Role of Dexamethasone in Bacterial Meningitis in Pediatric Patients
Dexamethasone is strongly recommended as adjunctive therapy for infants and children with Haemophilus influenzae type b meningitis, administered 10-20 minutes before or concomitant with the first antimicrobial dose at 0.15 mg/kg every 6 hours for 2-4 days. 1, 2
Evidence-Based Recommendations by Pathogen
H. influenzae type b Meningitis
- Dexamethasone is strongly recommended for children with H. influenzae type b meningitis (Level A-I evidence) 1
- Significantly reduces hearing impairment (OR 0.31; 95% CI, 0.14-0.69) 2
- Should be initiated 10-20 minutes before or concomitant with first antimicrobial dose 1, 2
- Recommended dosage: 0.15 mg/kg IV every 6 hours for 2-4 days 1, 2
- Both 2-day and 4-day regimens appear equally effective for H. influenzae meningitis 3
Pneumococcal Meningitis
- Evidence for dexamethasone use in pneumococcal meningitis in children is controversial (Level C-II evidence) 1
- May provide benefit for severe hearing loss when given early (OR 0.09; 95% CI, 0.0-0.71) 2
- American Academy of Pediatrics states: "For infants and children 6 weeks of age and older, adjunctive therapy with dexamethasone may be considered after weighing potential benefits and possible risks" 1
- Experts vary in recommending corticosteroids for pneumococcal meningitis in children 1
Meningococcal Meningitis
- Benefit less clear due to lower event rates and smaller numbers in studies 2
- In one study, children with meningococcal meningitis treated with dexamethasone had excellent outcomes with no neurologic or audiologic sequelae 3
Neonatal Bacterial Meningitis
- Not currently recommended for neonatal bacterial meningitis 2, 4
- A prospective study showed no improvement in mortality (22% vs 28%, p=0.87) or neurological sequelae (30% vs 39%) in neonates treated with dexamethasone 4
Timing of Administration
- Dexamethasone must be administered before or concomitant with the first antimicrobial dose to be effective 1, 2
- Should not be given to infants and children who have already received antimicrobial therapy (Level A-I evidence) 1
- Administration after antibiotics have been started is unlikely to improve patient outcomes 1
Mechanism of Action
- Attenuates subarachnoid space inflammatory response, a major factor contributing to morbidity and mortality 2
- Decreases cerebral edema, intracranial pressure, altered cerebral blood flow, cerebral vasculitis, and neuronal injury 2
- Reduces levels of inflammatory cytokines (tumor necrosis factor alpha and platelet-activating factor) in cerebrospinal fluid 5
Clinical Outcomes
- Early studies showed significant reduction in neurologic and audiologic sequelae (14% vs 38%, p=0.007) when dexamethasone was given before antibiotics 5
- Swiss Meningitis Study Group found reduced sequelae (5% vs 16%, p=0.066) with dexamethasone 6
- A Brazilian retrospective study showed improved outcomes in children 6-59 months old, with better case fatality rates (11% vs 25%, p=0.05) and higher rates of discharge without sequelae (73% vs 52%, p=0.02) 7
Important Considerations and Caveats
- Dexamethasone should be discontinued if the patient is found not to have bacterial meningitis 2
- The incidence of pneumococcal meningitis in children has decreased dramatically since the introduction of the 7-valent pneumococcal conjugate vaccine 1
- No beneficial effects have been identified in studies performed in low-income countries 2
- Dexamethasone should not be used in patients who have already received antimicrobial therapy 1
Practical Algorithm for Dexamethasone Use in Pediatric Bacterial Meningitis
For children ≥6 weeks with suspected bacterial meningitis:
If H. influenzae type b is confirmed:
If S. pneumoniae is confirmed:
- Consider continuing dexamethasone after weighing benefits and risks 1
If patient has already received antibiotics before presentation:
- Do not initiate dexamethasone 1
For neonates (<6 weeks):