Management of bacterial meningitis in children: Controversies in the

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Sep 7, 2002 - that may occur, including prolonged fever, subdural effusion or empyema and seizures. The Canadian Paediatric Society Infectious Diseases.
COMMENTARY

Management of bacterial meningitis in children: Controversies in the management of bacterial meningitis James D Kellner MD MSc FRCPC

here are at least 150 to 170 cases of bacterial meningitis in Canadian children younger than five years of age each year (http://cythera.ic.gc.ca/dsol/ndis/index_e.html). Streptococcus pneumoniae and Neisseria meningiditis each cause about 40% of the cases of bacterial meningitis, with other pathogens causing the remainder of cases. Haemophilus influenzae type b is a rare cause of meningitis, with just two cases identified in Canadian children in 2000, 14 years after the first vaccine was licensed (1). There are many more cases of suspected bacterial meningitis and viral meningitis that are initially treated as possible bacterial meningitis. Thus, the diagnosis of bacterial meningitis is still considered often enough that Canadian paediatricians must be aware of appropriate management considerations. In this issue of the Journal, Dr Trenna Sutcliffe (pages 449-453) reviews two important issues in the management of bacterial meningitis, namely empiric dexamethasone therapy to prevent hearing loss and routine fluid restriction to prevent or ameliorate the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). She first reviews dexamethasone use and highlights the main conclusions of the meta-analysis by McIntyre et al (2), which were that a benefit from dexamethasone was more apparent overall for H influenzae meningitis than for S pneumoniae meningitis, with a benefit for S pneumoniae meningitis being apparent only when dexamethasone was given with or before the first dose of antibiotics. After consideration of the McIntyre et al (2) meta-analysis, Sutcliffe recommends routine dexamethasone use before or with the first dose of antibiotics in cases of suspected bacterial meningitis. In

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contrast, I would suggest that, in 2002, with H influenzae virtually eliminated, there is not sufficient evidence to support a recommendation for the routine use of dexamethasone in suspected bacterial meningitis. The McIntyre et al (2) meta-analysis did not provide conclusive results. Only S pneumoniae and H influenzae cases were considered in detail. Limited data on any degree of hearing loss that occurred in just three of 93 children with N meningiditis meningitis showed no difference between those treated with dexamethasone and those not treated with dexamethasone. There were considerable differences in the study populations and interventions that were compared. In particular, the incidence of severe bilateral sensorineural hearing loss (more than 60 dB loss or requirement for bilateral hearing aids) was highly variable in the control groups that did not receive dexamethasone (5.0% to 24.1% for H influenzae meningitis and 7.7% to 40.0% for S pneumoniae meningitis). Surprisingly, dexamethasone given with or before the first dose of antibiotics did not prevent severe hearing loss in H influenzae meningitis (odds ratio 0.53, 95% CI 0.14 to 1.94). Another issue was that the benefit of early dexamethasone therapy in S pneumoniae meningitis was based on one case of severe hearing loss in 52 children who were treated with dexamethasone, compared with nine cases in 51 control children. The statistical significance for this finding was lost when results from one study from Egypt were excluded. The Egyptian study (3) had very different characteristics, including no evaluation of hearing loss in children younger than five years of age and a higher overall S pneumoniae meningitis mortality rate (19%) than the other studies.

Child Health Research Group, Departments of Pediatrics and Microbiology & Infectious Diseases, University of Calgary, Alberta Children’s Hospital, Calgary, Alberta Correspondence: Child Health Research Group, Departments of Pediatrics and Microbiology & Infectious Diseases, University of Calgary, Alberta Children’s Hospital, 1820 Richmond Road, SW, Calgary, Alberta T2T 5C7. Telephone 403-943-7687, fax 403-943-7665, e-mail [email protected] Paediatr Child Health Vol 7 No 7 September 2002

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Commentary

The McIntyre et al (2) meta-analysis did not evaluate the severity of the presenting illness in the dexamethasone and control groups, and this is likely an important factor. For example, Arditi et al (4) reviewed 181 cases of S pneumoniae meningitis in children and found with univariate analysis a higher incidence of moderate or severe hearing loss in those who did not receive dexamethasone compared with those who did (46% versus 23%, P