When is dexamethasone (corticosteroid) contraindicated in meningitis?

Contraindications of Dexamethasone in Meningitis

Dexamethasone should be discontinued if the patient is discovered not to have bacterial meningitis or if the causative organism is neither Streptococcus pneumoniae nor Haemophilus influenzae, although some experts recommend continuing regardless of the causative organism. 1

Key Contraindications

• Neonatal meningitis: Dexamethasone is not currently recommended for neonates with bacterial meningitis due to insufficient evidence 1

• Patients who have already received antimicrobial therapy: Dexamethasone should not be given to infants and children who have already received antibiotics, as it is unlikely to improve outcomes in this circumstance 1

• Low-income countries: No beneficial effects of adjunctive corticosteroids have been identified in studies performed in low-income countries 1, 2

• Non-bacterial meningitis: Dexamethasone should be discontinued if the patient is discovered not to have bacterial meningitis 1, 2

• Organisms other than S. pneumoniae or H. influenzae: It is recommended to stop dexamethasone if the causative organism is neither S. pneumoniae nor H. influenzae, though some experts advise continuing regardless of the causative organism 1, 2

Timing Considerations

• Optimal timing: Dexamethasone should ideally be administered 10-20 minutes before or at least concomitant with the first dose of antimicrobial therapy 1, 2

• Late administration: If antibiotics have already been started, dexamethasone can still be administered up to 4 hours after the first antibiotic dose, but benefits may be reduced 1, 2

• Duration of therapy: Standard regimen is 4 days, though some evidence suggests a 2-day regimen may be appropriate for H. influenzae and meningococcal meningitis 3, 4

Special Considerations

• Pneumococcal meningitis: Dexamethasone shows the greatest benefit in pneumococcal meningitis, with significant reduction in unfavorable outcomes (26% vs 52%) and mortality (14% vs 34%) 1, 2

• H. influenzae meningitis: Strong evidence supports use in H. influenzae type b meningitis, with confirmed reduction in hearing impairment 2, 4

• Meningococcal meningitis: Benefit is less clear due to lower event rates and smaller numbers in studies 1, 2

• Tuberculous meningitis: Different dosing regimen is recommended for TB meningitis (initial dose for 3 weeks, then gradually decreased over the following 3 weeks) 5, 6

Potential Adverse Effects

• Secondary fever: More common in patients receiving dexamethasone 7, 4

• Gastrointestinal bleeding: Risk increases with longer duration of dexamethasone treatment (0.5% in controls, 0.8% with 2 days of treatment, 3.0% with 4 days of treatment) 7, 4

• Psychiatric manifestations: May be more common in the dexamethasone group 7

Dosing Recommendations When Indicated

• Adults: 10 mg intravenously every 6 hours for 4 days 1, 2

• Children: 0.15 mg/kg intravenously every 6 hours for 2-4 days 1, 2

• TB meningitis: For adults and children weighing ≥25 kg: 12 mg/day initially; for children weighing <25 kg: 8 mg/day initially, with the initial dose given for 3 weeks, then decreased gradually over the following 3 weeks 5, 6