What is the role of corticosteroids in the treatment of Haemophilus influenzae meningitis?

Updated: Jul 02, 2019
  • Author: Joseph Adrian L Buensalido, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Answer

In January 2007, a systematic review of randomized controlled trials involving adjuvant corticosteroids therapy in acute bacterial meningitis found a significant benefit in children from developed countries but no beneficial or harmful effects in children in developing countries. This meta-analysis also found that dexamethasone administered to adults with community-acquired meningitis (including that caused by H influenzae) decreased the risk of mortality and neurologic sequelae. Based on data from 18 randomized controlled trials, the authors concluded that all adults and children with acute bacterial meningitis in developed countries who have good access to medical care should receive adjuvant corticosteroids. The authors also found no significant increase in adverse effects due to corticosteroids. The recommended dose for dexamethasone in adults and children is 0.6 mg/kg/d for 4 days. [67]

A systematic review of 25 randomized controlled trials published by the Cochrane group in 2015 showed that, in the treatment of Hib meningitis, corticosteroids were associated with a nonsignificant reduction in mortality, but a significant reduction in severe hearing loss and neurologic sequelae. However, this benefit was found only in high-income countries but not in low-income countries. [70]

A retrospective study of 425 patients in Ethiopia showed that the use of dexamethasone was significantly associated with increased mortality. However, in this study, acute bacterial meningitis was diagnosed based on clinical presentation. Lumbar puncture was performed in only 56% of patients, and only 19% had CSF findings compatible with bacterial meningitis. This study shows that there are potential deleterious effects to steroid therapy in unconfirmed cases, which can be reflective of low-income settings. [71]

A 2015 meta-analysis was conducted to assess the effectiveness and safety of corticosteroids in reducing death and neurologic sequelae in neonates with bacterial meningitis. Two studies were included, one of poor quality. Results suggested a reduction in mortality and hearing loss. [72]

A randomized prospective study in 1994 found that, in treatment for bacterial meningitis, a 2-day course of dexamethasone provided effectiveness similar to that of a 4-day course. [73] However, most studies recommend a 4-day dexamethasone course.

In November 2007, a prospective randomized double-blind placebo-controlled trial studied adjuvant glycerol and dexamethasone in children with bacterial meningitis. All patients were given ceftriaxone and randomized to receive intravenous dexamethasone, oral glycerol, both agents, or neither agent. In addition, a subgroup of patients with Hib meningitis was studied. Findings showed that glycerol, an inexpensive osmotic diuretic that can be administered orally, reduced the incidence of neurologic sequelae and death. Dexamethasone prevented profound hearing loss when the timing of dexamethasone and ceftriaxone administration was not taken into account. Few adverse effects were found with either adjuvant medication. Additional studies need to be performed to evaluate the impact of glycerol in bacterial meningitis. [74, 75]

However, in 2011, a double-blind randomized controlled trial of adjuvant glycerol in adult bacterial meningitis in Malawi showed no difference in mortality and neurologic sequelae. Possible reasons for the conflicting results could be that the dose used in this study was higher than that used by Peltola et al [75] . In addition, adjuvant glycerol was given for four days compared to two days. The population in this study had a high HIV seroprevalence. [76, 77]

In 2007, a Vietnamese study evaluated the benefit of dexamethasone in adults and adolescents with confirmed or suspected bacterial meningitis. Overall, initial findings showed that dexamethasone did not decrease the mortality rate at 1 month or the incidence of mortality or disability at 6 months. However, when the results were compared with culture-proven disease, dexamethasone was found to confer a significant benefit in terms of both mortality and disability in patients with confirmed bacterial meningitis. Among the patients studied, only 7 had H influenzae meningitis, and 6 of these were in the placebo group. [78]

In a 2007 study in Malawi, Africa, dexamethasone was given to adults with bacterial meningitis but was not found to reduce mortality or morbidity. However, 90% of the study patients had HIV infection. Of the 465 patients studied in this group, only 3 had H influenzae meningitis. [52]


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