van de Beek Diederik, de Gans Jan, McIntyre Peter, Prasad Kameshwar
Department of Neurology, Academic Medical Centre, University of Amsterdam, Netherlands.
Lancet Infect Dis. 2004 Mar;4(3):139-43. doi: 10.1016/S1473-3099(04)00937-5.
Bacterial meningitis is uncommon but causes significant mortality and morbidity, despite optimum antibiotic therapy. A clinical trial in 301 patients showed a beneficial effect of adjunctive steroid treatment in adults with acute community-acquired pneumococcal meningitis, but data on other organisms or adverse events are sparse. This led us to do a quantitative systematic review of adjunctive steroid therapy in adults with acute bacterial meningitis. Five trials involving 623 patients were included (pneumococcal meningitis=234, meningococcal meningitis=232, others=127, unknown=30). Overall, treatment with steroids was associated with a significant reduction in mortality (relative risk 0.6, 95% CI 0.4-0.8, p=0.002) and in neurological sequelae (0.6, 0.4-1, p=0.05), and with a reduction of case-fatality in pneumococcal meningitis of 21% (0.5, 0.3-0.8, p=0.001). In meningococcal meningitis, mortality (0.9, 0.3-2.1) and neurological sequelae (0.5, 0.1-1.7) were both reduced, but not significantly. Adverse events, recorded in 391 cases, were equally divided between the treatment and placebo groups (1, 0.5-2), with gastrointestinal bleeding in 1% of steroid-treated and 4% of other patients. Since treatment with steroids reduces both mortality and neurological sequelae in adults with bacterial meningitis, without detectable adverse effects, routine steroid therapy with the first dose of antibiotics is justified in most adult patients in whom acute community-acquired bacterial meningitis is suspected.
尽管采用了最佳抗生素治疗，但细菌性脑膜炎虽不常见，却会导致显著的死亡率和发病率。一项针对301名患者的临床试验表明，辅助性类固醇治疗对患有急性社区获得性肺炎球菌性脑膜炎的成年人有有益效果，但关于其他病原体或不良事件的数据却很稀少。这促使我们对成人急性细菌性脑膜炎的辅助性类固醇治疗进行定量系统评价。纳入了五项涉及623名患者的试验（肺炎球菌性脑膜炎=234例，脑膜炎球菌性脑膜炎=232例，其他=127例，不明=30例）。总体而言，类固醇治疗与死亡率显著降低相关（相对风险0.6，95%置信区间0.4 - 0.8，p = 0.002）以及神经后遗症减少相关（0.6，0.4 - 1，p = 0.05），并且肺炎球菌性脑膜炎的病死率降低了21%（0.5，0.3 - 0.8，p = 0.001）。在脑膜炎球菌性脑膜炎中，死亡率（0.9，0.3 - 2.1）和神经后遗症（0.5，0.1 - 1.7）均有所降低，但不显著。在391例病例中记录的不良事件，在治疗组和安慰剂组中分布相同（1，0.5 - 2），接受类固醇治疗的患者中有1%出现胃肠道出血，其他患者中有4%出现。由于类固醇治疗可降低成人细菌性脑膜炎的死亡率和神经后遗症，且无明显不良影响，对于大多数疑似患有急性社区获得性细菌性脑膜炎的成年患者，在使用首剂抗生素时常规使用类固醇治疗是合理的。
