Corticosteroids as adjunctive therapy in acute meningitis: a narrative review

Acute meningitis is a life-threatening neurological emergency with substantial global morbidity and mortality. Adjunctive corticosteroid therapy aims to mitigate the inflammatory response and improve clinical outcomes.

We analyzed data from randomized controlled trials, meta-analyses, Cochrane reviews, and international guidelines (e.g., WHO, IDSA, NICE), integrating findings from high-income and resource-limited settings. Key outcomes assessed include mortality, neurological sequelae (e.g., hearing loss, hydrocephalus), length of hospital stay, and treatment-related adverse events.

Corticosteroids significantly reduce mortality and neurological sequelae in acute bacterial meningitis (particularly pneumococcal), especially when administered before or with antibiotics. In tuberculous meningitis, steroids (dexamethasone or prednisolone) improve survival by 25%-30%, though long-term neurological outcomes remain inconsistent. In contrast, viral meningitis shows no clear benefit, and steroids are contraindicated in cryptococcal meningitis due to increased adverse events and worse outcomes. Limited evidence supports steroid use in parasitic meningitis (e.g., Angiostrongylus cantonensis) and non-infectious meningitis (e.g., neurosarcoidosis), where they reduce inflammation and symptom burden. Neonatal meningitis lacks sufficient evidence to support routine corticosteroid use due to potential harms.

Adjunctive corticosteroids are a valuable intervention in specific forms of meningitis, particularly bacterial and tuberculous types, where they improve survival and reduce complications. Their use must be tailored to the etiology, timing, and patient population to avoid harm. Global and regional guidelines recommend dexamethasone as part of initial empiric therapy in suspected bacterial meningitis (excluding neonates), and in all cases of TB meningitis.