Dexamethasone therapy for bacterial meningitis in children

Schaad, Urs B.; Wedgwood, Joanna; Lips, Ulrich; Gnehm, H. E.; Heinzer, I.; Blumberg, A

doi:10.1016/0140-6736(93)91592-a

Cited by 196 publications

(84 citation statements)

References 22 publications

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“…The study designs of two other prospective, double-blind trials ofadjunctive dexamethasone therapy for bacterial meningitis [7,14,15] were similar to that of our study (11); all children received ceftriaxone, and the diagnostic and supportive management of the patients in the two other studies was similar to that in ours. The results of a meta-analysis (table 1) of these three studies to determine the risk of developing any sequelae showed that the relative risk of developing persistent neurological and/or audiological sequelae for children treated with placebo was 2.29 (95% CI: 1.20-4.39).…”

mentioning

confidence: 49%

“…In fact, there is convincing evidence that dexamethasone reduces neurological sequelae, especially hearing loss, associated with meningitis due to Haemophilus influenzae type b [7,9,11]. This was also the conclusion of three influential groups that put forth guidelines for treatment of meningitis [17][18][19].…”

Section: Opposing Viewmentioning

confidence: 99%

“…This was also the conclusion of three influential groups that put forth guidelines for treatment of meningitis [17][18][19]. Several well-conducted, placebo-controlled, double blind studies in which optimal antibiotics were used have found fewer total neurological sequelae at discharge and at the time of short-term follow-up in children who received adjunctive dexamethasone therapy compared with those who received placebo [7,9,11]. However, the majority of the children in these studies had meningitis due to H. influenzae type b; thus, the findings cannot necessarily be applied to cases where meningitis is caused by S. pneumoniae, Neisseria meningitidis, or other bacteria.…”

Section: Opposing Viewmentioning

confidence: 99%

“…Because only 60 (17%) of 352 patients enrolled in these three studies [7,11,15] had meningitis caused by Streptococcus pneumoniae, it was not possible to determine conclusively whether dexamethasone was as effective when used to treat infants and children with pneumococcal meningitis. We compared the data from these three studies with the results of a retrospective analysis of pediatric patients with pneumococcal meningitis treated in Dallas from 1984 to 1990 [16].…”

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confidence: 99%

“…To assess the effects of dexamethasone therapy on the course and outcome of bacterial meningitis in Swiss children, we conducted a prospective, placebo-controlled, doubleblind, multicenter study of children who received ceftriaxone and routine supportive treatment for meningitis [11].…”

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confidence: 99%

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Steroid Therapy for Bacterial Meningitis

Schaad

Kaplan

McCracken

1995

Clinical Infectious Diseases

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Routine dexamethasone therapy for bacterial meningitis in pediatric patients is controversial. Two experts debated this topic at the 1993 meeting of the Infectious Diseases Society of America. Both experts agreed that for management of Haemophilus influenzae meningitis, dexamethasone significantly reduced sensorineural hearing loss and probably reduced other long-term sequelae. Because relatively few patients with pneumococcal and meningococcal meningitis have been studied, no conclusions could be reached regarding the effectiveness of dexamethasone. Dr. Urs Schaad emphasized the impressive anti-inflammatory effects of dexamethasone in experimental pneumococcal meningitis and the lack of any adverse events when given to children for 2 or 4 days. He recommended routine use of dexamethasone in treating pediatric patients with bacterial meningitis. Dr. Sheldon Kaplan expressed concern regarding the effectiveness of steroids in treating pneumococcal meningitis, especially when penicillin-resistant and cephalosporin-resistant isolates are present, and he addressed the question of the long-term effects of administration of dexamethasone in children with viral meningitis. He advised against the routine use of dexamethasone for non-H. influenzae meningitis.At the annual meeting of the Infectious Diseases Society of America in October 1993, one of the sessions was devoted to the controversy of whether dexamethasone should be routinely used to treat patients with bacterial meningitis. The two physicians chosen to address this issue had recently conducted multicenter, placebo-controlled, double-blind studies of dexamethasone therapy in children with meningitis. Dr. Urs B. Schaad was asked to present information supporting the routine use of dexamethasone therapy in these patients. Dr. Sheldon L. Kaplan took the opposing view-that dexamethasone should be used only in select patients with bacterial meningitis. The following paper represents a distillation of their presentations and a commentary by Dr. George H. McCracken, Jr. Affirmative ViewBacterial meningitis remains an important cause of death and permanent neurological disability despite advances in antimicrobial therapy, rapid diagnostic techniques, and sup- Data from recent in vitro and animal experiments indicate that the bacteria causing meningitis elaborate outer membrane-active or cell wall-active components that affect monocytes, leukocytes, cerebrovascular endothelial cells, and astrocytes [1][2][3]. These cells, in turn, produce various proinflammatory cytokines or express specific receptors on their surface. These cytokines and receptors initiate an accelerating cascade of events, resulting in alteration of the bloodbrain barrier, meningeal inflammation, increased intracranial pressure, and decreased cerebral vascular perfusion. If the interaction of these pathopysiological alterations is severe and sustained, it will produce neuronal injury and irreversible focal or diffuse brain damage.Dexamethasone is a potent antiinflammatory agent. There is convincing in ...

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mentioning

confidence: 49%

Section: Opposing Viewmentioning

confidence: 99%

Section: Opposing Viewmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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Steroid Therapy for Bacterial Meningitis

Schaad

Kaplan

McCracken

1995

Clinical Infectious Diseases

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Use of Corticosteroids in Treating Infectious Diseases

McGee¹

2008

Arch Intern Med

109

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linicians have generally avoided prescribing corticosteroids for active infection because of their known immunosuppressive effects and concern about long-term complications. We conducted a review of the published randomized, double-blind trials comparing corticosteroids and placebo in infections. Except in some trials of viral infections, sore throat, and cerebral cysticercosis, all patients also received active antimicrobial agents in addition to placebo or corticosteroids. For patients with bacterial meningitis, tuberculous meningitis, tuberculous pericarditis, severe typhoid fever, tetanus, or pneumocystis pneumonia with moderate to severe hypoxemia, treatment with corticosteroids improved patient survival (group 1 infections). For patients with bacterial arthritis, corticosteroids were also beneficial and reduced long-term disability (group 2 infections). For about a dozen other infections, corticosteroids significantly relieved symptoms (group 3 infections), and clinicians should consider using them if symptoms are substantial. Corticosteroids were harmful in 2 infections, viral hepatitis and cerebral malaria (group 5 infections). We conclude that corticosteroids are beneficial and safe for a wide variety of infections, although courses longer than 3 weeks should be withheld from patients with concomitant human immunodeficiency virus infection and low CD4 counts.

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