Improving Outcomes, Improving Throughput, Mythbusting

Steroids, Cellulitis, and the IV Antibiotics Hoax.

There’s been a rash of literature on steroids for infectious processes, and today’s post is no different. At the end of 2014, a study came out looking at 31 pediatric patients at a tertiary children’s hospital diagnosed with orbital cellulitis that were evaluated for the efficacy of adjuvant steroids.  All patients were initially treated with IV antibiotics and surgical decompression was performed as indicated by previously published criteria, regardless of treatment arm.  CRP was measured daily, and when it was below 4 mg/dl, 1 mg/kg of oral prednisone once daily for 7 days was initiated.


Admittedly, the numbers are small – only 24 patients received steroids while only 7 did not.  More patients in the steroid group underwent surgery before prednisone initiation (13/24, 54% vs 2/7, 29%).  Likewise, patients in the steroid treatment arm had a shorter length of stay after initiation of steroids (1.1 days vs 4.9 days), and had less time overall in the hospital (3.96 days vs 7.17 days) with one case of recurrence in both treatment arms, and no cases of vision loss or permanent ocular disability in either group.


Why wait for a number to tell you to start treating with steroids when this trial of 21 patients initiated oral steroids after an initial clinical response to IV antibiotics.  The steroid treated arm had better visual acuity, decreased residual ptosis, proptosis, and improved extracoular movements compared to those not treated with steroids with a significantly decreased length of stay and decreased duration of IV antibiotics.


Better yet, why start IV antibiotics? Or at least why not rapidly transition the patient to oral antibiotics?  This trial of 19 patients with orbital cellulitis started empirically on oral ciprofloxacin and oral clindamycin showed no difference between oral and IV therapy.  Again, small numbers, emerging trend.  Previous trials have shown oral antibiotics as sole treatment to be effective for high risk cases such as neutropenic fever, endocarditis and osteomyelitis.  The thought of “needing to stay for IV antibiotics” when an equivalent and efficacious oral alternative exists is downright silly – not to mention associated costs for the patient without an improvement in their care.


Don’t want to start steroids?  Well at least consider NSAIDs- where this trial showed that 83% of patients treated with 400mg of ibuprofen every 6 hours had regression of inflammation at 1-2 days vs only 9% of those treated without NSAIDs.  There is little reason aside from being allergic to everything not named vancomycin to start IV antibiotics for most infectious processes.


One thought on “Steroids, Cellulitis, and the IV Antibiotics Hoax.

  1. Pingback: Dueling (dual-ing?) cellulitis therapy! | EM in Focus

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