Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis -- Brouwer et al., 10.1212/WNL.0b013e3181f96297 -- Neurology

Published online before print September 29, 2010
(Neurology 2010, doi:10.1212/WNL.0b013e3181f96297)
Received March 3, 2010. Accepted in final form June 2, 2010.

Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis
M.C. Brouwer, MD, PhD*, S.G.B. Heckenberg, MD*, J. de Gans, MD, PhD, L. Spanjaard, MD, PhD, J.B. Reitsma, MD, PhD and D. van de Beek, MD, PhD

From the Department of Neurology (M.C.B., S.G.B.H., J.d.G., D.v.d.B.), Department of Medical Microbiology (L.S.), Netherlands Reference Laboratory for Bacterial Meningitis (L.S.), and Department of Clinical Epidemiology and Biostatistics (J.B.R.), Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, the Netherlands.

Address correspondence and reprint requests to Dr. Diederik van de Beek, Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, the Netherlands d.vandebeek@amc.uva.nl

Background: In this nationwide prospective cohort study, we evaluated the implementation of adjunctive dexamethasone therapy in Dutch adults with pneumococcal meningitis.

Methods: From March 2006 through January 2009, all Dutch patients over 16 years old with community-acquired pneumococcal meningitis were prospectively evaluated. Outcome was classified as unfavorable (defined by a Glasgow Outcome Scale score of 1 to 4 points at discharge) or favorable (a score of 5). Clinical characteristics and outcome were compared with a similar nationwide cohort of 352 patients with pneumococcal meningitis from a previous period before guidelines recommended dexamethasone therapy (1998–2002). A multivariable prognostic model was used to adjust for differences in case mix between the 2 cohorts.

Results: We evaluated 357 episodes with pneumococcal meningitis in 2006–2009. Characteristics on admission were comparable with the earlier cohort (1998–2002). Dexamethasone was started with or before the first dose of antibiotics in 84% of episodes in 2006–2009 and 3% in 1998–2002. At discharge, unfavorable outcome was present in 39% in 2006–2009 and 50% in 1998–2002 (odds ratio [OR] 0.63; 95% confidence interval [CI] 0.46–0.86; p = 0.002). Rates of death (20% vs 30%; p = 0.001) and hearing loss (12% vs 22%; p = 0.001) were lower in 2006–2009. Differences in outcome remained after adjusting for differences in case mix between cohorts.

Conclusions: Dexamethasone therapy has been implemented on a large scale as adjunctive treatment of adults with pneumococcal meningitis in the Netherlands. The prognosis of pneumococcal meningitis on a national level has substantially improved after the introduction of adjunctive dexamethasone therapy.

Classification of evidence: This study provides Class III evidence that dexamethasone (10 mg IV, given every 6 hours for 4 days started before or with the first dose of parenteral antibiotics) reduced the proportion of patients with unfavorable outcomes (Glasgow Outcome Scale score of 1 to 4) in the 2006–2009 cohort, as compared to the 1998–2002 cohort (39% vs 50%; OR 0.63; 95% CI 0.46–0.86; p = 0.002). Mortality rate (20% vs 30%; absolute risk difference 10%; 95% CI 4%–17%; p = 0.001) was also lower in 2006–2009.

Abbreviations: OR, odds ratio

* These authors contributed equally to this work.

Received March 3, 2010. Accepted in final form June 2, 2010.
Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis -- Brouwer et al., 10.1212/WNL.0b013e3181f96297 -- Neurology




NEUROLOGÍA
Un potente esteroide ayuda a reducir las muertes por meningitis
Actualidad Ultimas noticias - JANOes y agencias -
JANO.es y agencias · 01 Octubre 2010 12:18


Médicos holandeses publican en “Neurology” la efectividad observada con la dexametasona administrada por vía intravenosa

Investigadores de la Universidad de Amsterdam (Países Bajos) han demostrado que un potente fármaco esteroide contra la inflamación, la dexametasona, administrado por vía intravenosa puede ayudar a disminuir el riesgo de muerte por meningitis bacteriana y la pérdida de audición. Su investigación se publica en Neurology.

Según ha explicado el Dr. Diederik van de Beek, de la Universidad de Amsterdam, “el uso de este tratamiento en pacientes infectados de meningitis ha estado en debate porque en algunos ensayos amplios demostró ser ineficaz”.

“Nuestros resultados proporcionan evidencias valiosas que sugieren que la dexametasona es efectiva en adultos con meningitis bacteriana, por lo que debería seguir usándose”, apunta.

La meningitis bacteriana puede causar convulsiones, daño cerebral, pérdida de memoria y audición, e incluso la muerte en menos de 48 horas en personas saludables. Esta enfermedad tiene una tasa de mortalidad de alrededor del 15%, si se trata con antibióticos.

El equipo holandés estudió entre 2006 y 2009 a 357 pacientes de 16 años o más que desarrollaron meningitis neumocócica, la forma más grave de la enfermedad bacteriana. De ellos, el 84% recibió dexametasona por vía intravenosa junto o antes de la primera dosis de antibióticos.

Compararon a esos pacientes con los de un estudio previo sobre 352 personas tratadas por meningitis bacteriana entre 1998 y el año 2002, donde sólo el 3% de los participantes recibió la medicina esteroide.

El equipo descubrió que la tasa de muerte fue un 10% menor en las personas que recibieron este fármaco, comparado con la investigación anterior. La tasa de pérdida de la audición también fue un 10% inferior.

Neurology 2010;doi:10.1212/WNL.0b013e3181f96297
Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis -- Brouwer et al., 10.1212/WNL.0b013e3181f96297 -- Neurology

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