The Effect of Steroid Dosing on Risk of Secondary Infection in COVID-19 Critically Ill Patients

Abstract

Introduction: The COVID pandemic has led to devastating consequences for those afflicted. The use of dexamethasone has proven benefit, although the risks and benefits are not fully characterized nor is the optimal dose of steroid. The benefits of steroids may include reduced inflammation in patients with acute respiratory distress syndrome (ARDS), but the risk might include increased viral replication and/or risk of secondary infection. Using a retrospective review of our ICU experience (prior to RECOVERY NEJM publication) we sought to characterize the relationship between steroid use and secondary infections in COVID-19 patients in order to test the hypothesis that steroid dose may be associated with worse ICU outcomes in some patients. Methods: We conducted a retrospective review of our ICU experience from a large academic medical center. We defined secondary infection as positive bacterial or fungal culture from blood stream, urine or sputum deemed by the clinical team to require intervention. Among 130 consecutive patients who received critical care for COVID-19, we identified 41 who had received steroids in the ICU. Among these, 13 had received steroids prior to secondary infection (GP1) whereas 13 had secondary infection documented prior to receiving steroid (GP2) and 15 received steroids without secondary infection (GP3). Results: We observed mortality in all patients involved in this study (n=130) of 27.7%. Among patients who received steroids (n=41) of 29.3% vs. patients who never received steroids (n=89) of 27%. Mortality specific to the steroids groups was 15.4% for GP1 (n=13) vs. 53.8% for GP2 (n=13) vs. 20% for GP3 (n=15). Conclusions: We did not observe an impact of steroid dosage on the risk of secondary infection in a critically ill cohort of COVID-19 patients. We did observe a high mortality among patients who received steroids following documented secondary infection, but further work will be required to determine if this finding reflects confounding by indication i.e. whether steroids are a marker of sicker patients. Optimal steroid dosage in COVID remains unclear, but higher doses (as were given in the DExa-ARDS study) should be rigorously studied.