Corticosteroids of Little Use Against Childhood Meningitis
TUESDAY May 6, 2008 -- Corticosteroids are increasingly used to help treat children with bacterial meningitis, but a new study finds that adding the drugs to antibiotic treatment may not reduce death rates or the length of hospital stays.
But the study -- which involved 2,780 children treated for this potentially lethal infection of tissues lining the brain -- isn't the last word on the issue, said senior researcher Dr. Samir S. Shah, an infectious diseases specialist at the Children's Hospital of Philadelphia.
One reason is that the death rate from the infection in children is so low that a real difference is statistically hard to demonstrate, Shah said. Mortality among adults with bacterial meningitis runs as high as 30 percent, while in children "it is quite low, in the 4 to 5 percent range," he said.
So the study results didn't exclude the possibility that a benefit from corticosteroids could exist, Shah said, but "if it does, it is very small."
His team published its findings in the May 7 issue of the Journal of the American Medical Association.
In the study, just 248 of the nearly 2,800 children treated at 27 U.S. pediatric hospitals received corticosteroids, about 9 percent of the total. However, steroid use among youngsters with the illness doubled during the study period -- from under 6 percent in 2001 to 12 percent in 2006.
The overall death rate for children getting corticosteroids was 6 percent, compared to 4 percent among those not getting them. Hospital stays averaged 12 days for children getting corticosteroids and 10 days for those not receiving them. Neither difference was statistically significant, meaning this outcome could have happened by chance.
Shah himself pointed out what he saw as a flaw of the study: It did not consider the neurological damage done by meningitis, such as hearing loss. Some studies have indicated that corticosteroid treatment might reduce such damage, he said.
"The way I would want people to use our study is not to say there does not seem to be a benefit, or that [corticosteroids] should be used routinely, but to regard it as an impetus for a large, randomized trial," Shah said. "At this point, it would seem that the benefits do not outweigh the risks of using corticosteroids in children, but we need a large-scale clinical trial looking at neurological damage before deciding yes or no."
The study had another flaw, said Dr. Robert W. Frenck, a professor of pediatrics in the division of infectious diseases at Cincinnati Children's Hospital Medical Center: It did not include information on when in the course of the infection corticosteroids were given.
"A number of studies with animals and humans have shown that using corticosteroids before the first dose of antibiotics has the most benefit," Frenck said. "It reduces the inflammatory response that results when the immune system kills the bacteria."
Physicians who treat meningitis are likely to say that the study supports whatever they are now doing, he said. "If people are in the camp where corticosteroids are not regarded as helpful, they will say this shows that they don't help," Frenck said. "If they are in the camp where they are seen as beneficial, they will say that the study does not disprove it."
The large-scale trial proposed by Shah is not likely to happen, Frenck said, and for a cheerful reason -- the very low incidence of bacterial meningitis among American children. Vaccines against the bacteria that cause meningitis, such as Hemophilus influenzae type B, have successfully reduced the incidence of the disease, Frenck said. For that reason, bacterial meningitis now occurs in about eight in every 100,000 American children.
"The vaccines have had a tremendous effect," Frenck said. "What you want to do is prevent it."
Learn about meningitis from the U.S. Library of Medicine.
Posted: May 2008
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