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Re: Meningitis without rash – a suitable group for Dexamethasone?

Dear Editor

We read with interest the article by Bashir and colleagues [1] on the diagnosis and treatment of bacterial meningitis. Within this article they commented that they favour the empiric use of dexamethasone in developed countries for children with suspected meningitis.

The metanalysis by McIntyre et al [2] showed that the benefits for dexamethasone were greatest for H. influenzae meningitis, with a possible, though non-significant, benefit in pneumococcal meningitis. One practical solution to ensure that steroids are given to children with meningitis who may benefit from them, is to give dexamethasone to all children who present with meningitis without a petechial rash. Indeed, our local policy recommended dexamethasone to be given before antibiotics to children with meningitis and no rash, and we therefore audited its use.[3]

We performed a retrospective review of all children with >10 white cells/mm3 in their cerebrospinal fluid (CSF), admitted to Birmingham Heartlands Hospital between Jan 1998 and Aug 2002. Children were excluded if they had a non-blanching rash on admission or if their discharge diagnosis was not meningitis. CSF was cultured using standard microbiological methods and examined for viruses by PCR.

In our study 108 children were identified; median age 7 yrs. Causes of meningitis were: Viral 41 (enterovirus 40), bacterial 22 (Meningococcus 13, Hib 1, Pneumococcus 4). Sixteen children received dexamethasone, but only two prior to the first dose of antibiotic. If, as McIntyre et al.[2] suggest, only those with Haemophilus or pneumococcal meningitis may benefit from the use of dexamethasone, then this might have benefited only 5/108 (i.e. 1 in 22) children. None of those who may have benefited were given dexamethasone with or before the first dose of antibiotics. Local policy in our unit has now changed so that dexamethasone is only being administered if Haemophilus is seen on gram stain of the CSF. With the present controversy surrounding the use of dexamethasone it may be that routine use of steroids as an adjunctive treatment for children with meningitis without rash should be reconsidered or, at the least, individualised.

References

(1) H El Bashir, M Laundy, and R Booy. Diagnosis and treatment of bacterial meningitis. Arch Dis Child 2003;88:615-620.

(2) McIntyre P. Berkey C. King S. Schaad U. Kilpi T. Kanra G. Odio Perez C. Dexamethasone as adjunctive therapy in Bacterial Meningitis. A meta-analysis of randomised clinical trials since 1988. JAMA 1997;278(11):925–931.

(3) Makwana N, Riordan A. Retrospective study of Meningitis presenting without a rash over a four-year period to determine the most likely aetiology (Abstract). Current Paediatrics; in press.

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Re: Short course treatment for meningococcus - a warning

Dear Editor

I am concerned that Professor Choonara suggests that an evidence-based approach would suggest that a 4-day course of intravenous antibiotic treatment (benzylpenicillin or ceftriaxon) is sufficient for meningococcal meningitis. In support of this recommendation he mentions two studies totalling perhaps 63 patients in all who received antibiotic treatment for 4 days in total and amongst whom there were no relapses. Based on this number of cases the 95% confidence interval of the probability of an adverse event where no adverse event occurred is 4.7% or about 1 in 20 cases.[1,2] Given the serious consequences of undertreatment of meningococcal meningitis I would be unwilling to accept such odds. In my view further studies are necessary before such a recommendation can be made with confidence.

Sam Richmond

References

(1) Hanley JA, Lippman-Hand A. If nothing goes wrong is everything all right? JAMA 1983;13:1743-5.

(2) Eypasch e, Lefering R, Kum CK, Troidl H. Probability of adverse event that have not yet occurred: a statistical reminder. Br Med J 1995;311:619-20.