Current Infectious Disease Reports

, Volume 7, Issue 4, pp 285–291

Adjunctive corticosteroids in adults with bacterial meningitis

  • Diederik van de Beek
  • Jan de Gans
Article

Abstract

Bacterial meningitis is a complex disorder in which neurologic injury is caused, in part, by the causative organism and, in part, by the host’s own inflammatory response. In studies of experimental bacterial meningitis, adjuvant treatment with corticosteroids, specifically dexamethasone, has beneficial effects. On the basis of these experimental studies, several clinical trials were undertaken to determine the effects of adjunctive corticosteroids in patients with bacterial meningitis. On the basis of overall benefit without detrimental effects by subgroup analysis, dexamethasone therapy should be initiated before or with the first dose of antibiotic and should be continued in most patients with community-acquired acute bacterial meningitis. For patients with a low suspicion of meningitis but an urgent need for antibiotics before cerebrospinal fluid can be obtained, we recommend initiation of treatment with dexamethasone, with discontinuation of dexamethasone therapy as soon as the diagnosis has been excluded.

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References and Recommended Reading

  1. 1.
    Koedel U, Scheld WM, Pfister HW: Pathogenesis and pathophysiology of pneumococcal meningitis. Lancet Infect Dis 2002, 2:721–736.PubMedCrossRefGoogle Scholar
  2. 2.
    Scheld WM, Dacey RG, Winn HR, et al.: Cerebrospinal fluid outflow resistance in rabbits with experimental meningitis. Alterations with penicillin and methylprednisolone. J Clin Invest 1980, 66:243–253.PubMedCrossRefGoogle Scholar
  3. 3.
    Tauber MG, Khayam-Bashi H, Sande MA: Effects of ampicillin and corticosteroids on brain water content, cerebrospinal fluid pressure, and cerebrospinal fluid lactate levels in experimental pneumococcal meningitis. J Infect Dis 1985, 151:528–534.PubMedGoogle Scholar
  4. 4.
    Tunkel AR: Bacterial Meningitis. Philadelphia: Lippincott Williams & Wilkins; 2001.Google Scholar
  5. 5.
    McIntyre PB, Berkey CS, King SM, et al.: Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA 1997, 278:925–931.PubMedCrossRefGoogle Scholar
  6. 6.
    van de Beek D, de Gans J, McIntyre P, Prasad K: Corticosteroids in acute bacterial meningitis. Cochrane Database Syst Rev 2003, CD004305.Google Scholar
  7. 7.
    de Gans J, van de Beek D: Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002, 347:1549–1556. The European Dexamethasone Study is a landmark study on adjunctive corticosteroids in adults with bacterial meningitis. This randomized clinical trial showed adjunctive dexamethasone treatment to be beneficial in adults with bacterial meningitis.PubMedCrossRefGoogle Scholar
  8. 8.
    van de Beek D, de Gans J, McIntyre P, Prasad K: Steroids in adults with bacterial meningitis: a systematic review. Lancet Infect Dis 2004, 4:139–143. This is a systematic review of adjunctive dexamethasone in adults with bacterial meningitis.PubMedCrossRefGoogle Scholar
  9. 9.
    Schuchat A, Robinson K, Wenger JD, et al.: Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med 1997, 337:970–976.PubMedCrossRefGoogle Scholar
  10. 10.
    Peltola H: Worldwide Haemophilus influenzae type b disease at the beginning of the 21st century: global analysis of the disease burden 25 years after the use of the polysaccharide vaccine and a decade after the advent of conjugates. Clin Microbiol Rev 2000, 13:302–317.PubMedCrossRefGoogle Scholar
  11. 11.
    Whitney CG, Farley MM, Hadler J, et al.: Active Bacterial Core Surveillance of the Emerging Infections Program Network. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med 2003, 348:1737–1746.PubMedCrossRefGoogle Scholar
  12. 12.
    Klugman KP, Madhi SA, Huebner RE, et al.: A trial of a 9-valent pneumococcal conjugate vaccine in children with and those without HIV infection. N Engl J Med 2003, 349:1341–1348.PubMedCrossRefGoogle Scholar
  13. 13.
    van de Beek D, de Gans J, Spanjaard L, et al.: Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004, 351:1849–1859. The Dutch Meningitis Cohort is the first large prospective study of clinical features and prognostic factors in adults with bacterial meningitis. Patients were included in this study before routine dexamethasone use.PubMedCrossRefGoogle Scholar
  14. 14.
    Whitney CG, Farley MM, Hadler J, et al.: Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med 2000, 343:1917–1924.PubMedCrossRefGoogle Scholar
  15. 15.
    Appelbaum PC: Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin Infect Dis 1992, 15:77–83.PubMedGoogle Scholar
  16. 16.
    Tunkel AR, Hartman BJ, Kaplan SL, et al.: Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004, 39:1267–1284.PubMedCrossRefGoogle Scholar
  17. 17.
    Robinson KA, Baughman W, Rothrock G, et al.: Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995–1998: opportunities for prevention in the conjugate vaccine era. JAMA 2001, 285:1729–1735.PubMedCrossRefGoogle Scholar
  18. 18.
    Nuorti JP, Butler JC, Farley MM, et al.: Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team. N Engl J Med 2000, 342:681–689.PubMedCrossRefGoogle Scholar
  19. 19.
    Baraff LJ, Lee SI, Schriger DL: Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J 1993, 12:389–394.PubMedCrossRefGoogle Scholar
  20. 20.
    Prasad K, Haines T: Dexamethasone treatment for acute bacterial meningitis: how strong is the evidence for routine use? J Neurol Neurosurg Psychiatry 1995, 59:31–37.PubMedCrossRefGoogle Scholar
  21. 21.
    Molyneux EM, Walsh AL, Forsyth H, et al.: Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial. Lancet 2002, 360:211–218.PubMedCrossRefGoogle Scholar
  22. 22.
    Girgis NI, Farid Z, Mikhail IA, et al.: Dexamethasone treatment for bacterial meningitis in children and adults. Pediatr Infect Dis J 1989, 8:848–851.PubMedCrossRefGoogle Scholar
  23. 23.
    van de Beek D, de Gans J: Dexamethasone and pneumococcal meningitis. Ann Intern Med 2004, 141:327.PubMedGoogle Scholar
  24. 24.
    Weisfelt M, van de Beek D, de Haan RJ, de Gans J: Determinants for outcome in adults with bacterial meningitis treated with adjunctive dexamethasone. Intensive Care Med 2005, In press.Google Scholar
  25. 25.
    Tunkel AR, Scheld WM: Corticosteroids for everyone with meningitis? N Engl J Med 2002, 347:1613–1615.PubMedCrossRefGoogle Scholar
  26. 26.
    Davis LE, Greenlee JE: Pneumococcal meningitis: antibiotics essential but insufficient. Brain 2003, 126:1013–1014.PubMedCrossRefGoogle Scholar
  27. 27.
    Cohen J: Management of bacterial meningitis in adults. BMJ 2003, 326:996–997.PubMedCrossRefGoogle Scholar
  28. 28.
    Bennett IL, Finland M, Hamburger M, et al.: The effectiveness of hydrocortisone in the management of severe infections. JAMA 1963, 183:462–465.Google Scholar
  29. 29.
    Bhaumik S, Behari M: Role of dexamethasone as adjunctive therapy in acute bacterial meningitis in adults. Neurol India 1998, 46:225–228.Google Scholar
  30. 30.
    Thomas R, Le Tulzo Y, Bouget J, et al.: Trial of dexamethasone treatment for severe bacterial meningitis in adults. Adult Meningitis Steroid Group. Intensive Care Med 1999, 25:475–480.PubMedCrossRefGoogle Scholar
  31. 31.
    Gijwani D, Kumhar MR, Singh VB, et al.: Dexamethasone therapy for bacterial meningitis in adults: a double blind placebo control study. Neurol India 2002, 50:63–67.PubMedGoogle Scholar
  32. 32.
    Jadad AR, Moore RA, Carroll D, et al.: Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996, 17:1–12.PubMedCrossRefGoogle Scholar
  33. 33.
    Annane D, Sebille V, Charpentier C, et al.: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002, 288:862–871.PubMedCrossRefGoogle Scholar
  34. 34.
    Cronin L, Cook DJ, Carlet J, et al.: Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature. Crit Care Med 1995, 23:1430–1439.PubMedCrossRefGoogle Scholar
  35. 35.
    Lefering R, Neugebauer EA: Steroid controversy in sepsis and septic shock: a meta-analysis. Crit Care Med 1995, 23:1294–1303.PubMedCrossRefGoogle Scholar
  36. 36.
    Annane D, Bellissant E, Bollaert P, et al.: Corticosteroids for treating severe sepsis and septic shock. Cochrane Database Syst Rev 2004, CD002243.Google Scholar
  37. 37.
    Cooper MS, Stewart PM: Corticosteroid insufficiency in acutely ill patients. N Engl J Med 2003, 348:727–734.PubMedCrossRefGoogle Scholar
  38. 38.
    Syrogiannopoulos GA, Lourida AN, Theodoridou MC, et al.: Dexamethasone therapy for bacterial meningitis in children: 2-versus 4-day regimen. J Infect Dis 1994, 169:853–858.PubMedGoogle Scholar
  39. 39.
    King SM, Law B, Langley JM, et al.: Dexamethasone therapy for bacterial meningitis: better never than late? Can J Infect Dis 1994, 5:210–215.Google Scholar
  40. 40.
    Lutsar I, Friedland IR, Jafri HS, et al.: Factors influencing the anti-inflammatory effect of dexamethasone therapy in experimental pneumococcal meningitis. J Antimicrob Chemother 2003, 52:651–655.PubMedCrossRefGoogle Scholar
  41. 41.
    Heyderman RS, Lambert HP, O’Sullivan I, et al.: Early management of suspected bacterial meningitis and meningococcal septicaemia in adults. J Infect 2003, 46:75–77.PubMedCrossRefGoogle Scholar
  42. 42.
    Cartwright K, Strang J, Gossain S, Begg N: Early treatment of meningococcal disease. BMJ 1992, 305:774.PubMedGoogle Scholar
  43. 43.
    Sorensen HT, Möller-Petersen J, Krarup HB, et al.: Early treatment of meningococcal disease. BMJ 1992, 305:774.PubMedGoogle Scholar
  44. 44.
    Sorensen HT, Steffensen FH, Schonheyder HC, et al.: Clinical management of meningococcal disease. Prospective international registration may be needed. BMJ 1998, 316:1016–1017.PubMedGoogle Scholar
  45. 45.
    Klugman KP, Friedland IR, Bradley JS: Bactericidal activity against cephalosporin-resistant Streptococcus pneumoniae in cerebrospinal fluid of children with acute bacterial meningitis. Antimicrob Agents Chemother 1995, 39:1988–1992.PubMedGoogle Scholar
  46. 46.
    Viladrich PF, Gudiol F, Linares J, et al.: Evaluation of vancomycin for therapy of adult pneumococcal meningitis. Antimicrob Agents Chemother 1991, 35:2467–2472.PubMedGoogle Scholar
  47. 47.
    van de Beek D, de Gans J, Spanjaard L, et al.: Antibiotic guidelines and antibiotic use in adult bacterial meningitis in The Netherlands. J Antimicrob Chemother 2002, 49:661–666.PubMedCrossRefGoogle Scholar
  48. 48.
    van de Beek D, Schmand B, de Gans J, et al.: Cognitive impairment in adults with good recovery after bacterial meningitis. J Infect Dis 2002, 186:1047–1052.PubMedCrossRefGoogle Scholar
  49. 49.
    Leib SL, Heimgartner C, Bifrare YD, et al.: Dexamethasone aggravates hippocampal apoptosis and learning deficiency in pneumococcal meningitis in infant rats. Pediatr Res 2003, 54:353–357.PubMedCrossRefGoogle Scholar
  50. 50.
    Sapolsky RM, Pulsinelli WA: Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications. Science 1985, 229:1397–1400.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2005

Authors and Affiliations

  • Diederik van de Beek
    • 1
  • Jan de Gans
  1. 1.Department of Neurology, Academic Medical CenterUniversity of AmsterdamDE, AmsterdamThe Netherlands

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