In experimental studies, the clinical outcome of acute
bacterial meningitis has been related to the severity of the inflammatory process in the subarachnoidal space. Treatment with
corticosteroids can reduce this inflammatory response and thereby may improve outcome. We conducted a meta-analysis of randomised controlled trials (RCTs) of adjuvant
corticosteroids in the treatment of acute
bacterial meningitis.
OBJECTIVES: In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (1966 to July 2006); EMBASE (1974 to June 2006); Current Contents (2001 to June 2006); and reference lists of all articles. We also contacted manufacturers and researchers in the field.
SELECTION CRITERIA: Two review authors independently assessed trial quality and extracted data. Adverse effects were collected from the trials. Additional analyses were performed for children and adults, causative organisms, and low-income and developed countries.
MAIN RESULTS: Eighteen studies involving 2750 people were included. Overall, adjuvant
corticosteroids were associated with lower case fatality (relative risk (RR) 0.83, 95% CI 0.71 to 0.99), lower rates of severe
hearing loss (RR 0.65, 95% CI 0.47 to 0.91) and long-term neurological sequelae (RR 0.67, 95% CI 0.45 to 1.00). In children,
corticosteroids reduced severe
hearing loss (RR 0.61, 95% CI 0.44 to 0.86). In adults,
corticosteroids gave significant protection against death (RR 0.57, 95% CI 0.40 to 0.81) and short-term neurological sequelae (RR 0.42, 95% CI 0.22 to 0.87). Subgroup analysis for causative organisms showed that
corticosteroids reduced mortality in patients with
meningitis due to Streptococcus pneumoniae (RR 0.59, 95% CI 0.45 to 0.77) and reduced severe
hearing loss in children with
meningitis due to Haemophilus influenzae (RR 0.37, 95% CI 0.20 to 0.68); subgroup analysis for patients with meningococcal showed a nonsignificant favourable trend in mortality (RR 0.71, 95% CI 0.31 to 1.62). Sub analyses for high-income and low-income countries of the effect of
corticosteroids on mortality showed RRs of 0.83 (95% CI 0.52 to 1.05) and 0.87 (95% CI 0.72 to 1.05), respectively.
Corticosteroids were protective against short-term neurological sequelae in patients with
bacterial meningitis high-income countries (RR 0.56, 95% CI 0.3 to 0.84); in low-income countries this RR was 1.09 (95% CI 0.83 to 1.45). For children with
bacterial meningitis admitted in high-income countries,
corticosteroids showed a protective effect of on severe
hearing loss (RR 0.61, 95% CI 0.41 to 0.90) and favourable point estimates for severe
hearing loss associated with non-Haemophilus influenzae
meningitis (RR 0.51, 95% CI 0.23 to 1.13) and short-term neurological sequelae (RR 0.72, 95% CI 0.39 to 1.33). For children in low-income countries, the use of
corticosteroids was neither associated with benefit nor with harmful effects. Overall, adverse events were not increased significantly with the use of
corticosteroids.
AUTHORS' CONCLUSIONS: