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A 6 month old boy was admitted to the paediatric ward with history of fever, non-blanching petechial rash, shrill cry, and poor capillary refill. He required 20 ml/kg of fluid bolus. After a full sepsis screening including a lumbar puncture, he was started on intravenous cefotaxime for a presumed diagnosis of meningococcal meningitis. Next day on the ward round the specialist registrar wondered if a short course of dexamethasone should have been started with the first dose of antibiotic to improve neurological outcome in this child.
Structured clinical question
In children with meningococcal meningitis [patient group] does early treatment with dexamethasone [intervention] reduce the frequency of sensorineural hearing loss or other neurologic sequelae [outcome]?
Search strategy and outcome
Cochrane Database and Medline using PubMed interface.
Search words: “meningitis” AND “steroids”; “meningococcal” AND “steroids”; “meningitis” AND “dexamethasone”.
Limits (in PubMed): study type: randomised control trial; language: English.
Search outcome: 32 hits; four directly relevant to the question; one metaanalysis. See table 1.
Dexamethasone in meningococcal meningitis
Commentary
There appears to be a paucity of studies on the effects of adjunctive therapy with steroids in children specifically with meningococcal meningitis. Earlier studies4,5 done in children with bacterial meningitis, suggest improved neurological outcome with dexamethasone. However, the majority of children in these studies had H influenzae meningitis and hence these could not be considered as being representative studies for meningococcal meningitis. These results were reflected in a meta-analysis of randomised control trials assessing improved neurological outcome with dexamethasone in bacterial meningitis.1 The later study on adults by Thomas and colleagues,2 which had a mix of patients with pneumococcal and meningococcal meningitis, was inconclusive regarding systematic use of dexamethasone as an adjunctive therapy for bacterial meningitis. Meningococcal meningitis appears to have the lowest risk of major neurological sequelae compared with pneumococcal and H influenzae meningitis.1,6 In a multicentre prospective study on 124 children with bacterial meningitis by Richardson and colleagues,7 the children treated with steroids actually had a higher incidence of hearing loss (relative risk 1.70). In this population of children, hearing loss was more common in children who had been ill for more than 24 hours (relative risk 2.72; 95% CI 0.93 to 7.98) and hence the authors hypothesise that there is a critical period around second day of illness, during which hearing loss can be reversed, provided appropriate antimicrobial and supportive treatment is commenced.
Pollard and colleagues8 recommend a two day course of dexamethasone as an adjunctive treatment for children with bacterial meningitis, but admit that no data were available for meningococcal meningitis. None of the studies have stratified their results according to serotype of the causative organism or age group of patients, but the subjects in the paediatric studies were outside the neonatal period. It appears, hence, from the review of current best evidence, that use of dexamethasone as an adjunctive therapy could improve neurological outcome in children with suspected H influenzae meningitis and possibly pneumococcal meningitis. However, its use cannot be routinely recommended in cases of suspected meningococcal meningitis or in any case where the aetiology is uncertain.9
CLINICAL BOTTOM LINE
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Currently there is not sufficient published evidence to recommend early use of dexamethasone in order to improve neurological outcome in children with meningococcal meningitis. In fact, there is some evidence that its use in such a situation might be disadvantageous as far as hearing is concerned.
Footnotes
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Bob Phillips