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• W2043135025 abstract "Elizabeth Molyneux and colleagues (July 20, p 211)1Molyneux EM Walsh AL Forsyth H et al.Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial.Lancet. 2002; 360: 211-218Summary Full Text Full Text PDF PubMed Scopus (247) Google Scholar provide the most comprehensive report of a placebo controlled randomised trial of dexamethasone as adjunct therapy in acute bacterial childhood meningitis in a developing country. They found that dexamethasone as adjunct therapy in bacterial meningitis does not prevent death. In his Commentary, George McCracken Jr2McCracken Jr., GH Rich nations, poor nations, and bacterial meningitis.Lancet. 2002; 260: 183Summary Full Text Full Text PDF Scopus (17) Google Scholar discusses the importance of this finding. The effect of dexamethasone on the reduction of neurological sequelae is less conclusive, because of the small number of children in the study with neurological sequelae. Although there is evidence of the benefit of steroids in reducing hearing loss from Haemophilus influenzae type b (Hib) meningitis, the benefit of steroids for other forms of meningitis is unclear.3American Academy of PediatricsDexamethasone therapy for bacterial meningitis in infants and children.in: Peter G Red book: report of the committee on infectious diseases. 23rd edn. American Academy of Pediatrics, Elk Grove Village, IL1994: 558-559Google Scholar I have suggested that in acute bacterial meningitis the benefit of steroids may be dependent on the causative agent and mediated by antibiotic-steroids.4Obaro SK Management of acute bacterial meningitisLancet. 1996; 347: 538Crossref PubMed Google Scholar The recommendation for the use of dexamethasone in bacterial meningitis deserves re-evaluation, especially given the decline of H influenzae meningitis in some settings with the use of Hib conjugate vaccines. Molyneux and colleagues could have provided additional data to elucidate the interpretation of their findings. Blood was not cultured from those children whose cerebrospinal fluid samples showed the presence of bacteria on gram stain. This investigative approach, although practical in an impoverished developing country, may have compromised the results, since children with meningitis and bacteraemia do not have the same clinical outcome as children without bacteraemia, especially with steroid treatment. We are not told the number of children who had positive blood cultures and significant cerebrospinal fluid pleocytosis but a negative culture. Molyneux and co-workers report that of the 598 children, 78 had cerebrospinal fluid pleocytosis without a positive cerebrospinal fluid culture, and that 21 of these children died and 14 had neurological sequelae. Further characterisation of these cases by blood culture or cerebrospinal fluid bacterial antigen would offer additional insights into the management of cause-specific bacterial meningitis. Other factors that may have confounded outcome include multi-focal disease or comorbid disease such as pneumonia, the haemodynamic state of these children at presentation, and abnormal antidiuretic hormone secretion. More than 30% of the children had hyponatraemia, but it is not clear how many of these children also had abnormal secretion of antidiuretic hormone. In addition to late presentation, inadequate nursing and supportive care in resource-poor countries contribute to adverse outcome. In developing countries, the choice of antibiotics is limited, and may, at best, be administered intravenously for only a few days. Moreover, the absence of appropriate care facilities for the management of lengthy seizures, which frequently accompany bacterial meningitis, would also contribute to poor outcome. New bacterial vaccines offer some hope but are not a panacea. A long-term reduction in mortality and morbidity from bacterial meningitis in developing countries will require efforts that go beyond the donation of conjugate vaccines. We must ensure that such vaccines are appropriately delivered—a challenge that is often beyond the remit of the nurse and physician. Dexamethasone in acute bacterial meningitisAuthors' reply Full-Text PDF" @default.
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• W2043135025 title "Dexamethasone in acute bacterial meningitis" @default.
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• W2043135025 doi "https://doi.org/10.1016/s0140-6736(02)11553-4" @default.
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