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Background It is uncertain whether all adults with bacterial meningitis benefit from treatment with adjunctive dexamethasone.
Methods We conducted a randomized, double-blind, placebo-controlled trial of dexamethasone in 435 patients over the age of 14 years who had suspected bacterial meningitis. The goal was to determine whether dexamethasone reduced the risk of death at 1 month and the risk of death or disability at 6 months.
Results A total of 217 patients were assigned to the dexamethasone group, and 218 to the placebo group. Bacterial meningitis was confirmed in 300 patients (69.0%), probable meningitis was diagnosed in 123 patients (28.3%), and an alternative diagnosis was made in 12 patients (2.8%). An intention-to-treat analysis of all the patients showed that dexamethasone was not associated with a significant reduction in the risk of death at 1 month (relative risk, 0.79; 95% confidence interval [CI], 0.45 to 1.39) or the risk of death or disability at 6 months (odds ratio, 0.74; 95% CI, 0.47 to 1.17). In patients with confirmed bacterial meningitis, however, there was a significant reduction in the risk of death at 1 month (relative risk, 0.43; 95% CI, 0.20 to 0.94) and in the risk of death or disability at 6 months (odds ratio, 0.56; 95% CI, 0.32 to 0.98). These effects were not found in patients with probable bacterial meningitis. Results of multivariate analysis indicated that dexamethasone treatment for patients with probable bacterial meningitis was significantly associated with an increased risk of death at 1 month, an observation that may be explained by cases of tuberculous meningitis in the treatment group.
Conclusions Dexamethasone does not improve the outcome in all adolescents and adults with suspected bacterial meningitis; a beneficial effect appears to be confined to patients with microbiologically proven disease, including those who have received prior treatment with antibiotics. (Current Controlled Trials number, ISRCTN42986828
[controlled-trials.com]
.)
Source Information
From the Hospital for Tropical Diseases (N.T.H.M., T.T.H.C., L.V.C., D.X.S., H.D.T.N., N.H.P., T.S.D., N.V.C., N.M.D., N.T.C., T.T.H.); Oxford University Clinical Research Unit, Hospital for Tropical Diseases (G.T., P.Q.T., J.C., C.S., C.P., M.E.T., K.S., J.J.F.); and the University of Medicine and Pharmacy (N.D.P., N.W.) — all in Ho Chi Minh City, Vietnam; and the Department of Infectious Disease, Imperial College, London (G.T.); the Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford (C.S., M.E.T., K.S., J.J.F.); and the Department of Medical Microbiology, University of Liverpool, Liverpool (C.P.) — all in the United Kingdom.
Address reprint requests to Dr. Farrar at the Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City, Vietnam, or at jfarrar{at}oucru.org.
Related Letters:
Corticosteroids for Bacterial Meningitis
Chan E. D., Ong C. W., Hsu L. Y., Tambyah P. A., Taha M.-K., Alonso J.-M., Siberry G. K., McMillan J. A., Mai N. T. H., Thwaites G., Farrar J. J., Scarborough M., Gordon S., Peto T.
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N Engl J Med 2008;
358:1399-1401, Mar 27, 2008.
Correspondence
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