What is the protocol for dexamethasone (corticosteroid) taper in the treatment of meningitis?

From the Guidelines

Dexamethasone should be administered without a taper for a standard duration of 4 days in the treatment of certain types of bacterial meningitis, particularly pneumococcal meningitis. The use of dexamethasone as an adjunctive therapy in bacterial meningitis is supported by evidence from multiple studies, including those published in the Clinical Microbiology and Infection journal 1 and the Journal of Infection 1.

Key Considerations

• The standard regimen for dexamethasone is 0.15 mg/kg every 6 hours (or 10 mg every 6 hours for adults) for 4 days, as recommended by the escmid guideline 1 and the uk joint specialist societies guideline 1.
• A taper is not necessary for this short course of treatment, as the goal is to reduce inflammation and prevent neurological complications during the acute phase of the illness.
• Dexamethasone works by reducing inflammation in the subarachnoid space, decreasing cerebral edema, and potentially lowering intracranial pressure, which may help prevent neurological complications 1.
• It's most effective when given early in the course of bacterial meningitis, ideally before or simultaneously with the first antibiotic dose, as antibiotics can cause bacterial cell lysis and release of inflammatory components that worsen inflammation.
• The decision to use dexamethasone should be based on the likely pathogen, patient characteristics, and local resistance patterns, with a strong recommendation for its use in pneumococcal meningitis and Haemophilus influenzae type b meningitis 1.

Important Notes

• Dexamethasone is not recommended for viral, fungal, or tuberculous meningitis, as it may be harmful in these conditions.
• 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, dexamethasone should be stopped, although some experts advise that adjunctive treatment should be continued irrespective of the causative bacterium 1.

From the Research

Dexamethasone Taper in Meningitis

• The use of dexamethasone in bacterial meningitis has been studied in various trials, with some showing improvement in outcomes when given in the presence of poor prognostic CSF parameters 2.
• A meta-analysis of individual patient data found that dexamethasone was not associated with a significant reduction in death or neurological sequelae, but seemed to reduce hearing loss among survivors 3.
• A systematic review of clinical studies found that dexamethasone treatment may be associated with a lower mortality in adults and fewer neurological and auditory sequelae in adults and children from high-income countries 4.
• The efficacy of adjuvant corticosteroids, including dexamethasone, varied between high- and low-income countries, with greater mortality reduction in high-income countries 5.
• A study on ceftriaxone therapy of bacterial meningitis found that intramuscular injection of ceftriaxone in children treated with dexamethasone resulted in detectable CSF ceftriaxone concentrations and bactericidal activity 6.

Key Findings

• Dexamethasone may improve outcomes in bacterial meningitis when given in the presence of poor prognostic CSF parameters 2.
• Dexamethasone seems to reduce hearing loss among survivors of bacterial meningitis 3.
• The efficacy of dexamethasone varies between high- and low-income countries, with greater benefits seen in high-income countries 5, 4.

Treatment Considerations

• Dexamethasone should be given preferably before or with the first dose of antibiotics for cases of acute bacterial meningitis from high-income countries 5.
• The use of dexamethasone in low-income countries requires further study to determine its effectiveness 5, 4.
• Intramuscular ceftriaxone therapy may be a reasonable therapeutic option for convalescing children with good peripheral perfusion 6.