Corticosteroids as Adjunctive Therapy in Bacterial Meningitis: A Systematic Review of Clinical Trials

To evaluate the efficacy and safety of corticosteroids in decreasing mortality, reducing neurologic sequelae and diminishing hearing loss in acute bacterial meningitis, a computer search of the English-language literature of clinical trials using steroids in bacterial meningitis from 1982 to 1993 was performed. The bibliographies of articles obtained by the computer search were additional sources of references. Only randomized and controlled trials were included. Excluded were animal and in-vitro studies, editorials, reviews, abstracts, retrospective series and uncontrolled trials. Odds ratio, which approximates the relative risk with its 95 % confidence interval and the risk difference, were computed for each outcome of interest in each study. Pooled results were analyzed. Eight trials showed a significant benefit with dexamethasone use in terms of improved survival, decreased neurologic abnormalities and reduced moderate to severe hearing loss. Sensitivity analysis that excluded one trial showed no improvement in survival. However, the significant reduction in neurologic abnormality upon hospital discharge and reduction in the moderate to severe hearing loss was consistent with the pooled results of all trials. The available evidence is limited to Hemophilus influenzae and among children over 1 month of age. Of the eight trials included in the review, the Girgis et al 1989 study was weakened by the lack of blinding, alternate treatment allocation, and inclusion of both children and adults. All other trials were randomized, blind, placebo-controlled and were done among children. The advantages of dexamethasone therapy outweigh the possible disadvantages and therefore, its use should be considered for the treatment of bacterial meningitis in infants and children older than l month of age especially those caused by Hemophilus influenzae. The drug should be instituted as soon as the diagnosis of bacterial meningitis i