Adjunctive Corticosteroids in Pediatric Meningitis: Current Evidence, Clinical Controversies, and Future Directions

Background: Pediatric bacterial meningitis remains an important cause of death and long-term neurological disability despite advances in vaccination, antimicrobial therapy, and supportive care. Because host inflammation contributes substantially to secondary neuronal injury, adjunctive corticosteroids have been investigated as a strategy to reduce inflammation-mediated complications. This narrative review aims to critically evaluate the current evidence on corticosteroid therapy in pediatric meningitis, with particular emphasis on acute bacterial meningitis, major clinical and neurological outcomes, treatment timing, pathogen-specific effects, and the impact of changing post-vaccination epidemiology. Methods: A structured search of PubMed/MEDLINE, Scopus, and Web of Science was conducted for relevant publications available up to June 2026. Randomized controlled trials, observational studies, systematic reviews, meta-analyses, and international guidelines involving patients aged 0-18 years were considered. Evidence was synthesized narratively, focusing on mortality, hearing loss, neurological sequelae, long-term outcomes, safety, causative pathogen, and timing of corticosteroid administration. Results: Adjunctive dexamethasone has not demonstrated a consistent mortality benefit, while evidence concerning hospital stay, intensive care utilization, and healthcare costs remains limited. Its most reproducible benefit is a reduction in sensorineural hearing loss, particularly in Haemophilus influenzae type b (Hib) meningitis. Benefits in pneumococcal meningitis are less consistent, and evidence supporting routine use in meningococcal disease remains limited. Efficacy appears greatest when dexamethasone is administered before or with the first antibiotic dose and may be less pronounced in the post-vaccination era. In tuberculous meningitis, corticosteroids improve survival, whereas routine use is not supported in uncomplicated viral meningitis or cryptococcal meningitis. Conclusions: Adjunctive dexamethasone should be used selectively in pediatric meningitis, with its clearest benefit being hearing preservation in early-treated Hib meningitis. Treatment decisions should account for pathogen, timing, and epidemiological context.