Is dexamethasone (corticosteroid) recommended in the treatment of Streptococcal (Strep) pneumoniae meningitis?

From the Guidelines

Dexamethasone is recommended in streptococcal pneumonia meningitis, with a standard regimen of 10 mg IV every 6 hours for 4 days, starting shortly before or simultaneously with antibiotics. This adjunctive therapy is most beneficial when started before or concurrently with antibiotics in adults with suspected pneumococcal meningitis, as it reduces inflammation in the subarachnoid space, decreases cerebral edema, and potentially lowers intracranial pressure, leading to improved outcomes, including reduced mortality and neurological sequelae 1. The greatest benefit is seen in pneumococcal meningitis specifically, rather than meningitis from other bacterial causes. It's essential to note that dexamethasone should not delay antibiotic administration, and its use may be less beneficial if started after antibiotics have been given.

Key points to consider:

• Dexamethasone should be started shortly before or simultaneously with antibiotics in suspected pneumococcal meningitis 1
• The standard regimen is 10 mg IV every 6 hours for 4 days 1
• Dexamethasone is most beneficial in pneumococcal meningitis, with reduced mortality and neurological sequelae 1
• The use of dexamethasone may be less beneficial if started after antibiotics have been given, but it can still be started up to 4 hours after initiation of antibiotic treatment 1

In terms of specific guidelines, the UK Joint Specialist Societies guideline recommends starting dexamethasone shortly before or simultaneously with antibiotics in suspected meningitis, and continuing it for 4 days if pneumococcal meningitis is confirmed or thought probable 1. Similarly, the ESCMID guideline advises starting dexamethasone with the first dose of antibiotics, and stopping it if the patient is discovered not to have bacterial meningitis or if the bacterium causing the meningitis is a species other than H. influenzae or S. pneumoniae 1.

Overall, the evidence supports the use of dexamethasone in streptococcal pneumonia meningitis, with a focus on starting it promptly and continuing it for an appropriate duration to maximize its benefits and minimize potential harms 1.

From the Research

Use of Dexamethasone in Strep Pneumonia Meningitis

• The use of dexamethasone as an adjunctive therapy in strep pneumonia meningitis is a topic of debate, with some studies suggesting its potential benefits and others raising concerns about its effectiveness and potential risks 2, 3, 4.
• A study published in 2002 found that dexamethasone remains the only adjunctive anti-inflammatory therapy to consider in the treatment of pneumococcal meningitis 2.
• However, a study published in 1996 suggested that dexamethasone therapy may not be beneficial in meningitis caused by S. pneumoniae or N. meningitidis, and may even increase the risk of treatment failure in meningitis caused by antibiotic-resistant pneumococci 3.
• Another study published in 2011 found that dexamethasone as adjunctive therapy to antibiotics does not influence the outcome or complications in children and adults suffering from bacterial meningitis, but may improve the outcome when given in the presence of certain poor prognostic CSF parameters 4.
• The pathophysiology of acute meningitis caused by Streptococcus pneumoniae involves an intense inflammatory host response, which contributes to neurological sequelae, and adjunctive therapy approaches aim to mitigate this response 5.

Considerations for Dexamethasone Use

• The decision to use dexamethasone in strep pneumonia meningitis should be based on individual patient factors and the presence of certain prognostic parameters 4.
• The potential risks and benefits of dexamethasone therapy should be carefully weighed, particularly in cases of antibiotic-resistant pneumococci 3.
• Further clinical data are required to make solid recommendations regarding the use of dexamethasone in strep pneumonia meningitis 6.