Clinical review: A systematic review of corticosteroid use in infections

Traditional teaching suggests that corticosteroids impair the ability of the body to fight infection and that this may prove catastrophic if an appropriate antibiotic is not chosen. In recent years, however, the early use of steroid therapy has become progressively established in a wide range of infective conditions [1,2], including septic shock, its most severe systemic manifestation. We thus decided to conduct a systematic review of the literature to identify the current strength of evidence for the use of corticosteroids in specified infections, and to make appropriate graded recommendations.The Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE) and the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2005) were searched using medical subject headings (MeSH) for steroids, glucocorticoids, adrenal cortex hormones AND (virus diseases OR bacterial infections OR mycoses). In addition, phase 1 of the Cochrane highly sensitive strategy for randomised controlled trials [3] AND a steroid search (Table 1) AND search terms for specific clinical entities were utilised in both MEDLINE and EMBASE.Systematic reviews published since 1999 formed the mainstay of analysis. Trials published more recently, or not considered by the reviews, were also included. For infections with no prior review, original articles are summarised. The abstracts thus obtained were scanned for relevance, and the original papers retrieved. Specific clinical entities are reviewed in order of the strength of evidence, proceeding through meta-analyses of multiple well-controlled trials to single small studies and case reports.Table 2 shows the systems used to grade the level of evidence and consequent level of recommendation for the use of corticosteroids for each specified infection.The use of steroids in septic shock has been the subject of controversy for five decades. The lack of benefit reported by two large multi-centre randomised trials [