Suspected Meningitis Age > 56 days Clinical Pathway — Emergency Department, Inpatient and ICU
Steroid Use in Patients with Suspected Acute Bacterial Meningitis
The decision to administer adjunctive steroids should be informed by the CSF Gram stain and other CSF indices. If a Gram stain and/or CSF indices are not available, steroids are not recommended.
If indicated, steroids should ideally be given before or concomitant with the first dose of antibiotics. If this is not possible, try to give steroids within 4 hours of the first antibiotic dose, but do not start more than 12 hours after the first antibiotic dose.
Recommendations
Steroids are recommended in the following circumstances:
| Category of patients | CSF Gram stain or indices | Steroid dosing |
|---|---|---|
| All patients with Haemophilus influenzae | Pleomorphic Gram negative rods OR Gram negative rods suggestive of Haemophilus influenzae |
Dexamethasone 0.15 mg/kg/dose (max 10 mg/dose) every 6 hours for 2-4 days |
| Adults (age ≥ 17 yrs) with Streptococcus pneumoniae | Gram positive cocci in pairs or chains | Dexamethasone 0.15 mg/kg/dose (max 10 mg/dose) every 6 hours for 2-4 days |
Steroids can be considered in the following circumstances, after weighing potential benefits and possible risks (see below):
| Category of patients | CSF Gram stain or indices | Steroid dosing |
|---|---|---|
| Children (age < 17 yrs) with Streptococcus pneumoniae | Gram positive cocci in pairs or chains | Dexamethasone 0.15 mg/kg/dose (max 10 mg/dose) every 6 hours for 2-4 days |
| Children or adults with suspected Haemophilus influenzae or Streptococcus pneumoniae | Negative Gram stain with CSF WBC count > 1000 AND > 50% neutrophils on CSF WBC differential | Dexamethasone 0.15 mg/kg/dose (max 10 mg/dose) every 6 hours for 2-4 days |
Steroids are not recommended in the following circumstances:
| Category of patients | CSF Gram stain or indices | Steroid dosing |
|---|---|---|
| Children or adults with aseptic meningitis or bacterial meningitis caused by any other organism | Any CSF result not meeting the above criteria OR CSF studies not available |
No steroids recommended |
Steroids should be promptly stopped if an etiology other than H. influenzae or S. pneumoniae is determined.
Evidence for these recommendations
Benefits
Administration of adjunctive dexamethasone results in improved hearing outcomes in children with meningitis caused by Haemophilus influenzae type b. In adults with meningitis caused by Streptococcus pneumoniae (pneumococcus), steroids appear to reduce both mortality and hearing loss. The available data do not show a clear benefit of adjunctive steroid administration for children with pneumococcal meningitis. However, the relevant studies may have been underpowered to detect a benefit, and some clinicians may choose to administer dexamethasone in this setting. There is no evidence that steroids are beneficial in meningitis caused by any other organisms including Group B Streptococcus, Neisseria meningitidis, and E. coli.
Risks
Meta-analyses have shown significant risk of rebound fever with steroids. Animal (rabbit) models have also shown that steroids decrease CNS penetration of antibiotics such as vancomycin, but this is relevant only for cephalosporin resistant Streptococcus pneumoniae, which is present at a low incidence.
References
Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2015 Issue 9:CD004405.
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice Guidelines for the Management of Bacterial Meningitis (IDSA). Clin Infec Dis 2004; 39(9): 1267-84.
Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition and management. National Institute for Clinical Excellence (NICE) guidelines: 2010.