title: Corticosteroids for acute bacterial meningitis.
abstract: BACKGROUND
  In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response.
  
  
  OBJECTIVE
  To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis.
  
  
  METHODS
  We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015), EMBASE (1974 to February 2015), Web of Science (2010 to February 2015), CINAHL (2010 to February 2015) and LILACS (2010 to February 2015).
  
  
  METHODS
  Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis.
  
  
  METHODS
  We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality.
  
  
  RESULTS
  We included 25 studies involving 4121 participants (2511 children and 1517 adults; 93 mixed population). Four studies were of high quality with no risk of bias, 14 of medium quality and seven of low quality, indicating a moderate risk of bias for the total analysis. Nine studies were performed in low-income countries and 16 in high-income countries.Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P value = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P value = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events.
  
  
  CONCLUSIONS
  Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
authors.affiliation: Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center University of Amsterdam, P.O. Box 22660, Amsterdam, Netherlands, 1100 DE.
authors.forename: Matthijs C
authors.initials: MC
authors.lastname: Brouwer
authors.forename: Peter
authors.initials: P
authors.lastname: McIntyre
authors.forename: Kameshwar
authors.initials: K
authors.lastname: Prasad
authors.forename: Diederik
authors.initials: D
authors.lastname: van de Beek
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000009:adverse effects / Q000627:therapeutic use; D002648:Child; D019049:Developed Countries; D003906:Developing Countries; D003907:Dexamethasone / Q000627:therapeutic use; D005938:Glucocorticoids / Q000009:adverse effects / Q000627:therapeutic use*; D034381:Hearing Loss / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D016920:Meningitis, Bacterial / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D011239:Prednisolone / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic
chemical_list: D000893:Anti-Inflammatory Agents; D005938:Glucocorticoids; D003907:Dexamethasone; D011239:Prednisolone; D006854:Hydrocortisone