REVIEW QUESTION

Does adjuvant corticosteroid therapy improve the outcome of people with acute bacterial meningitis?

TYPE OF REVIEW

This intervention review examines the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss, and neurologic sequelae in people with acute bacterial meningitis.

RELEVANCE FOR NURSING

Bacterial meningitis is a severe, potentially life-threatening inflammation of the lining of the brain and spinal cord (meninges). It is associated with high mortality rates and long-term complications, including hearing loss, vision loss, and other neurologic problems. Timely initiation of appropriate intravenous antibiotic therapy is essential in preventing or minimizing potential serious complications of bacterial meningitis. Corticosteroids have been touted as a possible adjuvant therapy to reduce neurologic complications, particularly hearing loss; however results of numerous trials have been inconclusive.

CHARACTERISTICS OF THE EVIDENCE

Twenty-five randomized controlled trials with a total of 4,121 participants (both children and adults) were eligible for inclusion in the review. Nine studies were completed in low-income countries and 16 studies were completed in high-income countries.

Participants were treated with antibacterial agents and randomized to adjuvant corticosteroid therapy of any type (dexamethasone in 22 studies; hydrocortisone or prednisolone, alone or in combination, in the remaining three studies). Dexamethasone dosages ranged from 0.4 to 1.5 mg/kg per day and duration of treatment ranged from two to four days. Duration of hydrocortisone and/or prednisolone treatment ranged from three to 14 days. The primary outcomes assessed were effects on mortality, hearing loss, and short- and long-term neurologic sequelae.

The group treated with corticosteroids had an overall lower mortality rate than the placebo group (17.8% versus 19.8%); however this difference did not reach statistical significance. There was a significant reduction in the corticosteroid group compared with the placebo group in any hearing loss (14% versus 19%) and severe hearing loss (6% versus 9%). Short-term neurologic sequelae (excluding hearing impairment) were assessed in 1,756 participants from 13 studies. Fewer short-term neurologic sequelae were identified in the corticosteroid group than in the placebo group (17.9% versus 21.6%). Long-term neurologic sequelae were assessed in 1,652 participants from 12 studies and there were no significant differences between the groups. Corticosteroids reduced any hearing loss, severe hearing loss, and short-term neurologic sequelae in high-income countries. No beneficial effects of corticosteroids were observed in low-income countries.

Further analysis for causative pathogens revealed that corticosteroids decreased the hearing loss in children whose meningitis was due to Haemophilus influenzae but no other bacteria.

BEST PRACTICE RECOMMENDATIONS

This review identified a marginal improvement in hearing loss and short-term neurologic symptomology in participants from high-income countries following corticosteroid treatment. Its results justify the use of corticosteroids in individuals with acute bacterial meningitis specifically in high-income countries; however, the strength of the evidence is limited.

RESEARCH RECOMMENDATIONS

Because of the different causative bacteria in neonatal meningitis and the lack of applicable trial data, randomized controlled trials on the role of corticosteroids in neonatal meningitis are needed. Case series are also needed to determine the effect of adjunctive dexamethasone in patients with pneumococcal meningitis caused by highly penicillin- or cephalosporin-resistant strains.

REFERENCE