Corticosteroids Don't Reduce Mortality in Children with Bacterial Meningitis

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Corticosteroids Don’t Reduce Mortality in Children with Bacterial Meningitis

Adjuvant corticosteroid therapy had no effect, regardless of age or pathogen type.

Administration of adjuvant corticosteroids mitigates hearing loss in children with Haemophilus influenzae type B (Hib) meningitis. However, the introduction of vaccines against Hib in 1985 and against Streptococcus pneumoniae in 2000 has greatly altered the landscape of bacterial meningitis in children. In a retrospective cohort study, these authors reviewed data from 27 U.S. children’s hospitals to determine the effect of adjuvant corticosteroid therapy on mortality and time to discharge in children younger than 18 years who were discharged with a diagnosis of bacterial meningitis from 2001 through 2006.

Among 2780 children (median age, 9 months), 8.9% received adjuvant corticosteroid therapy. The leading bacterial pathogens were S. pneumoniae (18%) and Neisseria meningitidis (10%). The overall mortality rate was 4.2%. Adjuvant corticosteroid therapy did not reduce mortality or time to discharge in any age groups (<1 year, 1–5 years, or >5 years) or in subgroups of children with pneumococcal or meningococcal meningitis. Corticosteroid use increased significantly from 5.8% in 2001 to 12.2% in 2006.

Comment: The putative beneficial effects of corticosteroids are ascribed to reduction of the inflammatory response caused by antimicrobial-induced bacteriolysis. But corticosteroids also have adverse effects, including the possibility of decreasing delivery of antibiotics into cerebrospinal fluid. The findings of a Cochrane review and a large clinical study both published in 2007 are in line with those of this analysis. However, guidelines from the American Academy of Pediatrics state that "adjunctive therapy with dexamethasone may be considered after weighing the potential benefits and risks." Such equivocal recommendations and the failure of practitioners to appreciate the effect of vaccination have been partly responsible for the increase in use of corticosteroids for children with meningitis. The findings of this study, the largest multicenter study of its kind, suggest that healthcare providers should not administer adjuvant corticosteroids to a child with suspected bacterial meningitis unless the child has not received Hib vaccination.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine June 6, 2008