DEXAMETHASONE AS ADJUNCTIVE THERAPY IN BACTERIAL-MENINGITIS - A METAANALYSIS OF RANDOMIZED CLINICAL-TRIALS SINCE 1988

Objective.-To evaluate the effectiveness of dexamethasone in bacterial meningitis in the subcategories of causative organism and timing and nature of antibiotic therapy. Data Sources.-MEDLINE, HEALTHLINE, and A IDSLINE were searched with the Medical Subject Headings ''dexamethason e'' and ''meningitis'' in any language. Bibliographies, conference abs tracts, and the authors of identified studies were consulted. Study Se lection.-Randomized, concurrently controlled trials of dexamethasone t herapy in childhood bacterial meningitis published from 1988 to Novemb er 1996 were selected. Of 16 studies identified, 5 were not eligible. Data Extraction.-Data were extracted by means of standard outcomes in a protocol sent to all principal authors. Data Synthesis.-Random-effec ts meta-analysis models were used to obtain summary estimates. As the incidence of severe hearing loss differed significantly by organism am ong control subjects, organism-specific estimates were used. In Haemop hilus influenzae type b meningitis, dexamethasone reduced severe heari ng loss overall (combined odds ratio [OR], 0.31; 95% confidence interv al [CI], 0.14-0.69), Similar ORs were obtained after studies were stra tified by the timing of administration of dexamethasone (before or wit h antibiotics vs rater) or by type of antibiotic (cefuroxime vs other) . in pneumococcal meningitis, only studies in which dexamethasone was given early suggested protection, which was significant for severe hea ring loss (combined OR, 0.09; 95% CI, 0.0-0.71) and approached signifi cance for any neurological or hearing deficit (combined OR, 0.23; 95% CI, 0.04-1.05). For all organisms combined, the pooled OR suggested pr otection against neurological deficits other than hearing loss but was not significant (OR, 0.59; 95% CI, 0.34-1.02). Outcomes were similar in studies that used 2 vs more than 2 days of dexamethasone therapy, A dverse effects were not significantly increased with dexamethasone exc ept for secondary fever. The incidence of gastrointestinal tract bleed ing increased with longer duration of dexamethasone treatment (0.5% in controls, 0.8% with 2 days of treatment, 3.0% with 4 days of treatmen t). Conclusions.-The available evidence on adjunctive dexamethasone th erapy confirms benefit for H influenzae type b meningitis and, if comm enced with or before parenteral antibiotics, suggests benefit for pneu mococcal meningitis in childhood, Limiting dexamethasone therapy to 2 days may be optimal.