Patients taking corticosteroid therapy

The need for antimicrobial prophylaxis in patients taking corticosteroid therapy depends on:

corticosteroid dose and potency
duration of therapy and cumulative dose
whether the patient is taking other immunosuppressive drugs
whether the patient has a clinical condition associated with immune compromise (eg malignancy, autoimmune disease, T-cell defects or significant lymphopenia).

Patients taking at least 20 mg of prednisolone daily for more than 2 weeks are at increased risk of infection. For antimicrobial prophylaxis recommendations in patients taking at least 20 mg of prednisolone daily for 2 to 4 weeks, see Antimicrobial prophylaxis for patients taking at least 20 mg of prednisolone daily (or equivalent) for 2 to 4 weeks. For antimicrobial prophylaxis recommendations in patients taking at least 20 mg of prednisolone daily for more than 4 weeks, see Antimicrobial prophylaxis for patients taking at least 20 mg of prednisolone daily (or equivalent) for more than 4 weeks. For patients taking other corticosteroids, see Corticosteroid doses approximately equivalent to prednisolone 20 mg daily for doses approximately equivalent to prednisolone 20 mg. Short-course pulse corticosteroids (eg methylprednisolone 1 g intravenously daily for up to 5 days) may increase the risk of infection, but the role of antimicrobial prophylaxis is unclear—seek expert advice.

Antimicrobial prophylaxis reduces the risk of infection; however, infection can occur despite prophylaxis. Adherence to antimicrobial prophylaxis increases efficacy. Nonpharmacological preventive measures (including infection control, diet and lifestyle strategies) also reduce the risk of infection—see the guidelines listed in Further reading.

For patients taking systemic corticosteroids for a rheumatological condition, see also Specific considerations for use of systemic corticosteroids.

Table 1. Antimicrobial prophylaxis for patients taking at least 20 mg of prednisolone daily (or equivalent) for 2 to 4 weeks
[NB1] [NB2] [NB7]
*Strongyloides stercoralis*
Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB3]. S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for: patients with positive Strongyloides serology patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic. For antimicrobial regimens and duration of therapy, see here.
*Burkholderia pseudomallei*
Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB4]. B. pseudomallei prophylaxis is recommended for: patients with positive B. pseudomallei serology patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease. Consider giving primary prophylaxis during the wet season [NB5] to patients with negative B. pseudomallei serology who live in or visit an endemic area. For antimicrobial regimens and duration of therapy, see here.
Other
Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. See Hepatitis B virus prophylaxis and Prevention of tuberculosis. The risk of *Listeria monocytogenes* meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB6]. If the patient has recurrent oral mucocutaneous or genital herpes simplex virus (HSV) infection, consider suppressive therapy. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.
Note: NB1: It is not possible to establish the precise corticosteroid dosage and duration of therapy that increases the risk of infection. The consensus view of the Antibiotic Expert Groups is that antimicrobial prophylaxis is indicated for patients taking a daily prednisolone dose of at least 20 mg (or equivalent). NB2: For doses of other corticosteroids approximately equivalent to prednisolone 20 mg, see Corticosteroid doses approximately equivalent to prednisolone 20 mg daily. NB3: Patients at risk of acquiring S. stercoralis include those who were born, live in or visit endemic areas. This includes patients from tropical or central Australia or remote Aboriginal and Torres Strait Islander communities, as well as older patients from southern European countries, and refugees and migrants from developing countries. NB4: Tropical regions of Australia refer to regions north of 20°S latitude. This includes areas of Queensland north of Mackay, the Northern Territory north of Tennant Creek, and Western Australia north of Port Hedland. NB5: In tropical regions of Australia, the wet season is usually from October to April. Melioidosis is more common in this season. NB6: For dietary and food safety measures to prevent L. monocytogenes infection, see the Food Standards Australia New Zealand website. NB7: For corticosteroid doses approximately equivalent to prednisolone 20 mg daily see here

Table 2. Antimicrobial prophylaxis for patients taking at least 20 mg of prednisolone daily (or equivalent) for more than 4 weeks
[NB1] [NB2] [NB7]
Pneumocystis jirovecii pneumonia (PJP)
PJP prophylaxis is indicated for patients with at least one of the following risk factors: a condition associated with immune compromise (eg malignancy, T-cell defects, significant lymphopenia) an active autoimmune disease such as dermatological or rheumatological conditions (eg rheumatoid arthritis, scleroderma, systemic lupus erythematosus), giant cell arteritis or sarcoidosis use of other immunosuppressive drugs. For antimicrobial regimens, see here. Duration of PJP prophylaxis: The optimal duration of PJP prophylaxis is uncertain. Assess the patient’s level of immune compromise and risk of infection before stopping PJP prophylaxis. Review the benefit of ongoing prophylaxis regularly. After stopping corticosteroids, continue PJP prophylaxis for at least 6 weeks. However, a longer duration of prophylaxis may be needed if the patient is taking other immunosuppressive drugs—seek expert advice. If the corticosteroid dose has been tapered to below 20 mg daily of prednisolone (or equivalent) but is unlikely to be stopped, the need for ongoing PJP prophylaxis is uncertain—seek expert advice.
*Strongyloides stercoralis*
Perform baseline Strongyloides serology in patients with a past or present epidemiological risk of acquiring S. stercoralis [NB3]. S. stercoralis prophylaxis (or pre-emptive treatment) is recommended for: patients with positive Strongyloides serology patients with negative serology who live in or visit an area in which S. stercoralis infection is endemic. For antimicrobial regimens and duration of therapy, see here.
*Burkholderia pseudomallei*
Perform baseline B. pseudomallei serology in patients who live or have lived in an endemic region such as tropical regions of Australia [NB4]. B. pseudomallei prophylaxis is recommended for: patients with positive B. pseudomallei serology patients with a history of melioidosis (B. pseudomallei infection) but no clinical evidence of current disease. Consider giving primary prophylaxis during the wet season [NB5] to patients with negative B. pseudomallei serology who live in or visit an endemic area. For antimicrobial regimens and duration of therapy, see here.
Other
Hepatitis B virus and tuberculosis reactivation can occur—some patients require antimicrobial treatment. See Hepatitis B virus prophylaxis and Prevention of tuberculosis. The risk of *Listeria monocytogenes* meningitis is increased. Consult local protocols and consider dietary and food safety measures to prevent L. monocytogenes infection [NB6]. If the patient has recurrent oral mucocutaneous or genital herpes simplex virus (HSV) infection, consider suppressive therapy. See Recurrent oral mucocutaneous herpes and Suppressive therapy for genital herpes.
Note: NB1: It is not possible to establish the precise corticosteroid dosage and duration of therapy that increases the risk of infection. The consensus view of the Antibiotic Expert Groups is that antimicrobial prophylaxis is indicated for patients taking a daily prednisolone dose of at least 20 mg (or equivalent). NB2: For doses of other corticosteroids approximately equivalent to prednisolone 20 mg, see Corticosteroid doses approximately equivalent to prednisolone 20 mg daily. NB3: Patients at risk of acquiring S. stercoralis include those who were born, live in or visit endemic areas. This includes patients from tropical or central Australia or remote Aboriginal and Torres Strait Islander communities, as well as older patients from southern European countries, and refugees and migrants from developing countries. NB4: Tropical regions of Australia refer to regions north of 20°S latitude. This includes areas of Queensland north of Mackay, the Northern Territory north of Tennant Creek, and Western Australia north of Port Hedland. NB5: In tropical regions of Australia, the wet season is usually from October to April. Melioidosis is more common in this season. NB6: For dietary and food safety measures to prevent L. monocytogenes infection, see the Food Standards Australia New Zealand website. NB7: For corticosteroid doses approximately equivalent to prednisolone 20 mg daily see here

Table 3. Corticosteroid doses approximately equivalent to prednisolone 20 mg daily
Corticosteroid	Route	Equivalent daily dose
cortisone acetate	oral	100 mg
dexamethasone	oral, intravenous, intramuscular	3 mg
hydrocortisone	oral, intravenous, intramuscular	80 mg
methylprednisolone sodium succinate	intravenous, intramuscular	16 mg
prednisone	oral	20 mg