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Drug Insight: steroids in CNS infectious diseases—new indications for an old therapy

Nature Clinical Practice Neurology volume 4, pages 97–104 (2008)Cite this article

Abstract

Infectious diseases of the CNS lead to overwhelming inflammatory processes within the brain and spinal cord that contribute substantially to patient morbidity and mortality. Pharmacological strategies to modulate inflammation have been investigated, although the resulting guidelines have sometimes been contradictory. Steroids have been proposed as adjunctive treatments for bacterial meningitis, tuberculous meningitis and herpes simplex virus encephalitis. Well-designed randomized controlled trials have established dexamethasone as an adjunctive therapy for adult patients receiving antibiotics for bacterial meningitis, and physicians prescribing the initial antibiotics need to be aware of current guidelines. Morbidity and mortality in patients with tuberculous meningitis exceeds 50%. Steroid treatments reduce mortality through an as yet unknown mechanism, although their effects on morbidity are less clear. Herpes simplex virus encephalitis is also associated with considerable morbidity and mortality. Despite a lack of randomized trials, there is some evidence that steroids used alongside antiviral therapy might be beneficial in this condition. As we discuss in this Review, systemic steroid treatment is an important aspect of treatment regimens for CNS infectious diseases, and the recent literature provides guidelines for the use of steroids in combination with appropriate antimicrobial therapy.

Key Points

  • Dexamethasone is recommended for the treatment of suspected bacterial meningitis both in adults, and in children living in high-income countries

  • Adjunctive steroids should be administered before or with the first dose of antibiotics in cases of suspected bacterial meningitis

  • Dexamethasone should be considered as part of the treatment protocol for tuberculous meningitis

  • Steroid treatment might be beneficial in herpes simplex virus encephalitis, but more studies are needed to clarify its role in this condition

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Acknowledgements

MT Fitch received faculty funding support from the Brooks Scholars in Academic Medicine award at the Wake Forest University School of Medicine, Winston-Salem, NC, USA. D van de Beek is supported by a personal grant from the Netherlands Organization for Health Research and Development (NWO-Veni grant 2006; no. 916.76.023). Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. MT Fitch is an Assistant Professor of Emergency Medicine at Wake Forest University, Winston-Salem, NC, USA,

    Michael T Fitch

  2. D van de Beek is a Clinical Neurologist and Researcher at the Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands.,

    Diederik van de Beek

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Correspondence to Diederik van de Beek.

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Fitch, M., van de Beek, D. Drug Insight: steroids in CNS infectious diseases—new indications for an old therapy. Nat Rev Neurol 4, 97–104 (2008). https://doi.org/10.1038/ncpneuro0713

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