What is the recommended steroid dose for bacterial meningitis?

Steroid Dose for Bacterial Meningitis

For adults with bacterial meningitis, administer dexamethasone 10 mg intravenously every 6 hours for 4 days, with the first dose given 10-20 minutes before or simultaneously with the first antibiotic dose. 1, 2

Dosing by Age Group

Adults

• Dexamethasone 10 mg IV every 6 hours for 4 days 1, 2
• First dose must be given 15-20 minutes before or at minimum simultaneously with initial antibiotics 2
• If not started with antibiotics, can still initiate up to 4 hours after antibiotic administration, though earlier is superior 1

Children (Beyond Neonatal Period)

• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days 1, 2
• Alternative pediatric regimen: 0.4 mg/kg every 12 hours for 2 days has also shown efficacy 3
• First dose should be given 10 minutes before initial antibiotic 3

Neonates

• Dexamethasone is NOT recommended in neonatal meningitis due to insufficient evidence 1

Pathogen-Specific Recommendations

Strong Indications (Continue Full Course)

• Streptococcus pneumoniae (pneumococcal meningitis): Grade A recommendation in adults; reduces mortality and unfavorable outcomes from 25% to 15% 2, 4
• Haemophilus influenzae type b: Grade A-I evidence in children; dramatically reduces hearing loss (OR 0.31) 1, 2

Discontinue Dexamethasone If:

• Bacterial meningitis is ruled out 1
• Causative organism is identified as species other than S. pneumoniae or H. influenzae (though some experts continue regardless) 1
• Gram-negative bacillary meningitis is confirmed 5

Controversial/Limited Benefit

• Neisseria meningitidis (meningococcal meningitis): Safe to use but does not significantly reduce hearing loss or death 1

Critical Timing Considerations

The benefit of dexamethasone is maximized when given before bacteriolysis occurs from antibiotics, which triggers the inflammatory cascade responsible for neurologic damage 1, 2.

• Optimal: 10-20 minutes before first antibiotic dose 2
• Acceptable: Simultaneously with first antibiotic dose 1
• Still beneficial: Up to 4 hours after antibiotics initiated (expert consensus) 1
• Do NOT give: If patient has already received prior antimicrobial therapy 2

Outcomes Improved by Dexamethasone

Based on Cochrane meta-analysis of 25 RCTs with 4,121 patients 1:

• Significantly reduces hearing loss and neurologic sequelae 1
• Reduces mortality in pneumococcal meningitis specifically 1
• Does NOT reduce overall mortality across all bacterial causes 1
• Greatest benefit in patients with moderate-to-severe disease (lower Glasgow Coma Scale scores) 2
• Benefit demonstrated only in high-income countries with high standard of medical care 1

Important Caveats and Monitoring

Antibiotic Penetration Concerns

• In pneumococcal meningitis patients receiving dexamethasone, consider adding rifampin to the empiric vancomycin plus third-generation cephalosporin regimen (Grade B-III) due to concerns about reduced CSF antibiotic penetration from decreased inflammation 2
• Monitor for treatment failure in resistant pneumococcal strains 2

Adverse Effects

• No excess dexamethasone-related adverse effects compared to placebo in large trials 1
• Some studies reported increased gastrointestinal bleeding and psychiatric manifestations, though neurologic outcomes remained superior 6

Special Consideration: Tuberculous Meningitis

For tuberculous meningitis specifically, use a different regimen:

• Adults and children ≥25 kg: Dexamethasone 12 mg/day for 3 weeks, then taper over 3 weeks 7
• Children <25 kg: Dexamethasone 8 mg/day for 3 weeks, then taper over 3 weeks 7