What is the recommended dose of dexamethasone (steroid) for adults and children with suspected or confirmed bacterial meningitis?

Steroid Dosing for Bacterial Meningitis

For adults with suspected bacterial meningitis, administer dexamethasone 10 mg IV every 6 hours for 4 days, starting immediately before or simultaneously with the first antibiotic dose. 1, 2

Adult Dosing Protocol

Dexamethasone 10 mg IV every 6 hours (total 40 mg/day) for 4 days is the standard regimen for all adults with suspected bacterial meningitis in high-income countries. 1, 2, 3

Critical Timing Considerations

• The first dose must be given 10-20 minutes before or at minimum concomitant with the first antimicrobial dose to maximize benefit and reduce mortality and neurological sequelae. 2, 3

• If antibiotics have already been started, dexamethasone should still be initiated up to 12 hours after the first antibiotic dose according to UK guidelines, though some sources suggest benefit up to 4 hours. 1, 3

• Do not delay antibiotics to give steroids first - simultaneous administration is acceptable if pre-treatment is not feasible. 2, 3

Pathogen-Specific Continuation

• If pneumococcal meningitis is confirmed or highly probable, continue dexamethasone for the full 4 days, as this provides the greatest mortality benefit (reducing mortality from 34% to 14% and unfavorable outcomes from 52% to 26%). 1, 2, 3

• If another bacterial cause is confirmed (not S. pneumoniae or H. influenzae), discontinue dexamethasone. 1, 2, 3

• If meningitis is ruled out entirely, stop dexamethasone immediately. 3

Pediatric Dosing Protocol

For children with suspected bacterial meningitis, administer dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days. 2, 3

Duration in Children

• A 2-day regimen (8 doses total) appears equally effective as 4 days for H. influenzae and meningococcal meningitis, with similar rates of neurological and audiological sequelae. 4, 5

• The strongest pediatric evidence supports use in H. influenzae type b meningitis, where it reduces hearing impairment significantly (OR 0.31; 95% CI 0.14-0.69). 2, 3

• For pneumococcal meningitis in children, early dexamethasone reduces severe hearing loss (OR 0.09; 95% CI 0.0-0.71). 3

Timing in Pediatric Patients

• Administer 10 minutes before the first antibiotic dose when possible, as demonstrated in the Swiss study that showed significant reduction in CSF inflammation and sequelae. 5

• The same timing principles apply as in adults: ideally 10-20 minutes before or concomitant with antibiotics. 2, 3

Special Population: Tuberculous Meningitis

For TB meningitis, use a different regimen: dexamethasone 0.4 mg/kg/day (maximum 12 mg/day) IV for 3 weeks, then taper over the following 3 weeks (total 6 weeks). 2, 6

Alternative TB Meningitis Regimen

• Prednisolone 60 mg/day tapered over 6-8 weeks is an acceptable alternative to dexamethasone for TB meningitis. 6

• One tapering schedule: 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for the final week. 6

• Corticosteroids must be initiated before or concurrently with the first dose of anti-tuberculosis medication for maximum mortality benefit. 2, 6

Mechanism of Benefit

Dexamethasone attenuates the subarachnoid space inflammatory response, which is the major contributor to morbidity and mortality rather than the infection itself. 2, 3, 7

• It decreases cerebral edema and intracranial pressure. 2, 3

• It reduces altered cerebral blood flow and cerebral vasculitis. 2, 3

• It prevents neuronal injury mediated by pro-inflammatory cytokines. 2, 3

Evidence Quality and Geographic Considerations

The mortality and morbidity benefits of dexamethasone are only clearly demonstrated in high-income countries with high standards of medical care. 2, 3

• No beneficial effects were identified in studies performed in low-income countries, likely due to differences in healthcare infrastructure, delayed presentation, and HIV co-infection rates. 2, 3

• The landmark 2002 European Dexamethasone Study showed reduction in unfavorable outcomes from 25% to 15% in adults, providing the highest quality evidence for this practice. 7

Common Pitfalls to Avoid

• Do not delay dexamethasone administration - timing is absolutely critical, and benefit is maximized when given before or with antibiotics. 2

• Do not withhold dexamethasone due to concerns about antibiotic penetration - while dexamethasone may theoretically decrease CSF antibiotic concentrations, the overall clinical benefit outweighs this concern when appropriate high-dose antibiotics are used. 2

• Do not use dexamethasone in neonatal bacterial meningitis - it is not currently recommended for this population. 3

• Do not continue dexamethasone for the full 4 days if a non-pneumococcal, non-H. influenzae pathogen is identified - stop it once another organism is confirmed. 1, 2