Steroid UseGiven that many of the damaging sequelae of acute bacterial meninges are due to the host’s inflammatory response, several studies have looked at the role of steroids as an adjunctive measure. Many of the studies have been done in children, and steroids have been shown to decrease the incidence of hearing loss in cases of H. influenzae meningitis in this population. Corroborating retrospective studies, a recent randomized double-blinded study from the Netherlands found significant mortality and morbidity benefit with the use of dexamethasone during the first 4 days of therapy for acute bacterial meningitis, convincingly for pneumococcal meningitis. The authors used doses of 10 mg IV every 6 hours for 4 days, commencing before or concomitant with the first dose of antibiotics. While they did not demonstrate better outcomes with steroids for non-pneumococcal meningitides, the number of non-pneumococcal cases was too small to reach a conclusion. Early steroid use should strongly be considered when the clinical picture with or without CSF data points to bacterial meningitis.
Supportive CareEach patient’s neurologic status should be monitored closely and vigilantly for clinical deterioration, and, if this occurs, the practitioner should consider prompt reimaging, the use of modalities to lower intracranial pressure, and neurosurgical consultation for placement of a ventricular shunt or other neurosurgical intervention. While debate has surrounded intravenous fluid administration and cerebral edema, it is now generally accepted that fluids are often needed to maintain an adequate mean arterial pressure to provide sufficient cerebral perfusion pressure.*7/348/5*