Source:Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticosteroids and mortality in children with bacterial meningitis.
–2055; doi:10.1001/jama.299.17.2048

Investigators from the Children’s Hospital of Philadelphia and the University of Pennsylvania conducted a retrospective cohort study to determine the association between use of adjuvant corticosteroids and survival and length of hospital stay in children with bacterial meningitis.

Data from the Pediatric Health Information System (PHIS), a national administrative database containing resource utilization data from 27 freestanding, tertiary care children’s hospitals, were analyzed. Children younger than 18 years with bacterial meningitis were eligible for inclusion if they were discharged between 2001 and 2006. Children with a ventricular shunt were excluded from analysis. Patients with more than one admission with bacterial meningitis were included only for the first hospitalization.

There were 2,780 children treated for meningitis in the study cohort with a median age of 9 months. Adjuvant corticosteroids were administered to 248 children (9%). Frequency of adjuvant steroid treatment increased during the study years from 6% in 2001 to 12% in 2006.

The most common pathogens were Streptococcus pneumoniae (18%), Staphylococcus species (14%), Neisseria meningitidis (10%), and unspecified (28%). The overall mortality rate was 4%, with almost a quarter of these occurring within the first 24 hours of admission and approximately half occurring in the first week of admission.

Adjuvant corticosteroid administration was not associated with decreased mortality for any age group, nor with time to hospital discharge. Subgroup analysis of children with pneumococcal (n=504) or meningococcal meningitis (n=280) and adjuvant steroid treatment failed to demonstrate a significant association with mortality or length of hospital stay.

The authors conclude that in patients with bacterial meningitis, adjuvant corticosteroid therapy was not associated with mortality risk or time to hospital discharge. However, the authors noted that their study did not include adjustment for severity of illness nor evaluate for morbidity such as hearing loss or learning disabilities. Furthermore, they could not assess the dose or timing of corticosteroid administration

Dr. Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

In recent studies of adults with bacterial meningitis, investigators have found that adjuvant administration of corticosteroids was associated with decreased mortality, especially among patients with pneumococcal disease.1,2 

However, adult mortality rates for pneumococcal meningitis range from 19% to 37% and up to 30% of survivors have long-term neurologic impairment.3 In adults, risk factors that have been associated with an increased risk for mortality are tachycardia, impaired consciousness, low white cell count in the cerebrospinal fluid, and pneumococcus infection.

In the present study of children with meningitis, a relatively low mortality rate of 4% was found, making comparisons between treatment groups more challenging.

Moreover, patients were not randomized and the multivariate model contained no measure of severity of illness. Because death was uncommon and sicker children may have been more likely to receive adjuvant steroids, drawing firm conclusions...

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