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Corticosteroids in Children with Bacterial Meningitis: The Debate Continues

A retrospective study finds no effect of corticosteroids on overall mortality in children with bacterial meningitis — morbidity was not evaluated.

Use of adjuvant corticosteroids for treatment of bacterial meningitis in children is controversial. The AAP guidelines state that in children older than 6 weeks, corticosteroids should be "considered after weighing the potential benefits and risks." Results are conflicting from studies that have examined whether corticosteroids reduce mortality in children with bacterial meningitis. To further examine this issue, investigators analyzed data from the Pediatric Health Information System (representing 27 tertiary care children’s hospitals) for 2001 through 2006.

Of 2780 children (age, <18 years) who were discharged with a diagnosis of bacterial meningitis, only 8.9% received adjuvant corticosteroids (mostly dexamethasone) during the first day of hospitalization; the percentage increased from 5.8% in 2001 to 12.2% in 2006. No statistically significant differences in mortality (overall rate, 4.2%), time to death, or length of stay were found between children who did and did not receive corticosteroids.

Comment: This study, which found no mortality benefit from corticosteroids in children with bacterial meningitis, is fraught with methodologic problems. The study used retrospective administrative data based on ICD-9 discharge diagnosis codes and included children younger than 6 months, and about 65% of children in the study did not have documentation of the three most common causes of bacterial meningitis (Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae). In addition, corticosteroid use was defined as administration of corticosteroids at any time during the first day of hospitalization. Previous studies have demonstrated the benefit of corticosteroids on morbidity in children with meningitis when corticosteroids were given before the first dose of antibiotics, and other studies have shown that when steroids are first given as early as 4 hours after the first antibiotic dose, the beneficial effect is negated. Therefore, the results should not change the current recommendation for corticosteroid use in children with bacterial meningitis. The risks associated with corticosteroids in children with bacterial meningitis are primarily theoretical and unproven, while the benefit of corticosteroids in reducing hearing loss in children with H. influenzae is evidence-based.

— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 6, 2008

Citation(s):

Mongelluzzo J et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA 2008 May 7; 299:2048.

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