Should corticosteroids be given to every child with bacterial meningitis, including a 12‑ to 36‑month‑old immunized toddler?

Should Corticosteroids Be Administered in Every Bacterial Meningitis Case in Children?

No, corticosteroids should not be given to every child with bacterial meningitis—the decision depends critically on the causative pathogen, clinical presentation, and timing of antibiotic administration. 1

Initial Empirical Treatment Approach

When bacterial meningitis is suspected and the pathogen is unknown, dexamethasone (0.15 mg/kg every 6 hours) should be administered with or within 24 hours of the first antibiotic dose for children starting empirical treatment. 1 This recommendation applies to children aged 6 weeks and older with suspected bacterial meningitis of unknown etiology. 1

Critical timing requirement: Dexamethasone must be given 10-20 minutes before or at least concomitant with the first antimicrobial dose to be effective. 1, 2 If the child has already received antimicrobial therapy, dexamethasone should not be given, as administration after antibiotics have been started is unlikely to improve patient outcome. 1

Pathogen-Specific Recommendations

Once the causative organism is identified, the corticosteroid regimen must be tailored:

Haemophilus influenzae Type B Meningitis

• Continue dexamethasone for the full 2-4 day course. 1
• Strong evidence supports benefit in preventing severe hearing loss (risk reduction to 0.34). 3
• This represents the clearest indication for corticosteroid use in pediatric bacterial meningitis. 1, 4

Pneumococcal (Streptococcus pneumoniae) Meningitis

• The evidence is controversial and insufficient to demonstrate clear benefit in children. 1
• Dexamethasone may be considered after weighing potential benefits and risks, but experts vary in their recommendations. 1
• The American Academy of Pediatrics states that data are not sufficient to demonstrate clear benefit in children with pneumococcal meningitis. 1
• Important caveat: Dexamethasone may be less beneficial in children with delayed presentation and may be unfavorable with cephalosporin-resistant pneumococci. 4
• Given the dramatic decrease in pneumococcal meningitis incidence since the 7-valent conjugate vaccine, definitive efficacy data are unlikely to be obtained. 1

Meningococcal Meningitis

• Steroids are NOT recommended for children with meningococcal septicemia. 1
• For confirmed meningococcal meningitis without septicemia features, dexamethasone may be administered. 1
• However, there is no strong evidence to recommend corticosteroids specifically for meningococcal meningitis. 4
• Exception: In cases of inotrope-resistant shock, corticosteroids may be used as a rescue strategy. 1

Listeria monocytogenes Meningitis

• Dexamethasone must be discontinued immediately if Listeria is identified. 5
• French national cohort data (252 patients) demonstrated that dexamethasone within the first 24 hours was associated with increased mortality in neurolisteriosis. 5
• Current ESCMID guidelines (2016-2017) maintain the recommendation to suspend dexamethasone when Listeria is identified. 5

Special Considerations for the 12-36 Month Immunized Toddler

For an immunized toddler in this age group:

• The likelihood of H. influenzae type B is extremely low due to routine Hib vaccination, making the strongest indication for corticosteroids less relevant. 1
• Pneumococcal meningitis remains possible despite conjugate vaccine coverage, but the evidence for benefit is insufficient in this population. 1
• Empirical dexamethasone should still be initiated with the first antibiotic dose when bacterial meningitis is suspected, then discontinued if the pathogen proves to be meningococcus with septicemia or Listeria. 1

Dosing Regimen

When indicated, the standard pediatric dosing is:

• Dexamethasone 0.15 mg/kg intravenously every 6 hours for 2-4 days 1, 2
• First dose must be given 10-20 minutes before or simultaneously with the first antibiotic dose 1, 2

Common Pitfalls to Avoid

• Do not give dexamethasone after antibiotics have already been started—this negates any potential benefit. 1
• Do not continue dexamethasone if Listeria is identified—this increases mortality risk. 5
• Do not routinely use corticosteroids in meningococcal septicemia—they are not beneficial except in inotrope-resistant shock. 1
• Do not assume benefit in all bacterial meningitis cases—the evidence is pathogen-specific and strongest only for H. influenzae. 1, 4, 3

Adverse Effects

Corticosteroid treatment is associated with increased recurrent fever (RR 1.27), but not with other significant adverse events. 3