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Steroids for Acute Orbital Cellulitis or a Retropharyngeal/Parapharyngeal Abscess: Should We Use Them or Not?

October 27, 2021

The use of steroids as adjuvant therapy in addition to antibiotics for a serious bacterial infection is a practice that many of us consider to reduce inflammation. But is it the right thing to do? This week, two articles being early released in our journal address this question in regard to two types of infections—acute orbital cellulitis and retropharyngeal/parapharyngeal abscesses, both using registry data from the Pediatric Health Information System (PHIS), which includes data from up to 51 free-standing children’s hospitals.

Leszczynska et al (10.1542/peds.2021-050677) analyzed a retrospective cohort of 5,645 children under 18 years of age from 2007 to 2018 with acute orbital cellulitis to see if the use of corticosteroids was associated with reduced length of stay, surgical interventions, intensive care admission, or 30-day readmission. 1,347 of these patients received steroids and no reduction in length of stay was associated with their use. On the other hand, steroid use was associated with significantly increased intensive care admissions and operative care after two days of hospitalization.

Goenka et al (10.1542/peds.2020-037010) also conducted a multicenter retrospective study using data from the PHIS registry. The authors report on 2,259 patients between 2 months and 8 years of age with a retropharyngeal/parapharyngeal abscess (RPA/PPA) between 2016 and 2019 to see if the use of systemic corticosteroids was associated with reduced need for surgical drainage. 582 of these patients received steroids and had a significantly lower rate of surgical drainage, but no difference in length of stay. The group of children receiving steroids also had lower hospital costs and were less likely to have opioid medications administered for pain, although they did also have a higher 7-day revisit rate to the emergency department but no increase in readmissions 30 days after discharge.

So, does this mean we should be avoiding steroids for acute orbital cellulitis and using them for treatment of RPA/PPA? Not necessarily, according to an important accompanying commentary by Drs. Ellen Wald and Jens Eickhoff from the University of Wisconsin (10.1542/peds.2021-053062). They point out the strengths of both studies but also the limitations inherent in the retrospective use of data from the PHIS registry due to residual confounders. They raise the question of whether those who got steroids in the cellulitis study may be sicker than those who did not, leading to the negative findings. In both cases, the use of PHIS data does not allow determining whether observed associations are causally related.

So, what do we do? Drs. Wald and Eickhoff along with the authors of these studies call for prospective randomized controlled trials to provide a definitive answer. Until then, check out both of these large studies and the commentary to better understand the potential benefits versus the risks of using steroids as adjuvant therapy to antibiotics for serious bacterial infections as well as the benefits versus the risks of using large administrative data bases like PHIS.

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