Adding anti-inflammatory corticosteroids to antibiotics for certain pediatric throat and ocular infections may have some benefit, according to results from two recent database studies, but their benefit remains unclear.
Dr. Pratichi K. Goenka
Using steroids in this setting is a practice many pediatricians consider, although no clear guidance exists.
Drawing on data from a registry of 51 free-standing children’s hospitals in the Pediatric Health Information System (PHIS), and published online in Pediatrics, the analyses looked, respectively, at retro- and parapharyngeal abscesses (RPAs/PPAs) and acute orbital cellulitis.
Throat abscesses
In the first study, pediatrician Pratichi K. Goenka, MD, of Cohen Children’s Medical Center–Northwell Health and an assistant professor at Hofstra University, both in New Hyde Park, N.Y., and colleagues reported on the effect of systemic corticosteroids on several outcomes in RPAs/PPAs in 2,259 well-matched patients. The patients, aged 2 months to 8 years, were treated at 46 hospitals during the period from January 2016 to December 2019.
The data revealed that the 582 (25.8%) who received steroids had a significantly lower rate of surgical drainage, the study’s primary endpoint (odds ratio, 0.28; 95% confidence interval, 0.22-0.36). There was no difference, however, in length of hospital stay (rate ratio, 0.97; 95% CI, 0.92-1.02).
Those in the steroid group also had lower overall hospital costs and were less likely to be given opioid medications for pain. They were, however, more likely to undergo repeat CT imaging and also had a higher 7-day ED revisit rate but no increase in readmission 30 days after discharge: 4% versus 3% in the nonsteroid group (P = .29).
“As hospitalists, we share the care of young children with RPAs and PPAs with our otolaryngology colleagues. The primary therapy is antibiotics but there was no clear guidance on the next step, and the current literature had no answers as to how systemic corticosteroids might impact the care of these children,” Dr. Goenka said in an interview. “So we wanted to leverage the PHIS data to better understand the association with the need for surgery and length of stay. Surgery is painful and often involves IV administration of opioid painkillers. It’s something we may be able to avoid if we can optimize medical treatment.”
Pending results from randomized trials, what immediate impact could these registry findings have? “We hope that physicians will think about the best initial medical treatment plan for these children,” Dr. Goenka said. ”Given these data, I would be more likely to incorporate steroids early on in medical treatment.”
She emphasized, however, that before routine adoption prospective studies are needed to clearly identify which patients will have a strong benefit and which will not benefit. “That is the nuanced discussion that will happen with more prospective work.”
Dr. Goenka and associates explained that the rising incidence of RPAs and PPAs over the past 20 years has been attributed to more cases of tonsillitis because of a shift away from tonsillectomies, as well as the changing epidemiology of methicillin-resistant Staphylococcus aureus.
In an accompanying editorial, Ellen R. Wald, MD, and Jens C. Eickhoff, PhD, of the University of Wisconsin–Madison, stated that the use of corticosteroids in bacterial meningitis is often cited as an example of the benefits of steroids in infection. “The specific rationale for use of corticosteroids is [their] anti-inflammatory effects, which may result in decreases of swelling and/ or edema to facilitate drainage, perfusion, reduction in pain, and healing.”
They cautioned, however, that the pharmacologic effects of steroids are myriad and complicated, and include potential masking of the clinical course of disease, thereby delaying appropriate therapy for unrecognized deterioration, as well potential immunosuppression.