When should corticosteroids be used for COVID-19 infection?

At the beginning of the COVID-19 pandemic there was therapeutic mayhem, with a large variety of potentially toxic drugs given to critically ill patients, frequently in combination [1]. Most of these drugs have since been shown to be ineffective and their contribution to the high mortality rate in initial reports remains to be counted. From early on, there has been considerable debate as to the potential benefit of the use of corticosteroids in infected patients [2]. Initial recommendations from a number of organisations, institutions and societies, including the Infectious Diseases Society of America (these guidelines, initially published in April 2020, have recently been updated with new information provided) [3], were against the routine use of corticosteroids for treatment of COVID-19 generally, unless there were other reasons, such as asthma, or refractory shock. In addition, this and other publications indicated that corticosteroids should not be used in early or mild disease [3, 4]. For critically ill COVID-19 cases, the Surviving Sepsis Campaign COVID-19 subcommittee indicated that corticosteroids should not be routinely used in those with respiratory failure, but without acute respiratory distress syndrome (ARDS), while supporting a weak recommendation for corticosteroid use in the sickest cases, those with septic shock, and those with ARDS [4]. The World Health Organization recommended corticosteroids in severe and critical COVID-19 infection [5].