1. S TEROID IN INFECTIOUS DISEASES Dr Farhad Abbasi Infectious diseases specialist

2. S TEROIDS AND I NFECTIONS

3. Where? When? How much? How long?

4. B ACTERIAL MENINGITIS Concomitant or before antibiotic therapy Dose: 10 mg stat, 10 mg q6h for 2-4 day Machanism?

5. Dexamethasone0.15 mg/kg IV q6°x4 days Reduced hearing loss 50 % decrease in mortality Decreased neurologic sequelae No adverse effects de Gras and van de Beek. N EnglJ Med 2002;347:1549-1556

6. TUBERCULOUS MENINGITIS Improved patient survival Stage II and III Prednisolone 60-80 mg/day for 2 weeks with tapering in 4 weeks

7. S EPTIC S HOCK 50 mg hydrocortisone q6 hours for 5 days No survival benefit We suggestIV hydrocortisone be given ONLY when unresponsive to fluid resuscitation and vasopressortherapy Sprung et al. N EnglJ Med 2008;358(2):111-124 Dellinger et al. CritCare Med 2008;36(1):296-327

8. S TEROIDS IN S EPSIS ? Inconclusive evidence Diverging expert opinion New trials underway…. “Embrace Uncertainty” Jaeschkeand Angus. 2009 JAMA;301(22):2388- 2390

9. TUBERCULOUS PERICARDITIS Decreased mortality Prednisolone 60 mg for 4 weeks Prednisolone 30 mg for 4 weeks Prednisolone 15 mg for 2 weeks

10. TUBERCULOUS PLEURITIS Steroid hasten symptomatic improvement and fluid resorption but no long term benefit has been shown

11. SEVERE TYPHOID FEVER Significant reduction in mortality Dexamethasone 3 mg/kg IV stat then 8 dose of 1 mg/kg q6h In Pt with altered mental status or shock

13. I NFECTIOUS MONONUCLEOSIS Steroid indiation: 1. Airway obstruction 2. Hemolytic anemia 3. Aplastic anemia 4. Severe thrombocytopenia 5. CNS involvement 6. Myocarditis/ pericarditis 7. Severe prolong prostration

14. Prednisolone 60-80 mg/ day tarared in 1-2 weeks

15. H ERPES Z OSTER

16. 208 patients Age > 50 years and immunocompetent Rash < 72 hours Acyclovir & Prednisone for 21 days Improved quality of life measures, decreased pain, better sleep, return to normal Whitley et al. Ann Intern Med 1996;125:376-383.

17. Acyclovir 800 mg 5 times a day for 7 –10 days ADD if age > 50 years Prednisone: 30 mg BID days 1 –7 15 mg BID days 8 –15 7.5 mg BID days 16 -21

19. P HARYNGITIS & S TEROIDS Meta-analysis 8 Trials: All 8 = earlier reduction in pain (range 5 hours –1 day) No difference in time off work/school No serious adverse events IM steroids no better than PO Korbet al. Ann FamMed 2010:8:58-63

21. B ELL ’ S P ALSY Herpes Simplex Virus Meta-analysis 18 trials ( 2786 patients ) Antivirals alone - Steroids alone + Antivirals AND steroids +++ deAlmediaet al. JAMA 2009;302:985-993.

22. PCP AND S TEROIDS Pneumocystisjiroveci PaO2< 70 mm Hg Reduces respiratory failure and death Prednislone: 80 mg days 1-5 40 mg days 6-10 20 mg days 11-21