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Steroids in Meningitis

Benefit was seen in patients with definite disease but not in those with probable disease.

The evidence for benefit from steroids in bacterial meningitis is conflicting. During a 9-year period at a hospital for tropical diseases in Vietnam, 435 patients with suspected bacterial meningitis were randomized in double-blind fashion to receive either dexamethasone (0.4 mg/kg) or placebo twice a day for 4 days.

At the time of hospital discharge or death, 69% of patients were classified as having definite meningitis (positive blood or cerebrospinal fluid cultures or positive Gram stain) and 29% were classified as having probable meningitis (bacteria either not detected or cultured, and no alternative diagnosis).

Thirty days after randomization, mortality rates were 10% in the dexamethasone group and 12.4% in the placebo group. The relative risk for death in the dexamethasone group was 0.79. Subgroup analysis showed a greater benefit in patients with definite meningitis (RR, 0.43) and no benefit in those with probable meningitis, possibly because some patients in the latter group had tuberculous meningitis. At 6 months, disability and hearing loss were significantly less prevalent in the dexamethasone group. The most common etiologic organism was Streptococcus suis, which is common in Asia but not in North America.

Comment: When the results of the single European trial (Journal Watch Emergency Medicine Dec 30 2002) are added to these data, the evidence becomes strong enough to unequivocally recommend that adults with suspected meningitis be treated with steroids. Although S. suis was the most common cause of meningitis in this study, other species of streptococcus likely would have a similar response to treatment.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine January 18, 2008

Citation(s):

Mai NTH et al. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med 2007 Dec 13; 357:2431.

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