MIAMI BEACH — Dexamethasone should be started before or with the first dose of antibiotics in patients with suspected pneumococcal meningitis, Karen L. Roos, M.D., said at the annual meeting of the American Academy of Neurology.
It is vital to stop the inflammatory process at the point where inflammatory cytokines are released. “If you can stop the evolution here, all of the things that go forward from there that lead to the neurologic morbidity from meningitis can be stopped,” she said.
In the future, there may be all kinds of effective treatments, such as monoclonal antibodies injected at the time of lumbar puncture, but “today, what we have is dexamethasone,” said Dr. Roos, the John and Nancy Nelson Professor of Neurology at Indiana University, Indianapolis, and an author of the Practice Guidelines for the Management of Bacterial Meningitis.
An excellent, prospective, randomized, double-blind trial (N. Engl. J. Med. 2002;347:1549–56) has demonstrated that adjunctive dexamethasone improved outcomes in adults with acute bacterial meningitis, giving us evidence-based medicine to back this treatment, she said.
The adult dose is dexamethasone 10 mg, given 15–20 minutes before the first dose of antimicrobial agent or with the agent, and 10 mg IV thereafter every 6 hours for 4 days.
In response to a question from the audience, Dr. Roos said she does not prescribe dexamethasone to patients who have been on antimicrobials for 24 hours or more at the time she sees them.
There has been some concern that dexamethasone might interfere with the absorption of vancomycin into the cerebrospinal fluid, but this stemmed from a small study in which the dose of vancomycin was 15 mg/kg every 8 hours or 7.5 mg/kg every 6 hours—the recommended dose is 60 mg/kg per day. In studies in which patients were given the recommended doses of vancomycin with dexamethasone, there was reliable penetration of vancomycin into the cerebrospinal fluid, Dr. Roos said.
Dr. Roos has received an educational grant from Pfizer Inc.