Steroid for Bacterial meningitis李慧玲 高雄市立小港醫院 神經科臨床問題 P (patient) : Becterial meningitis I (intervention) : Steroid C (comparison) : Placebo O (outcome) : Efficacy背景說明Steroid 在臨床上已被廣泛地應用，它具有 抗炎、止痛及減緩異常血腦障壁之微血管的 通透，以及降低顱內壓等作用。治療細菌性腦膜炎，雖然有著抗生素的介入 治療，但卻仍具高死亡率，且造成嚴重的後 遺症，不僅是一個衝擊，也是我們要去突 破的瓶頸。 背景說明 感染性疾病有著強烈的地域性特色，在西方國 家細菌性腦膜炎最常見到的致病菌是鏈球菌 (Streptococcus Pneumoniae)、李斯特菌(Listeria monocytogenes)，或是奈瑟氏菌(Neisseria meningitids)；我國則是鏈球菌(Streptococcus Pneumoniae)和取而代之的克雷伯氏菌 (Klebsiella Pneumoniae)為主。 至於Steroid針對Bacterial meningitis的使用，目 前仍受爭議，至今尚無定論，但在有些病人身 上是可以加速改善症狀，但對於減少後遺症則 很難說。 期待目標 提供有用的文獻資料，期待進一步釐清 Steroid 使用於Bacterial meningitis的角 色及療效。 搜尋步驟- 1Cochrane Library： Key Word： Combine bacterial meningitis AND steroidFound：【Reviews：1篇】【DARE：1篇】【CENTRAL：7篇】 Combine bacterial meningitis ANDdexamethasoneFound：【Reviews：1篇】【DARE：3篇】【CENTRAL：23篇】搜尋步驟- 2EBMR- ACP Journal Club Key Word： Combine bacterial meningitis AND steroidFound：0篇 Combine bacterial meningitis ANDdexamethasoneFound：2篇搜尋步驟- 3 NGC（National Guideline Clearinghouse） Key Word： Combine bacterial meningitis AND steroidFound：1篇 Combine bacterial meningitis ANDdexamethasoneFound：1篇搜尋步驟- 4 PubMedKey Word： Combine bacterial meningitis AND steroidFound：9篇 Combine bacterial meningitis AND dexamethasoneFound：8篇搜尋步驟- 5 MEDLINEKey Word： Combine bacterial meningitis AND steroidFound：10篇 Combine bacterial meningitis AND dexamethasoneFound：8篇搜尋步驟- 6 EBM ONLINEKey Word： Combine bacterial meningitis AND steroidFound：2篇 Combine bacterial meningitis ANDdexamethasoneFound：2篇結果摘要 Eighteen studies involving 1853 people were included. Overall, adjuvant corticosteroids were associated with lower case fatality (relativerisk (RR) 0.76, 95% condence intervals (CI) 0.59 to 0.98) and lower rates of both severe hearing loss (RR 0.36, 95% CI 0.22 to 0.60) and long-term neurological sequelae (RR 0.66, 95% CI 0.44 to 0.99). In children, corticosteroids reduced severe hearing loss in bacterial meningitis caused by Haemophilus influenzae (RR 0.31, 95% CI 0.15 to 0.62), as well as in meningitis caused by other bacteria than H. influenzae (RR 0.42, 95%CI 0.20 to 0.89). van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. The Cochrane Database of Systematic Reviews 2003, Issue 3.結果摘要 In adults, there was a reduction in case-fatality (RR 0.38, 95% CI 0.18 to 0.78), however there were few data. Adverse events were not increased signicantly with the use of corticosteroids. Adjuvant corticosteroids are benecial in the treatment of children with acute bacterial meningitis. The limited data available in adults shows a trend in favour of adjuvant corticosteroids but a denite recommendation must await more studies.van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. The Cochrane Database of Systematic Reviews 2003, Issue 3.結果摘要 7 RCTs（848 pt in total）： 1. In Haemophilus influenzae type b meningitis, dexamethasone reduced severe hearing loss. (pooled OR0.31,95%CI:0.14,0.69) 2. In pneumoccal meningitis, the pooled odds ratio for severe hearing loss was 0.52. (95%CI:0.17, 1.46) 3. Limiting dexamethasone therapy to 2 days may be optimal.結果摘要 7 RCTs（848 pt in total）： 4. The available evidence on adjunctive dexamethasone therapy confirms benefit for Haemophilus influenzae type b meningitis and, if commenced with or before parenteral antibiotics, suggests benefit for pneumoccal meningitis in childhood.P B McIntyre, C S Berkey, S M King, U B Schaad, T Kilpi, G Y Kanra, C M Perez.Dexamethasone as adjunctive therapy in bacterial meningitis: a meta- analysis of randomized clinical trials since 1988 (Structured abstract). The Cochrane Database of Systematic DARE . 2000 結果摘要 1 RCT（301 pt ）: 1. Early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of G-I bleeding. 1 double blind placebo control study(40 pt ): 1. Dexamethasone was given in dose of 0.6mg/kg/day in divided dose, for first 4 days of therapy. 2. First dose of dexamethasone was given 15 minutes prior to first dose dose of ceftriaxone. 3. Neurological complications and hearing loss were more common and severe in placebo group as compared to the dexamethasone group (p0.05).結果摘要 1 Controlled Clinical Trial (68 pt): 1. Dexamethasone was given in dose of 0.6mg/kg/day in divided dose, for first 4 days of therapy. 2. Mortality was lower in the group treated with dexamethasone but the difference was not statistically significant. 3. Dexamethasone should be administered to all adultes patients with acute bacterial meningitis.Neonates At present, there are insufficient data to make a recommendation on the use of adjunctive dexamethasone in neonates with bacterial meningitis. (C-I) 結果摘要結果摘要Infants and Children 1. Despite some