What is the dosage of dexamethasone (corticosteroid) in the treatment of bacterial meningitis?

Dexamethasone Dosing in Bacterial Meningitis

For bacterial meningitis, dexamethasone should be administered at 0.15 mg/kg every 6 hours for 2-4 days in children and 10 mg every 6 hours for 4 days in adults, with the first dose given before or with the first dose of antibiotics. 1

Age-Specific Dosing Recommendations

Adults

• Dose: 10 mg intravenously every 6 hours 1
• Duration: 4 days 1
• Timing: First dose should be administered 10-20 minutes before or at least concomitant with the first dose of antibiotics 1

Children (≥6 weeks of age)

• Dose: 0.15 mg/kg intravenously every 6 hours 1, 2
• Duration: 2-4 days 1
• Timing: First dose should be administered 10-20 minutes before or with the first dose of antibiotics 1

Neonates (<6 weeks)

• Not recommended - Insufficient evidence supports the use of dexamethasone in neonatal bacterial meningitis 1

Timing of Administration

The timing of dexamethasone administration is critical for maximizing benefit:

• Optimal timing: 10-20 minutes before the first antibiotic dose 1
• Alternative timing: If antibiotics have already been started, dexamethasone can still be initiated up to 4 hours after the first antibiotic dose 1
• Grade C recommendation: Starting dexamethasone after antibiotics have begun but within 4 hours may still provide benefit 1

Duration of Treatment

Evidence supports both 2-day and 4-day regimens:

• 4-day regimen: Most commonly recommended in guidelines 1
• 2-day regimen: May be appropriate for H. influenzae and meningococcal meningitis 3

When to Discontinue Dexamethasone

Dexamethasone should be discontinued in the following situations:

• If bacterial meningitis is ruled out 1
• If the causative organism is determined to be something other than S. pneumoniae or H. influenzae 1
  • Note: Some experts recommend continuing dexamethasone regardless of the causative organism 1

Clinical Benefits

The benefits of dexamethasone in bacterial meningitis include:

• Reduced hearing loss: Particularly effective in H. influenzae and pneumococcal meningitis 1
• Reduced neurological sequelae: Especially in pneumococcal meningitis 1
• Reduced mortality: Primarily in pneumococcal meningitis in adults 1

Pathogen-Specific Considerations

The efficacy of dexamethasone varies by causative organism:

• S. pneumoniae: Most beneficial effect, with reduced unfavorable outcomes (26% vs. 52%) and mortality (14% vs. 34%) 1
• H. influenzae: Strong effect on reducing hearing impairment 1
• N. meningitidis: Less clear benefit, but some experts recommend continuing treatment 1

Important Caveats

• Dexamethasone is most beneficial in high-income countries with high standards of medical care 1
• No beneficial effects have been identified in studies from low-income countries 1
• Regular monitoring for adverse effects is essential, including hyperglycemia, gastrointestinal complications, psychiatric disturbances, and increased infection risk 2

Special Considerations for Resistant Organisms

For suspected pneumococcal meningitis with highly resistant strains:

• Continue dexamethasone even if the isolate is highly resistant to penicillin and cephalosporins 1
• Consider adding rifampin to the empirical combination of vancomycin plus a third-generation cephalosporin pending culture results 1