection.

Recalcitrant Staphylococcus aureus Infections: Obstacles and Solutions

Antibiotic treatment failure of Staphylococcus aureus infections is very common. In addition to genetically encoded mechanisms of antibiotic resistance, numerous additional factors limit the efficacy of antibiotics in vivo Identifying and removing the barriers to antibiotic efficacy are of major importance, as even if new antibiotics become available, they will likely face the same barriers to efficacy as their predecessors. One major obstacle to antibiotic efficacy is the proficiency of S. aureus to enter a physiological state that is incompatible with antibiotic killing. Multiple pathways leading to antibiotic tolerance and the formation of tolerant subpopulations called persister cells have been described for S. aureus Additionally, S. aureus is a versatile pathogen that can infect numerous tissues and invade a variety of cell types, of which some are poorly penetrable to antibiotics. It is therefore unlikely that there will be a single solution to the problem of recalcitrant S. aureus infection. Instead, specific approaches may be required for targeting tolerant cells within different niches, be it through direct targeting of persister cells, sensitization of persisters to conventional antibiotics, improved penetration of antibiotics to particular niches, or any combination thereof. Here, we examine two well-described reservoirs of antibiotic-tolerant S. aureus, the biofilm and the macrophage, the barriers these environments present to antibiotic efficacy, and potential solutions to the problem.

Length of hospital stay among oral and maxillofacial patients: a retrospective study

OBJECTIVES

: Many conditions of the oral and maxillofacial region require hospitalization and in-patient care. The average length of stay (LOS) of these patients varies and is usually affected by multiple confounding variables. However, even with an increasing number of hospital admissions, published evidence on the factors that affect the LOS of oral and maxillofacial patients is lacking. Therefore, this study assessed the LOS of in-patients at the oral and maxillofacial surgery department of a government-funded, multi-specialty hospital in Malaysia, based on their reasons for admission and other factors.

MATERIALS AND METHODS

Our samples were collected retrospectively over a 5-year period and included patients with maxillofacial infections, post-trauma stabilization, facial bone fracture surgery, benign and malignant lesion surgery, dentoalveolar surgery, and other maxillofacial surgeries as reasons for admission. Factors potentially affecting LOS were also recorded, and their significance was determined using multiple logistic regression analyses. A P-value of less than 0.05 was considered to be statistically significant.

RESULTS

A total of 1,380 patients were included in this study. Most (84.5%) of our in-patients were of Malay ethnicity, and males outnumbered females in our sample by 502 subjects. The median LOS of our in-patients was 3 days. Sex, ethnicity, age, reason for admission, and American Society of Anesthesiology (ASA) classification were factors that significantly affected LOS.

CONCLUSION

The median LOS reported in this study was 3 days. LOS was significantly affected by sex, ethnicity, age, reason of admission and ASA classification.

The Binary Classification Of Chronic Diseases

Acute diseases start with an insult and end when insult disappears. If the trauma induces an immune reaction (which happens in most cases), this reaction must be terminated with some type of resolution mechanism, when the cause of the trauma ceases. Chronicity develops if insult is permanent or if the resolution mechanism is defective. Another way to reach disease chronicity is a positive feedback loop, whereby the immune reaction activates an internal, insult-like reaction. A distinction between chronic states characterized by a persistent, low suppressive effect and those characterized by a persistent, high suppressive effect of regulatory T cells (Treg), is proposed. This two-class division represents two ways to reach chronicity: (a) by maintaining inflammatory reaction long after insult disappears ("low Treg"), or (b) by suppressing inflammatory reaction prior to the disappearance of insult ("high Treg"). This two-class division may explain the strong association between certain pathogens and cancer, on one hand, and between several other pathogens and autoimmunity, on the other hand. The weak association between autoimmune diseases and HIV infection and the relatively weak association between autoimmune diseases and cancer may be elucidated as well. In addition, the model rationalizes why immune-modulating drugs, which are effective in cancer, are also effective in "high Treg" viral infections, while corticosteroids, which are generally effective in autoimmune diseases, are also effective in other "low Treg" diseases (such as asthma, atopic dermatitis, and "low Treg" infections) but are not effective in solid malignancies and "high Treg" infections. Moreover, the model expounds why certain bacteria inhibit tumor growth and why these very bacteria induce autoimmune diseases.

Outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in HIV-infected patients when using systemic steroids and/or intravenous immunoglobulins in Pietermaritzburg, South Africa

Background

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe life-threatening mucocutaneous reactions. There is an ongoing controversy regarding the use of systemic corticosteroids and intravenous immunoglobulin (IVIG) in SJS/TEN and their utility in HIV-infected patients.

Objectives

The objective was to assess the outcome of a combination of intensive supportive care with oral corticosteroids in SJS and a combination of systemic steroids and IVIG for 3 consecutive days in HIV-infected patients with TEN. In addition, we assessed management in a general dermatology ward without implementing wound debridement.

Methods

This was a retrospective cohort study of 36 HIV-infected adults with SJS/TEN admitted to a tertiary dermatology unit between 1st January 2010 and 31st July 2011. Standard-of-care protocols included identification and elimination of the possible causative drug, meticulous wound care without debridement, initiation of oral prednisone (1 mg/kg/day) on admission for 3 consecutive days, and the addition of IVIG (1 g/kg/day) for 3 consecutive days to those with TEN.

Results

Of the 36 patients in the study, 32 were female. Nevirapine was the commonest drug implicated. A diagnosis of tuberculosis did not increase the case fatality rate. Complications included infections, anaemia, drug-induced hepatitis, ocular involvement, renal impairment, deep vein thrombosis, respiratory distress, Leucopenia, gastritis and hypernatremia. The overall survival rate was 97%.

Conclusion

HIV-infected SJS and TEN patients were treated in a tertiary dermatology ward with a treatment plan of skin care, and a combination of systemic corticosteroids and IVIG respectively had a survival rate of 97%.

Management of Systemic Steroid in HIV Patient with Toxoplasma Papillitis

BACKGROUND

Toxoplasmosis is a zoonotic disease caused by Toxoplasma gondii. Ocular manifestations are seen in both congenital and acquired toxoplasmosis. These can include focal inflammation within or around the optic nerve head (papillitis). Purpose of this study is evaluating the efficacy of systemic steroid in HIV patient with toxoplasma papillitis.

CASE PRESENTATION

We present a case report of a male, 46 years old with a decrease of visual acuity on the right eye for three weeks before admission to the hospital. An ophthalmology examination showed visual acuity of the right eye 1/60, mild dilatation of the pupil and posterior synechiae, vitreous was hazy, and fundus examination showed optic nerve head not well demarcated and hyperaemic with the good retina and macula reflex. Laboratory examination showed reactive anti-Toxoplasma immunoglobulin G. Patient had been treated with antiretroviral and anti-Toxoplasma drugs, then he was given steroid 250 mg intravenously four times per day for three days and tapering off orally. Visual acuity on the right eye improve from 1/60 became 6/60 after use of steroid on the third day.

DISCUSSION

Steroid can improve visual acuity for toxoplasma papillitis in this patient. But the long term and close follow up in steroid therapy is needed.

Drug incompatibilities in the adult intensive care unit of a university hospital

Objectives

This study sought to identify the physical and chemical incompatibilities among the drugs administered intravenously to patients admitted to an adult intensive care unit. We also aimed to establish pharmaceutical guidelines for administering incompatible drugs.

Methods

This cross-sectional, prospective, and quantitative study was conducted from July to September 2015. Drug incompatibilities were identified based on an analysis of the patient prescriptions available in the hospital online management system. A pharmaceutical intervention was performed using the guidelines on the preparation and administration of incompatible drugs. Adherence to those guidelines was subsequently assessed among the nursing staff.

Results

A total of 100 prescriptions were analyzed; 68 were incompatible with the intravenous drugs prescribed. A total of 271 drug incompatibilities were found, averaging 4.0 ± 3.3 incompatibilities per prescription. The most commonly found drug incompatibilities were between midazolam and hydrocortisone (8.9%), between cefepime and midazolam (5.2%), and between hydrocortisone and vancomycin (5.2%). The drugs most commonly involved in incompatibilities were midazolam, hydrocortisone, and vancomycin. The most common incompatibilities occurred when a drug was administered via continuous infusion and another was administered intermittently (50%). Of the 68 prescriptions that led to pharmaceutical guidelines, 45 (66.2%) were fully adhered to by the nursing staff.

Conclusion

Patients under intensive care were subjected to a high rate of incompatibilities. Drug incompatibilities can be identified and eliminated by the pharmacist on the multidisciplinary team, thereby reducing undesirable effects among patients.

The Therapeutic Potential of Targeting Substance P/NK-1R Interactions in Inflammatory CNS Disorders

The inflammatory responses of resident central nervous system (CNS) cells are now known to play a critical role in the initiation and progression of an array of infectious and sterile neuroinflammatory disorders such as meningitis, encephalitis, Parkinson's disease, Alzheimer's disease and multiple sclerosis (MS). Regulating glial inflammatory responses in a timely manner is therefore critical in preserving normal CNS functions. The neuropeptide substance P is produced at high levels within the CNS and its selective receptor, the neurokinin 1 receptor (NK-1R), is abundantly expressed by neurons and is present on glial cell types including microglia and astrocytes. In addition to its functions as a neurotransmitter in the perception of pain and its essential role in gut motility, this tachykinin is widely recognized to exacerbate inflammation at peripheral sites including the skin, gastrointestinal tract and the lungs. Recently, a number of studies have identified a role for substance P and NK-1R interactions in neuroinflammation and described the ability of this neuropeptide to alter the immune functions of activated microglia and astrocytes. In this review article, we describe the expression of substance P and its receptor by resident CNS cells, and we discuss the ability of this neuropeptide to exacerbate the inflammatory responses of glia and immune cells that are recruited to the brain during neurodegenerative diseases. In addition, we discuss the available data indicating that the NK-1R-mediated augmentation of such responses appears to be detrimental during microbial infection and some sterile neurodegenerative disorders, and propose the repurposed use of NK-1R antagonists, of a type that are currently approved as anti-emetic and anti-anxiolytic agents, as an adjunct therapy to ameliorate the inflammatory CNS damage in these conditions.

Steroids alone or as adjunctive therapy with doxycycline fail to improve oviduct damage in mice infected with Chlamydia muridarum

In women, Chlamydia trachomatis can ascend from the cervix to the fallopian tubes, where an overly aggressive host inflammatory response can cause scarring that leads to chronic pelvic pain, infertility, or ectopic pregnancy. Although screening and treatment programs for women have resulted in decreased rates of sequelae, morbidities associated with oviduct scarring continue to occur. Since corticosteroids have anti-inflammatory and antifibrotic effects, we tested the ability of dexamethasone to inhibit inflammation and prevent oviduct scarring in mice genitally infected with Chlamydia muridarum. The administration of 1 or 2.5 mg/kg of body weight of dexamethasone on days 7 to 21 of infection resulted in reduced accumulation of inflammatory cells in the oviducts compared to that in controls. However, a concomitant increase in bacterial burden was observed, and chronic oviduct disease was not reduced. Adjunctive administration of a prolonged (21-day) or short (3-day) course of dexamethasone in combination with the antibiotic doxycycline also failed to reduce chronic oviduct pathology compared to antibiotic treatment alone. Steroids administered alone or adjunctively with antibiotics failed to prevent oviduct damage in this murine model of C. trachomatis infection.

Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure

Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza. Specific modalities covered include conservative fluid management, prone positioning, inhaled nitric oxide, inhaled vasodilatory prostaglandins, and extracorporeal membrane oxygenation and life support. Pharmacologic strategies (including steroids) investigated for the treatment of severe respiratory failure are also reviewed.

Should we abandon corticosteroids during septic shock? No

PURPOSE OF REVIEW

With the publication of the results of the recent CORTICUS trial, stress ('low') doses of corticosteroids for the treatment of vasopressor-dependent septic shock in adults can still be considered controversial. The purpose of this narrative review is to elaborate the pros and cons of this treatment in clinical practice and to formulate clinical and research directions.

RECENT FINDINGS

The recent CORTICUS study only shows a beneficial effect of stress doses of corticosteroids in the time interval to shock reversal and not on mortality, potentially explained by an increased risk for superinfection. The mortality in the placebo arm was relatively low and lower than in earlier randomized studies in which stress doses of corticosteroids had a favorable hemodynamic effect and conferred a survival benefit in septic shock.

SUMMARY

Treatment by stress doses of corticosteroids should not be abandoned during septic shock. Additional studies are needed, however, to better delineate the patient group with the highest likelihood to benefit from this therapy, as a function of severity of illness, response to adrenocorticotrophic hormone testing or both. For now, results of the CORTICUS study should not change current clinical practice of administering 200-300 mg of hydrocortisone daily (in divided doses) in case of fluid and vasopressor-insensitive septic shock and rapid tapering of this treatment on the basis of a hemodynamic response.