OBJECTIVE. Several studies have evaluated dexamethasone for prevention of hearing loss in childhood bacterial meningitis, but results have varied. We compared dexamethasone and/or glycerol recipients with placebo recipients, and measured hearing at 3 threshold levels.
METHODS. Children aged 2 months to 16 years with meningitis were treated with ceftriaxone but were double-blindly randomly assigned to receive adjuvant dexamethasone intravenously, glycerol orally, both agents, or neither agent. We used the Glasgow coma scale to grade the presenting status. The end points were the better ear's ability to detect sounds of >40 dB, ≥60 dB, and ≥80 dB, with these thresholds indicating any, moderate-to-severe, or severe impairment, respectively. All tests were interpreted by an external audiologist. Influence of covariates in the treatment groups was examined by binary logistic regression.
RESULTS: Of the 383 children, mostly with meningitis caused by Haemophilus influenzae type b or Streptococcus pneumoniae, 101 received dexamethasone, 95 received dexamethasone and glycerol, 92 received glycerol, and 95 received placebo. Only the presenting condition and young age predicted impairment independently through all threshold levels. Each lowering point in the Glasgow scale increased the risk by 15% to 21% (odds ratio: 1.20, 1.21, and 1.15 [95% confidence interval: 1.06–1.35, 1.07–1.37, and 1.01–1.31]; P = .005, .003, and .039) for any, moderate-to-severe, or severe impairment, respectively. Each increasing month of age decreased the risk by 2% to 6% (P = .0001, .0007, and .041, respectively). Neither dexamethasone nor glycerol prevented hearing loss at these levels regardless of the causative agent or timing of antimicrobial agent.
CONCLUSIONS: With bacterial meningitis, the child's presenting status and young age are the most important predictors of hearing impairment. Little relief is obtained from current adjuvant medications.
Comments
Corticosteroids in bacterial meningitis
Rossetto and Ventura (1) suggested to interpret with caution the results of the study by Peltola et al. (2), as a silent HIV infection could lead to underestimate the effect of dexamethasone. A recent meta- analysis showed that the lack of effect of corticosteroids on the outcome of bacterial meningitis was independent of HIV status (3). Furthermore, Rossetto and Ventura pointed out that the timing of therapy is a crucial factor for the efficacy of corticosteroids. Indeed, the mentioned study showed that delayed presentation had no effect on mortality in the multivariable analysis, including HIV status (4). To date there is still little evidence that adjuvant corticosteroid treatment is of any benefit on the outcome of bacterial meningitis.
References
1.Rossetto E, Ventura A. Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol [E-letter], Pediatrics (January 29, 2010), http://pediatrics.aappublications.org/cgi/eletters/125/1/e1 (accessed February 11, 2010).
2.Peltola H, Roine I, Fernandez J, Gonzalez Mata A, Zavala I, Gonzalez Ayala S, et al. Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol. Pediatrics 2010;125(1):e1-8.
3.van de Beek D, Farrar JJ, de Gans J, Mai NT, Molyneux EM, Peltola H, et al. Adjunctive dexamethasone in bacterial meningitis: a meta- analysis of individual patient data. Lancet Neurol, published online: February 3, 2010 (doi:10.1016/S1474-4422(10)70023-5).
4.Scarborough M, Gordon SB, Whitty CJ, French N, Njalale Y, Chitani A, et al. Corticosteroids for bacterial meningitis in adults in sub- Saharan Africa. N Engl J Med 2007;357(24):2441-50.
Conflict of Interest:
None declared
Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol
We have read with interest the article by Peltola H et al (1) published on the current issue and regarding the use of dexamethasone or glycerol to reduce hearing impairment in children with bacterial meningitis. In our opinion this study does not consider two important variables that are mandatory instead. First of all the authors do not consider HIV infection in their population, although it has been demonstrated that neither young adults nor children with HIV positivity benefit by corticosteroids.(2,3) Even though the prevalence of HIV infection in Latin America is reported to be lower than in other developing countries (4), it is higher than in developed ones. Thus a silent coinfection could be responsible of the lower than expected efficacy of corticosteroid treatment. Moreover there are no data about the time between the onset of symptoms and the start of therapy. This information should be available since the delayed treatment, especially in developing countries, seems to be a crucial factor in determining the efficacy of corticosteroids.(3) These are two methodological weaknesses that raise doubts about the results of the study.
Conflict of Interest: None declared
Elena Rossetto, MD, Alessandro Ventura, MD. Department of Pediatrics, Burlo Garofolo, University of Trieste, Italy
e-rossetto@libero.it
References:
1. Peltola H et al, Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol, Pediatrics 125;1: e1-8
2. Molyneux E M et al, Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial, Lancet 2002; 360:211- 18
3. Scarborough M. et al, Corticosteroids for bacterial meningitis in adults in Sub-Saharan Africa, N Engl J Med, 2007; 357: 2441-50
4. World Health Organisation, AIDS epidemic update 2009, www.who.int
Conflict of Interest:
None declared