E Coli En Pediatria

The new england journal of medicine

established in 1812 december 13, 2007 vol. 357 no. 24

Dexamethasone in Vietnamese Adolescents and Adults
with Bacterial Meningitis

Nguyen Thi Hoang Mai, M.D., Tran Thi Hong Chau, M.D., Guy Thwaites, M.D., Ly Van Chuong, M.D., Dinh Xuan Sinh, M.D., Ho Dang Trung Nghia, M.D., Phung Quoc Tuan, M.D., Nguyen Duy Phong, M.D., Nguyen Hoan Phu, M.D., ToSong Diep, M.D., Nguyen van Vinh Chau, M.D., Nguyen Minh Duong, M.D., James Campbell, Constance Schultsz, M.D., Chris Parry, M.D., M. Estee Torok, M.D., Nicholas White, F.R.C.P., Nguyen Tran Chinh, M.D., Tran Tinh Hien, M.D., Kasia Stepniewska, Ph.D., and Jeremy J. Farrar, F.R.C.P.

A b s t r a c t

Background
It is uncertain whether all adults with bacterial meningitis benef it fromtreatment with adjunctive dexamethasone.

Methods
We conducted a randomized, double-blind, placebo-controlled trial of dexametha- sone in 435 patients over the age of 14 years who had suspected bacterial meningi- tis. The goal was to determine whether dexamethasone reduced the risk of death at
1 month and the risk of death or disability at 6 months.

Results
A total of 217 patients were assigned tothe dexamethasone group, and 218 to the placebo group. Bacterial meningitis was conf irmed in 300 patients (69.0%), prob- able meningitis was diagnosed in 123 patients (28.3%), and an alternative diagno- sis was made in 12 patients (2.8%). An intention-to-treat analysis of all the patients showed that dexamethasone was not associated with a signif icant reduction in the risk of death at 1 month(relative risk, 0.79; 95% conf idence interval [CI], 0.45 to
1.39) or the risk of death or disability at 6 months (odds ratio, 0.74; 95% CI, 0.47 to
1.17). In patients with confirmed bacterial meningitis, however, there was a signifi- cant reduction in the risk of death at 1 month (relative risk, 0.43; 95% CI, 0.20 to
0.94) and in the risk of death or disability at 6 months (odds ratio, 0.56;95% CI,
0.32 to 0.98). These effects were not found in patients with probable bacterial men- ingitis. Results of multivariate analysis indicated that dexamethasone treatment for patients with probable bacterial meningitis was signif icantly associated with an increased risk of death at 1 month, an observation that may be explained by cases of tuberculous meningitis in the treatment group.Conclusions
Dexamethasone does not improve the outcome in all adolescents and adults with suspected bacterial meningitis; a beneficial effect appears to be confined to patients with microbiologically proven disease, including those who have received prior treat- ment with antibiotics. (Current Controlled Trials number, ISRCTN42986828.)

From the Hospital for Tropical Diseas- es (N.T.H.M.,T.T.H.C., L.V.C., D.X.S., H.D.T.N., N.H.P., T.S.D., N.V.C., N.M.D., N.T.C., T.T.H.); Oxford University Clinical Research Unit, Hospital for Tropical Dis- eases (G.T., P.Q.T., J.C., C.S., C.P., M.E.T., K.S., J.J.F.); and the University of Medi- cine and Pharmacy (N.D.P., N.W.) — all in Ho Chi Minh City, Vietnam; and the De- partment of Infectious Disease, Imperial College, London (G.T.); theNuffield De- partment of Clinical Medicine, John Rad- cliffe Hospital, Oxford (C.S., M.E.T., K.S., J.J.F.); and the Department of Medical Microbiology, University of Liverpool, Liver- pool (C.P.) — all in the United Kingdom. Address reprint requests to Dr. Farrar at the Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190
Ben Ham Tu, Quan 5, Ho Chi Minh City,Vietnam, or at jfarrar@oucru.org.

N Engl J Med 2007;357:2431-40.
Copyright © 2007 Massachusetts Medical Society.

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