Meningitis: Steroids or not?

17 November, 2011 by: colinparker

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The most important thing about treating meningitis is to give antibiotics as soon as possible.  The second most important thing is to institute appropriate supportive care.  Whether or not to give steroids as an adjunctive treatment is perhaps less clear to us…

A recent Cochrane review goes a long way to pointing us in the right direction, but still leaves a few questions open.  Join us for a quick tour of the literature and guidelines, in our quest for the truth about using steroids in meningitis.


Outline: Steroids for Meningitis PEMcast

[cp]: intro, disclaimer, rationale / theory: decrease inflammatory damage due to bacterial lysis

[cp]: Historical background: original studies were from an era when Haemophilus & Strep were common, decreased by vaccinations
?applicability to current (developed world) population of children and infectious agents

[CB]: Comments from Chris

Papers:

[RR]: Kennedy 1991 AmJDisChild – Pneumococcus

[cp]: Gupta 2004 ArchDisChild – Meningococcus

[cp]: Brouwer 2010 Cochrane review

[CB]: Peltola 2010 Pediatrics

Guidelines:

[cp] AAP (nothing recent – litigation fear??)
1990 guideline regarding steroids in meningitis
Nigrovic 2007 JAMA (Bacterial Meningitis Score)

[RR]: NICE Guideline (esp section 1.4.39 – steroids): Over 3 months age, start ASAP if within 12 hours: dexamethasone 0.15mg/kg IV, 6-hourly for 4 days
http://guidance.nice.org.uk/CG102

Review of NICE Guidance by Radcliffe, October 2011

[RR]: SIGN Guideline (esp section 6.4.2) Invasive MCD, start within 24 hours
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

[cp/CB]: local guidelines (dexamethasone 0.2mg/kg IV 6-hourly)

[all] Summary, goodbye

References

Kennedy WA, Hoyt MJ, McCracken GH Jr.
The role of corticosteroid therapy in children with pneumococcal meningitis.
Am J Dis Child. 1991 Dec;145(12):1374-8.
PubMed PMID: 1669663.

Gupta S, Tuladhar AB.
Does early administration of dexamethasone improve neurological outcome in children with meningococcal meningitis?
Arch Dis Child. 2004 Jan;89(1):82-3. Review. PubMed PMID: 14709520.

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004405. Review. PubMed PMID: 20824838.

Peltola H, Roine I, Fernández J, González Mata A, Zavala I, Gonzalez Ayala S,
Arbo A, Bologna R, Goyo J, López E, Miño G, Dourado de Andrade S, Sarna S,
Jauhiainen T.
Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol.
Pediatrics. 2010 Jan;125(1):e1-8. Epub 2009 Dec 14. PubMed PMID: 20008417.

American Academy of Pediatrics Committee on Infectious Diseases:
Dexamethasone therapy for bacterial meningitis in infants and children.
Pediatrics. 1990 Jul;86(1):130-3. PubMed PMID: 2193301.

Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM,
Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL,
Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kanegaye JT, Malley R; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.
Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
JAMA. 2007 Jan 3;297(1):52-60. PubMed PMID: 17200475.

National Institute for Health and Clinical Excellence
The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
Last updated: 10 November 2011
http://guidance.nice.org.uk/CG102

Radcliffe RH.
Review of the NICE guidance on bacterial meningitis and meningococcal septicaemia.
Arch Dis Child Educ Pract Ed. 2011 Oct 27. [Epub ahead of print] PubMed PMID: 22034519.

Scottish Intercollegiate Guidelines Network
Management of Invasive Meningococcal Disease in Children and Young People
Guideline No. 102, ISBN 978 1 905813 31 5, May 2008
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

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