Glucocorticoids infection risk

In loiasis both adult and microfilariae are susceptible to diethylcarbamazine. However, encephalitis is a major risk in patients with heavy infestation (SEDA-17, 356) (7), and ivermectin should be preferred. Severe allergic reactions can need treatment with antihistamines and glucocorticoids. The risk of encephalitis has led to the recommendation that prophylactic use of diethylcarbamazine against Loa loa should only be contemplated when the chance of infection is considerable. 

Infection risk Patients receiving infliximab are more susceptible to serious infections, including mycobacterial infections [128 ] and pneumonia [129 ]. Concomitant treatment with glucocorticoids was the only independent susceptibility factor for infections in patients with inflammatory bowel disease treated with infliximab [130. ... 

Therapy of coccidioidomycosis is difficult, and the results are unpredictable. Only 5% of infected persons require therapy. Candidates for therapy include those with severe primary pulmonary infection or concurrent risk factors (e.g., human immunodeficiency virus infection, organ transplant, or high doses of glucocorticoids), particularly patients with high complement fixation antibody titers in whom dissemination is likely. 

Glucocorticoids are widely used as drugs to treat arthritis and dermatitis. In pharmacological doses, they are used to suppress various allergic, inflammatory and autoimmune diseases. They are also administered as post-transplant immunosuppressants. Nevertheless, they do not prevent infection and they also inhibit subsequent regenerative processes. Excessive glucocorticoid levels have side effects on many systems, such as the inhibition of bone formation, delayed wound healing, muscle weakness and an increased risk of infection. 

The most common side effects of glucocorticoids when used to prevent transplant rejection include hyperglycemia, increased risk of infection, poor wound healing,... 

Bacterial keratitis is one of the most frequent ophthalmic infections. In a meta-analysis of publications from 1950 to 2000, the use of a topical glucocorticoid before the diagnosis of bacterial keratitis significantly predisposed to ulcerative keratitis in eyes with preexisting corneal disease (OR = 2.63 95% Cl = 1.41, 4.91). Previous glucocorticoid use significantly increased the risk of antibiotic failure or other infectious complications (OR = 3.75 95% Cl = 2.52, 5.58). The use of glucocorticoids with an antibiotic for the treatment of bacterial keratitis did not increase the risk of complications, but neither did it improve the outcome of treatment. 

In a retrospective study, postoperative infectious complications were evaluated in 159 patients with inflammatory bowel disease undergoing elective surgery (317). Immunosuppression consisted of glucocorticoid monotherapy (n = 56), a glucocorticoid + azathioprine or mercaptopurine (n — 52), and neither a glucocorticoid nor azathioprine or mercaptopurine (n — 51). The adjusted odds ratios for any infection and major infections in patients who took glucocorticoid were 3.69 and 5.54 respectively, and in patients who took azathioprine or mercaptopurine 1.68 and 1.20. Thus, preoperative use of glucocorticoid in patients with inflammatory bowel disease increased the risk of postoperative infectious complications. 

The authors commented that the onset of the lung infection appeared to be closely related to methotrexate and glucocorticoid pulse therapy, because of the interval between drug administration and the onset of tuberculosis, and the lack of other risk factors for opportunistic infections. 

In a retrospective study that included 163 consecutive recipients of allogenic hemopoietic stem cell transplants with invasive fungal infections, the possible role of glucocorticoid therapy was evaluated. The administration of high-dose glucocorticoids (2 mg/kg/day or more) was associated with an increased risk of mold infection (HR = 4.0, 95% Cl = 1.7, 9.6) and an increased risk of mold infection-related death (1 year survival 11% compared with 44% when patients took doses less than 2 mg/ kg/day) (343). 

Pneumocystis jiroveci pneumonia has been precipitated or aggravated by glucocorticoids (SEDA-20, 377 SEDA-22, 450 272,350,351). There is some concern about the use of glucocorticoids as adjunctive therapy in patients with AIDS who develop Pneumocystis jiroveci pneumonia. The immunosuppressant properties of glucocorticoids have been reported to enhance the risk of tuberculosis and other AIDS-related diseases (for example Kaposi s sarcoma or cytomegalovirus infection). 

Glucocorticoids inhibit the formation of antibodies. Of 111 consecutive heart transplant recipients taking oral prednisone (mean 13.8 months), 57% developed hypogammaglobulinemia (IgG below 7 g/1) (266). Those with severe hypogammaglobulinemia (IgG below 3.5 g/1) were at increassed risk of opportunistic infections compared with those with IgG concentrations over 3.5 g/1 (55 versus 5%, OR = 23). Parenteral glucocorticoid pulse therapy... 

In a retrospective study, the use of glucocorticoids during Pneumocystis jiroveci pneumonia (mean total dose methylprednisolone 420 mg, mean treatment duration 12 days) did not increase the risk of development or relapse of tuberculosis or other AIDS-related diseases (SEDA-20, 377) (276). The study included 129 patients (72 who took glucocorticoids and 57 who did not) who were followed up at 6,12,18, and 24 months of glucocorticoid therapy. The rates of infections were similar in both groups, and the cumulative rate of tuberculosis at 2 years was 12-13%. 

The main adverse effect of pimecrolimus is local skin irritation, with a stinging or burning sensation, which occurs in 30% of patients. Typically, children have less skin irritation than adults. Adverse effects such as local immunosuppression and an increased risk of local bacterial and viral infections (notably eczema herpeticum) are less common than with topical glucocorticoids (5). In addition, there is a lack of skin atrophy (6,7). However, topical corticosteroids have the advantage of better skin penetration than pimecrolimus and will therefore continue to be used for more heavily keratinized skin such as in psoriasis (8). 

Intra-articular glucocorticoid injections can provide excellent pain relief, particularly when ajoint effusion is present. Aspiration of the effusion and injection of glucocorticoid are carried out aseptically, and examination of the aspirate to exclude crystalline arthritis or infection is recommended. After injection, the patient should minimize activity and stress on the joint for several days. The risk of infection is estimated at 1 in 50,000 joint injections. 

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