Question: Do steroids have benefit in treating children with bacterial meningitis?

The incidence of bacterial meningitis has significantly decreased since the pre-vaccine era and dexamethasone has been studied as an adjunctive treatment to antibiotics for bacterial meningitis.¹ Is it helpful, though? Beyond the neonatal period, recent literature identifies the three most common pediatric bacterial meningitis pathogens in North America as Streptococcus. pneumoniae, Neisseria meningitidis, and Hemophilus influenzae.² Fortunately, bacterial meningitis is relatively uncommon in the United States. So, does the addition of dexamethasone to antibiotic therapy improve clinical outcomes? With lower incidence of bacterial meningitis in the U.S. and some of the most recent, randomized, controlled trials being about two decades ago, we rely on older data that has been revisited in systematic reviews and meta-analyses.

A 2015 Cochrane meta-analysis evaluated both pediatric and adult patients and included only randomized controlled trials.³ The primary outcomes of the analysis were mortality, hearing loss, and neurological sequelae (defined as focal neurologic deficits, new epilepsy, severe ataxia, and severe memory or concentration disturbances). Regarding mortality in children, there were 18 pediatric studies (n=2,511 children) eligible for the meta-analysis, which demonstrated no significant difference in mortality with the addition of dexamethasone to antibiotics (Relative risk [RR], 0.89; 95 percent confidence interval [CI], 0.74-1.07). Looking at severe hearing loss in children, there were 14 studies (n=1,524) included in the data which found that dexamethasone decreased the risk of developing severe hearing loss (RR, 0.67; 95 percent CI, 0.49-0.91) as well as any hearing loss (RR, 0.72; 95 percent CI, 0.61-0.86). Dexamethasone, overall, appears to decrease the risk of developing both severe and any hearing loss in children. When broken down by specific pathogen, though, adjunctive dexamethasone had its significant beneficial effects when treating H. influenzae meningitis (RR, 0.34; 95 percent CI, 0.2-0.59) but no significant effects when treating non-H. influenzae meningitis (RR, 0.95; 95 percent CI, 0.65-1.39). The exact timing of dexamethasone dosing (before, simultaneously, or after) in relationship to the administration of antibiotics has not been definitively established. Most dosing regimens for children were 0.6 mg/kg/day for two to four days. A separate 2018 systematic review and meta-analysis found similar results with decreased odds ratios (OR) for both hearing loss (OR, 0.68; 95 percent CI, 0.53-0.89) and severe neurological sequelae (OR, 0.59; 95 percent CI, 0.37-0.95) without any significant change in mortality. There were 15 trials with 2,409 children included in this metaanalysis by Wang, et al.⁴

Summary

In children with bacterial meningitis, adjunctive dexamethasone appears to decrease the risk of developing secondary hearing loss and severe neurological sequelae. These effects appear to be strongest in cases where H. influenzae is the bacterial pathogen.

Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.

Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Regional Poison Control Center at Upstate Medical University in Syracuse, New York.

References

1. De Gaudio M, et al. Therapeutic management of bacterial meningitis in children: a systematic review and comparison of published guidelines from a European perspective. J Chemother. 2010;22(4):226-237.
2. Oordt-Speets AM, et al. Global etiology of bacterial meningitis: a systematic review and meta-analysis. PLoS One. 2018;13(6):e019877.
3. Brouwer MC, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;2015(9):CD004405.
4. Wang Y, et al. Metaanalysis of adjunctive dexamethasone to improve clinical outcome of bacterial meningitis in children. Childs Nerv Syst. 2018;34(2): 217-223.