Corticosteroids for bacterial meningitis

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D

Published Online:

September 8, 2010

Acute bacterial meningitis is an infection of the meninges (the system of membranes which envelops the brain and spinal cord) that often causes hearing loss and is fatal in 5% to 40% of children and 20% to 50% of adults despite treatment with adequate antibiotics. It is caused by bacteria that usually spread from an ear or respiratory infection and is treated with antibiotics. Corticosteroids are drugs that can reduce the inflammation caused by infection. This inflammation has been shown to aggravate damage to the nervous system in experimental meningitis studies in animals. Research on the use of corticosteroids in addition to antibiotics has had conflicting results. This review of 24 trials, including 4041 participants, found that the corticosteroid dexamethasone leads to a reduction in hearing loss and other neurological sequelae in participants in high-income countries who have bacterial meningitis. Dexamethasone increased the rate of recurrent fever but was not associated with other adverse events.

Abstract (click to read)

Background:

In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response.

Objectives:

To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 1), MEDLINE (1966 to February 2010), EMBASE (1974 to February 2010) and Current Contents (2001 to February 2010).

Selection criteria:

Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis.

Data collection and analysis:

We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality.

Main results:

Twenty-four studies involving 4041 participants were included. Similar numbers of participants died in the corticosteroid and placebo groups (18.0% versus 20.0%; risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.04, P = 0.18). There was a trend towards lower mortality in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.76, 95% CI 0.64 to 0.89) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).

Subgroup analyses for causative organisms showed that corticosteroids reduced severe hearing loss in Haemophilus influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) and reduced mortality in Streptococcus pneumoniae meningitis (RR 0.84, 95% CI 0.72 to 0.98).

In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.

Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high quality studies.

Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events.

Authors' conclusions:

Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

This record should be cited as:

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD004405. DOI: 10.1002/14651858.CD004405.pub3

Assessed as up to date:

March 25, 2010

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Primary Review Group:

Acute Respiratory Infections Group

Health topics:

Infectious disease > Respiratory infections > Meningitis

Lungs & airways > Respiratory infections > Meningitis

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Corticosteroids for bacterial meningitis

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