Brouwer Matthijs C, McIntyre Peter, Prasad Kameshwar, van de Beek Diederik
Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center University ofAmsterdam, Amsterdam, Netherlands.
Cochrane Database Syst Rev. 2013 Jun 4(6):CD004405. doi: 10.1002/14651858.CD004405.pub4.
In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response.
To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis.
We searched CENTRAL 2012, Issue 12, MEDLINE (1966 to January week 2, 2013), EMBASE (1974 to January 2013), Web of Science (2010 to January 2013), CINAHL (2010 to January 2013) and LILACS (2010 to January 2013).
Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis.
We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality.
Twenty-five studies involving 4121 participants were included. Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events.
AUTHORS' CONCLUSIONS: Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
在实验研究中，细菌性脑膜炎的预后与蛛网膜下腔炎症的严重程度相关。皮质类固醇可减轻这种炎症反应。
探讨辅助性皮质类固醇治疗与安慰剂相比，对各年龄段急性细菌性脑膜炎患者死亡率、听力损失及神经后遗症的影响。
我们检索了2012年第12期的Cochrane系统评价数据库、MEDLINE（1966年至2013年1月第2周）、EMBASE（1974年至2013年1月）、科学引文索引（2010年至2013年1月）、护理学与健康领域数据库（2010年至2013年1月）以及拉丁美洲和加勒比卫生科学数据库（2010年至2013年1月）。
皮质类固醇治疗急性细菌性脑膜炎的随机对照试验。
我们对随机对照试验的方法学质量进行评分。收集结局和不良反应。我们对儿童和成人、致病微生物、低收入与高收入国家、类固醇给药时间以及研究质量进行亚组分析。
纳入了25项研究，涉及4121名参与者。皮质类固醇与死亡率的非显著降低相关（17.8%对19.9%；风险比（RR）0.90，95%置信区间（CI）0.80至1.01，P = 0.07）。在接受皮质类固醇治疗的成人中观察到类似的死亡率非显著降低（RR 0.74，95% CI 0.53至1.05，P = 0.09）。皮质类固醇与严重听力损失发生率较低（RR 0.67，95% CI 0.51至0.88）、任何听力损失（RR 0.74，95% CI 0.63至0.87）以及神经后遗症（RR 0.83，95% CI 0.69至1.00）相关。对致病微生物的亚组分析表明，皮质类固醇可降低肺炎链球菌脑膜炎患者的死亡率（RR 0.84，95% CI 0.72至0.98），但对流感嗜血杆菌或脑膜炎奈瑟菌脑膜炎患者无效。皮质类固醇可降低流感嗜血杆菌脑膜炎患儿的严重听力损失（RR 0.34，95% CI 0.20至0.59），但对非流感嗜血杆菌属引起的脑膜炎患儿无效。在高收入国家，皮质类固醇可降低严重听力损失（RR 0.51，95% CI 0.35至0.73）、任何听力损失（RR 0.58，95% CI 0.45至0.73）以及短期神经后遗症（RR 0.64，95% CI 0.48至0.85）。在低收入国家，皮质类固醇治疗没有有益效果。对研究质量的亚组分析表明，在高质量研究中皮质类固醇对严重听力损失没有影响。皮质类固醇治疗与反复发热增加相关（RR 1.27，95% CI 1.09至1.47），但与其他不良事件无关。
皮质类固醇可显著降低听力损失和神经后遗症，但未降低总体死亡率。数据支持在高收入国家的细菌性脑膜炎患者中使用皮质类固醇。我们发现在低收入国家没有有益效果。
