The European Dexamethasone study for adults with proven bacterial meningitis1 was a multi‐centred double blind randomised controlled trial of 300 patients, comparing 10 mg intravenous dexamethasone six hourly for four days with placebo. The study demonstrated an absolute risk reduction (ARR) in an unfavourable outcome of 26% (95% CI 8–44%) in those patients with pneumococcal meningitis who received dexamethasone. The results were less impressive in all patients with meningitis: ARR of 8% (95% CI 1–15%) for all types of bacteria and an ARR in death of 10% (95% CI 1–19%) in those receiving dexamethasone. The complications were surprisingly low.
We performed a retrospective survey of patients in our hospital that had a discharge diagnosis of bacterial meningitis. We conducted the survey over an eight year period (1996–2004), reviewing 35 case notes. We found that our patient characteristics were very similar to those in the study (see table 1).
Table 1 .
| Our Study | De Gans Study | Statistical test | |
|---|---|---|---|
| Mean Age | 50.3 SD 21.1 | 45 SD 19 (average of two arms of trial) | p = 0.12 Independent samples t‐test |
| Male Sex Ratio | 54% | 56% | p = 0.98 Chi‐squared test for assoc. with Yates Connection |
| Glasgow Coma Score <8 | 21% | 16% | p = 0.69 |
| Pneumococcus | 40% | 36% | p = 0.79 |
| Meningococcus | 20% | 32% | p = 0.19 |
| Negative CSF culture | 40% | 30% | p = 0.4 |
| Mortality | 11% | 15% placebo group | p = 0.83 |
Our survey also revealed of the 28 cases where documentation of time of antibiotics was recorded, 19 patients (68%) had antibiotics given prior to LP. In the study all patients had antibiotic therapy withheld until after LP had been performed (within 30 minutes of patient arrival) and the CSF analysis known. In our survey the mean door‐ antibiotic time for all patients was 216 minutes and the medical team performed all LPs.
It would appear to us that where Emergency Physicians (EP) give antibiotics to patients with suspected meningitis before an LP is performed, they are actually preventing patients with pneumococcal meningitis from getting the significant benefit that steroids would confer. Such EPs should therefore consider performing LPs themselves in patients with suspected bacterial meningitis and withholding antibiotics until CSF analysis is performed. The infrastructure to allow this to happen in a very timely manner, regardless of the grade of doctor seeing the patient, would have to be put in place. Alternatively, EPs should consider giving 10 mg dexamethasone concurrently with antibiotics to patients for whom they have a high clinical suspicion of bacterial meningitis and only continuing to give subsequent doses to those with proven pneumococcal meningitis. This is very important when patients present with a depressed conscious level and suspected meningitis as these patients have the most to gain from steroids and are unlikely to have an LP for a significant length of time.
In conjunction with the Medical team in our hospital, a proforma has been constructed to help doctors select appropriate patients where steroids are to be given prior to LP. We are currently reviewing the final diagnoses of those patients who are given dexamethasone.
Are you implementing the evidence or ignoring it?
References
- 1.De Gans J, Van de Beek D, for the European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators Dexamethasone in Adults with Bacterial Meningitis. N Engl J Med 20023471549–1556. [DOI] [PubMed] [Google Scholar]