Role of Steroids in Bacterial Meningitis

Introduction to Steroid Use

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend adjunctive dexamethasone therapy for adults and children with suspected or proven bacterial meningitis, particularly for pneumococcal and H. influenzae meningitis, as it reduces hearing loss, neurological sequelae, and mortality in pneumococcal meningitis 1, 2

The Infectious Diseases Society of America recommends dexamethasone 10 mg intravenously every 6 hours for 4 days for all adults with suspected bacterial meningitis in high-income countries 1
The first dose of dexamethasone should be administered 10-20 minutes before or at least concomitant with the first antimicrobial dose, according to the Infectious Diseases Society of America 3, 4
If antibiotics have already been started, dexamethasone can still be administered up to 4 hours after the first antibiotic dose, as recommended by the Infectious Diseases Society of America 1, 2
Dexamethasone has shown greatest benefit in pneumococcal meningitis, with significant reduction in unfavorable outcomes (26% vs 52%) and mortality (14% vs 34%), according to the Infectious Diseases Society of America 4

The American Academy of Pediatrics recommends dexamethasone 0.15 mg/kg intravenously every 6 hours for 2-4 days for children with suspected bacterial meningitis 5, 1
The strongest evidence supports use in H. influenzae type b meningitis, with confirmed reduction in hearing impairment (OR 0.31; 95% CI, 0.14-0.69), according to the American Academy of Pediatrics 5
For pneumococcal meningitis in children, evidence suggests benefit for severe hearing loss when dexamethasone is given early (OR 0.09; 95% CI, 0.0-0.71), as recommended by the American Academy of Pediatrics 5

Dexamethasone attenuates subarachnoid space inflammatory response, which is a major factor contributing to morbidity and mortality in bacterial meningitis, according to the Infectious Diseases Society of America 5, 6
It helps decrease cerebral edema, increased intracranial pressure, altered cerebral blood flow, cerebral vasculitis, and neuronal injury mediated by pro-inflammatory cytokines, as explained by the Infectious Diseases Society of America 5, 6

Dexamethasone should be stopped if the patient is discovered not to have bacterial meningitis, according to the Infectious Diseases Society of America 1, 2
It is recommended to discontinue dexamethasone if the causative organism is neither H. influenzae nor S. pneumoniae, although some experts advise continuing regardless of the causative organism, as stated by the Infectious Diseases Society of America 1, 2
For N. meningitidis meningitis, the benefit is less clear due to lower event rates and smaller numbers in studies, according to the Infectious Diseases Society of America 1, 2
Dexamethasone is not currently recommended for neonatal bacterial meningitis, as recommended by the Infectious Diseases Society of America 1, 2
No beneficial effects have been identified in studies performed in low-income countries, according to the Infectious Diseases Society of America 1, 2