Steroid Use in Bacterial Meningitis

Introduction to Steroid Use

• The American Academy of Pediatrics and Infectious Diseases Society of America recommend adjunctive dexamethasone for adults and children with suspected or proven bacterial meningitis, given 10-20 minutes before or concomitant with the first antibiotic dose, as it significantly reduces mortality, hearing loss, and neurological sequelae, particularly in pneumococcal and H. influenzae type b meningitis 1

Adult Dosing and Administration

• Dexamethasone 10 mg intravenously every 6 hours for 4 days is recommended for all adults with suspected bacterial meningitis in high-income countries 1
• The first dose must be given 10-20 minutes before or at least concomitant with the first antimicrobial dose for maximum benefit 1
• In pneumococcal meningitis specifically, dexamethasone reduces unfavorable outcomes from 52% to 26% and mortality from 34% to 14% 1

Pediatric Dosing and Administration

• Dexamethasone 0.15 mg/kg intravenously every 6 hours for 2-4 days for children with suspected bacterial meningitis 1
• The steroid should ideally be administered 10-20 minutes before or concomitant with the first antimicrobial dose 2
• 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) 1

Mechanism of Benefit

• Dexamethasone attenuates the subarachnoid space inflammatory response, which is a major contributor to morbidity and mortality in bacterial meningitis, by decreasing cerebral edema and increased intracranial pressure 1
• Dexamethasone reduces altered cerebral blood flow and cerebral vasculitis 1
• Dexamethasone prevents neuronal injury mediated by pro-inflammatory cytokines 1

Special Populations and Caveats

• For TB meningitis, use dexamethasone 0.4 mg/kg/day (maximum 12 mg/day) intravenously for 3 weeks, then taper over the following 3 weeks 3
• Corticosteroids should be initiated before or concurrently with the first dose of anti-tuberculosis medication 3

Common Pitfalls to Avoid

• Do not delay dexamethasone administration - timing is critical, and benefit is maximized when given before or with antibiotics 1
• Do not withhold dexamethasone due to concerns about antibiotic penetration - while dexamethasone may decrease CSF antibiotic concentrations, the overall clinical benefit outweighs this theoretical concern when appropriate antibiotics are used 4

Dexamethasone Use in Bacterial Meningitis

Guideline-Based Recommendation

• The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) provides a Grade B recommendation to stop dexamethasone if the causative bacterium is a species other than H. influenzae or S. pneumoniae 5, 6, 7
• The ESCMID recommends discontinuing dexamethasone for organisms other than pneumococcus and H. influenzae, as the consensus guideline recommendation is to discontinue it for these pathogens 5, 6, 7

Evidence Supporting Pathogen-Specific Use

• Dexamethasone showed greatest benefit in pneumococcal meningitis, reducing mortality and unfavorable outcomes 7
• A strong effect on hearing loss was demonstrated specifically for H. influenzae meningitis 5, 6, 7
• No specific evidence exists demonstrating benefit for Staphylococcus aureus (including MRSA) meningitis 5, 6, 7

Empiric Treatment Algorithm

• The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recommends starting dexamethasone empirically for all adults with suspected bacterial meningitis: 10 mg IV every 6 hours 5, 6, 7
• Pediatric dosing is recommended at 0.15 mg/kg IV every 6 hours 5, 6, 7
• Dexamethasone should be discontinued once MRSA is identified 5, 6, 7

Important Clinical Caveats

• Benefits of dexamethasone are only demonstrated in high-income countries with high standards of medical care 5, 7, 8
• No beneficial effects of dexamethasone were identified in low-income country studies 5, 8