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Steroids Can Improve Survival in Adults with Meningitis

Steroid therapy benefited adults with pneumococcal meningitis but not those with meningococcal meningitis.

Since the late 1980s, data from randomized clinical trials have shown that early adjuvant therapy with corticosteroids can be beneficial for bacterial meningitis in children. This approach has not been adopted in adults, however, because data showing safety and efficacy are lacking. Now, European investigators report the results of a manufacturer-supported trial showing that early dexamethasone treatment benefits adult patients with pneumococcal meningitis. Between June 1993 and December 2001, 301 adult patients with suspected bacterial meningitis were randomized to receive either placebo or 10 mg of dexamethasone intravenously every 6 hours for 4 days, beginning 15 to 20 minutes before the first dose of antibiotic.

At 8 weeks postenrollment, fewer dexamethasone recipients than placebo recipients had unfavorable outcomes (15% vs. 25%, P=0.03); dexamethasone also was associated with a lower mortality rate (7% vs. 15%, P=0.04). For patients with pneumococcal meningitis, unfavorable outcomes were reported in 26% of dexamethasone recipients and in 52% of placebo recipients, a highly significant difference. Steroid therapy had no effect on mortality or on unfavorable outcomes in patients with meningococcal meningitis. The incidence of adverse events was comparable in the 2 treatment groups.

Comment: These results support routine use of dexamethasone in adult patients with apparent pneumococcal meningitis. Because the study design required a lumbar puncture before starting dexamethasone and antibiotic therapy, these results are not directly applicable if antibiotic therapy is begun presumptively pending results of cranial CT scan and lumbar puncture. An editorialist notes that more information is needed about dexamethasone's effectiveness in pneumococcal meningitis caused by highly penicillin-resistant strains, because steroid treatment may limit concentrations of vancomycin in cerebrospinal fluid.

— Richard T. Ellison III, MD

Published in Journal Watch Infectious Diseases December 20, 2002

Citation(s):

de Gans J and van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002 Nov 14; 347:1549-56.

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Tunkel AR and Scheld WM. Corticosteroids for everyone with meningitis? N Engl J Med 2002 Nov 14; 347:1613-5.

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