Dexamethasone meningitis

The adjunctive agent dexamethasone has been shown to improve outcomes in selected patient populations with meningitis. Dexamethasone inhibits the release of proinflammatory cytokines and limits the CNS inflammatory response stimulated by infection and antibiotic therapy. 

The adjunctive agent dexamethasone has been shown to improve outcomes in selected patient populations with meningitis. 

See Table 67-1 for empirical treatment recommendations. cSee text for specific recommendations for use of adjunctive dexamethasone in adults with bacterial meningitis. dSee Table 67-3 for pathogen-based definitive treatment recommendations. (Adapted, with permission, ref. 14.)... 

In adults, a significant benefit was observed with dexamethasone over placebo in reducing meningitis complications,... 

There is concern regarding administration of dexamethasone to patients with pneumococcal meningitis caused by penicillin- or cephalosporin-resistant strains, for which vancomycin would be required. Animal models indicate that concurrent steroid use reduces vancomycin penetration into the CSF by 42% to 77% and delays CSF sterilization due to reduction in the inflammatory response.23 Treatment failures have been reported in adults with resistant pneumococcal meningitis who were treated with dexamethasone, but the risk-benefit of using dexamethasone in these patients cannot be defined at this time. Animal models indicate a benefit of adding rifampin in patients with resistant pneumococcal meningitis whenever dexamethasone is used.21,23... 

Randomised clinical trials have demonstrated a significant beneficial effect of dexamethasone on mortality and morbidity in pneumococcal meningitis, although no benefit was seen for patients with meningococcal meningitis. Steroid treatment is now recommended routinely with or before the first dose of antibiotics, beyond which time dexamethasone begins to lose its effectiveness (van de Beek et al., 2004). 

Dexamethasone given i.v. and early appears to reduce long-term neurological sequelae, especially sensorineural deafness, in infants and children. There is not, however, general agreement about the use of dexamethasone for meningitis in adults. 

Odio C M, Faingezicht I, Paris M et al 1991 The beneficial effects of early dexamethasone administration in infants and children with bacterial meningitis. New England Journal of Medicine 324 1525-1531... 

Syrogiannopouios G A, Olsen K D, Reisch J S et al 1987 Dexamethasone in the treatment of experimental Haemophilus influenzae type b meningitis. Journal of Infectious Diseases 155 213-219... 

Steroid treatment includes dexamethasone 0.15 mg/kg per dose to be given four times daily for 4 days in infants and children older than 2 months of age with proven or strongly suspected bacterial meningitis. Steroids should be given prior to antibiotics. 

In addition to antibiotics, dexamethasone has become a commonly used therapy for the treatment of pediatric meningitis. Corticosteroids inhibit the production of both TNF and IL-1. A series of clinical studies assessing the efficacy of corticosteroid therapy for the initial treatment of bacterial meningitis has reported conflicting results. " The majority of trials were conducted on small sample populations, each with different pathogenic bacterial causes and treatment modalities. The findings of several studies have shown significant... 

Routine use of dexamethasone in meningitis is not without controversy. A potential concern is that adjunctive dexamethasone therapy might reduce the penetration of antibiotics into the CSF by inhibiting meningeal inflammation. In experimental models of meningitis, steroids decreased the CSF concentrations of ampiciUin, rifampin, vancomycin, and gentamicin. Ceftriaxone penetration into CSF was unaffected by concurrent dexamethasone administration in pediatric patients. ... 

The American Academy of Pediatrics suggests that dexamethasone be considered for infants and children 2 months of age or older with pneumococcal meningitis and be given to those with H. influenzae meningitis. The commonly used intravenous dose is 0.15 mg/kg every 6 hours for 4 days. Alternatively, prospective, randomized, double-blind studies have found dexamethasone 0.15 mg/kg... 

Girgis NI, Earid Z, Mikhail lA, et al. Dexamethasone treatment for bacterial meningitis in children and adults. Pediatr Infect Dis J 1989 8 848-851. 

Lebel MH, Ereij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis Results of two double-blind, placebo-controlled trials. N Engl J Med 1988 319 964—971. 

Lebel MH, Hoyt Ml, Waagner DC, et al. Magnetic resonance imaging and dexamethasone therapy for bacterial meningitis. Am J Dis Child 1989 143 301-306. 

Paris MM, Hickey SM, Uscher MI, et al. Effect of dexamethasone on therapy of experimental penicilUn- and cephalosporin-resistant pneumococcal meningitis. Antimicrob Agents Chemother 1994 38 1320-1324. 

Gaillard JL, Abadie V, Cheron G, et al. Concentrations of ceftriaxone in cerebrospinal fluid of children with meningitis receiving dexamethasone therapy. Antimicrob Agents Chemother 1994 38 1209-1210. 

McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis A meta-analysis of randomized clinical trials since 1988. JAMA 1997 278 925-931. 

Syrogiannopoulos GA, Lourida AN, Theodoridou MC, et al. Dexamethasone therapy for bacterial meningitis in children 2- versus 4-day regimen. J Infect Dis 1994 169 853-858. 

Nervous system Methotrexate-induced myelopathy occurred in a woman with breast cancer and meningeal carcinomatosis, who was treated with intrathecal chemotherapy with methotrexate 15 mg and dexamethasone [70 ]. Five days after the last cycle, she developed bloody diarrhea, vomiting, urinary retention, and pancytopenia. While she recovered, progressive neurological deficits emerged. High doses of the key metabolites of the methyl-transfer pathway (adenosylmethio-nine, folinate, cyanocobalamin, and methionine) were substituted, after which the tetraparesis improved markedly. 

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