Adjuvant Therapies for Meningitis and Ventriculitis in Children
Steroids – dexamethasone (0.6 mg/kg/day intravenously, divided every 6 hours for 2 days: Currently, dexamethasone is most commonly used for the rare patient with H. influenzae meningitis (11). In fungal and tuberculous meningitis, data suggest a role for dexamethasone in reducing the rates of mortality and morbidity (52, 65). The initiation of antibiotic therapy for bacterial meningitis results in a massive release of cytokines, which may cause further damage to the CNS. The mechanism for increased survival rates and decreased neurologic sequelae when used for fungal and tuberculous infections is not known (52). A number of studies have suggested that in patients with H. influenzae type b meningitis, the administration of dexamethasone reduces neurologic complications, especially hearing loss (11). This reduction is most significant if the dexamethasone is started prior to or coincident with the first dose of parenteral antibiotics. Similar studies in small numbers of patients with S. pneumoniae meningitis in the United States and Europe have failed to show a reduction in hearing loss or other neurologic complications with dexamethasone therapy (11). Dexamethasone had no beneficial effect in patients with N. meningitidis meningitis (11).
Glycerol may be helpful in bacterial meningitis: The use of glycerol was proposed over 30 years ago to help prevent sequelae from H. influenzae type b meningitis. With the lack of proven efficacy of dexamethasone in the treatment of bacterial meningitis, attention has again been turned to the use of glycerol. Glycerol is a hyperosmolar agent and an osmotic diuretic. It has been proposed that the mechanism of protection of glycerol is through an increase in serum osmolarity (64). Overall, there is insufficient clinical evidence to support glycerol therapy in bacterial meningitis, but studies have shown that glycerol therapy may lower the incidence of severe neurological sequelae, with only a modest decrease in hearing loss (30). Further studies are necessary to determine any beneficial effect of glycerol in the treatment of bacterial meningitis; but if one is shown, certainly glycerol would be an inexpensive adjuvant therapy in the treatment of meningitis, particularly in countries with inadequate H. influenzae vaccination programs.
Shunting or ETV for tuberculosis meningitis: Some patients with tuberculous meningitis will develop hydrocephalus. Ventriculoperitoneal shunting may be performed early or late in the disease process but may fail due to high CSF protein levels (40). Endoscopic third ventriculostomy may be beneficial in cases of multiple shunt malfunctions or obstructive hydrocephalus but may fail due to dense adhesions in the subarachnoid space and third ventricle (36).