What is the recommended dose and frequency of corticosteroids (e.g. dexamethasone) in bacterial meningitis?

Recommended Dose and Frequency of Steroids in Bacterial Meningitis

For bacterial meningitis, dexamethasone should be administered at a dose of 10 mg every 6 hours for 4 days in adults, and 0.15 mg/kg every 6 hours for 2-4 days in children. 1

Dosing Recommendations by Age Group

Adults

• Dose: 10 mg dexamethasone
• Frequency: Every 6 hours
• Duration: 4 days
• Timing: Optimally 10-20 minutes before first antimicrobial dose, but can be effective if given concomitantly with or up to 4 hours after first antibiotic dose 1

Children (≥6 weeks)

• Dose: 0.15 mg/kg dexamethasone
• Frequency: Every 6 hours
• Duration: 2-4 days
• Timing: Before or with first antimicrobial dose 1

Evidence-Based Benefits

The use of adjunctive dexamethasone in bacterial meningitis is supported by strong evidence:

• In adults with pneumococcal meningitis, dexamethasone significantly reduces:

  • Unfavorable outcomes (26% vs 52%, p=0.006)
  • Mortality (14% vs 34%, p=0.02) 1

• In children, dexamethasone reduces:

  • Hearing impairment (particularly in H. influenzae type b meningitis)
  • Neurological sequelae 2, 1

Important Clinical Considerations

Timing of Administration

• Critical factor: First dose should ideally be given 10-20 minutes before the first antimicrobial dose 1
• Still effective if given with first antimicrobial dose
• May provide some benefit if started within 4 hours of first antibiotic dose 1
• Should NOT be given to children who have already received antimicrobial therapy 1

Pathogen-Specific Considerations

• Most beneficial in pneumococcal meningitis 1
• Benefits less established for meningococcal meningitis 1
• Not recommended for neonatal meningitis 1

Duration Considerations

• A 2-day regimen appears appropriate for H. influenzae and meningococcal meningitis in children 3
• The standard 4-day regimen is recommended for pneumococcal meningitis 1

Monitoring and Adverse Effects

When administering dexamethasone, monitor for:

• Hyperglycemia (especially in diabetic patients)
• Hypertension
• Increased risk of infection/sepsis
• Gastrointestinal bleeding
• Psychiatric manifestations 1, 4

Special Populations

• Immunocompromised patients: Use with caution but without modifying existing immunosuppressive regimens 1
• Patients with septic shock: Benefit is less clear, but lower doses may be reasonable 5

Clinical Algorithm

1. Confirm suspected bacterial meningitis
2. Determine patient age and likely pathogen
3. Administer dexamethasone:
   • Adults: 10 mg IV every 6 hours for 4 days
   • Children: 0.15 mg/kg IV every 6 hours for 2-4 days
4. Time first dose 10-20 minutes before first antimicrobial dose
5. Continue for full duration unless contraindications develop
6. Monitor for adverse effects throughout treatment

Remember that dexamethasone should not be given if antimicrobial therapy has already been initiated in children, and its benefits are primarily established in high-income countries with high levels of medical care 1.