On the Shoulders of Giants
Dexamethasone before antibiotics
Dexamethasone 10mg IV 15 minutes before or with antibiotics (and dexamethasone Q6h x 4 days) in adults with confirmed bacterial meningitis led to a far greater probability of favorable neurological outcome, NNT = 10, and to a marked decrease in mortality, NNT = 13. There was no increased risk of adverse reaction, including GI bleeding or hyperglycemia, in the steroid group. Subgroup analysis found the benefit was only for patients with S. pneumoniae meningitis with lower GCS on admission and did not benefit those with N. meningitidis meningitis at all.
The positive effect of dexamethasone was not as great in patients with bacterial meningitis in developing countries, possibly because of a delayed presentation for care, higher prevalence of HIV, or greater number of patients with tuberculous meningitis. The editorial for these trials in 2007, one from Malawi and one from Vietnam, gives a good synopsis.
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Pretreatment with dexamethasone 10mg IV before or with antibiotics for adults with bacterial meningitis improved neurological outcome and decreased mortality. Wiki Journal Club has an outstanding review of this article.
Abstract
N Engl J Med. 2002 Nov 14;347(20):1549-56.
Dexamethasone in adults with bacterial meningitis.
de Gans J1, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators.
Author information:
1Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands. [email protected]
Comment in
- Dexamethasone for adult bacterial meningitis. [Curr Neurol Neurosci Rep. 2007]
- Corticosteroids for everyone with meningitis? [N Engl J Med. 2002]
- Dexamethasone in adults with bacterial meningitis. [CMAJ. 2003]
- Dexamethasone in adults with bacterial meningitis. [N Engl J Med. 2003]
- Dexamethasone improved disability in acute bacterial meningitis. [ACP J Club. 2003]
- Dexamethasone in adults with bacterial meningitis. [N Engl J Med. 2003]
- Dexamethasone in adults with bacterial meningitis. [N Engl J Med. 2003]
- Dexamethasone in adults with bacterial meningitis. [N Engl J Med. 2003]
- Dexamethasone in adults with bacterial meningitis. [N Engl J Med. 2003]
Abstract
BACKGROUND:
Mortality and morbidity rates are high among adults with acute bacterial meningitis, especially those with pneumococcal meningitis. In studies of bacterial meningitis in animals, adjuvant treatment with corticosteroids has beneficial effects.
METHODS:
We conducted a prospective, randomized, double-blind, multicenter trial of adjuvant treatment with dexamethasone, as compared with placebo, in adults with acute bacterial meningitis. Dexamethasone (10 mg) or placebo was administered 15 to 20 minutes before or with the first dose of antibiotic and was given every 6 hours for four days. The primary outcome measure was the score on the Glasgow Outcome Scale at eight weeks (a score of 5, indicating a favorable outcome, vs. a score of 1 to 4, indicating an unfavorable outcome). A subgroup analysis according to the causative organism was performed. Analyses were performed on an intention-to-treat basis.
RESULTS:
A total of 301 patients were randomly assigned to a treatment group: 157 to the dexamethasone group and 144 to the placebo group. The base-line characteristics of the two groups were similar. Treatment with dexamethasone was associated with a reduction in the risk of an unfavorable outcome (relative risk, 0.59; 95 percent confidence interval, 0.37 to 0.94; P=0.03). Treatment with dexamethasone was also associated with a reduction in mortality (relative risk of death, 0.48; 95 percent confidence interval, 0.24 to 0.96; P=0.04). Among the patients with pneumococcal meningitis, there were unfavorable outcomes in 26 percent of the dexamethasone group, as compared with 52 percent of the placebo group (relative risk, 0.50; 95 percent confidence interval, 0.30 to 0.83; P=0.006). Gastrointestinal bleeding occurred in two patients in the dexamethasone group and in five patients in the placebo group.
CONCLUSIONS:
Early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.
Copyright 2002 Massachusetts Medical Society
PMID: 12432041 [PubMed – indexed for MEDLINE]
