NEW TRENDS IN TB MENINGITIS

Dexamethasone useful in some cases of meningitis

by Anthony J. Brown, MD

Last Updated: 2007-12-13 14:03:26 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Taken together, the findings of two new studies
suggest that dexamethasone therapy can reduce the morbidity and mortality of
bacterial meningitis in developing countries, provided that the disease is
microbiologically confirmed and that the patient does not have advanced HIV disease.

In a study conducted in Vietnam, Dr. Jeremy J. Farrar and colleagues show that
dexamethasone is only effective if given to patients with confirmed bacterial
meningitis, not to those with probable disease. In fact, giving the drug to patients with
probable disease seemed to increase the risk of death at 1 month.

The findings from the second study, conducted in a sub-Saharan African city with a
high HIV prevalence, indicated little or no benefit of using the corticosteroid for this
indication. The results of both studies are reported in The New England Journal of
Medicine for December 13th.

"Dexamethasone is a very, very cheap drug and probably because there is no industry
interest there has remained a question for more than 30 years as to whether it reduces
mortality in patients with meningitis," Dr. Farrar, from the John Radcliffe Hospital in
Oxford, UK, told Reuters Health.

The results of this study indicate that the drug can produce a "major" reduction in
morbidity and mortality if the patient has confirmed disease, Dr. Farrar said.

This last part is important, he emphasized, because in the developing world, TB

meningitis is fairly common and can mimic bacterial meningitis, which refers to
meningitis caused by non-TB bacteria, usually Streptococcus pneumoniae or
Neisseria meningitidis.
The study involved 435 adolescents and adults with suspected bacterial meningitis
who were randomized to receive intravenous dexamethasone or placebo for 4 days in
addition to a 10- to 14-day course of ceftriaxone. Some of the patients had received
antibiotics before inclusion in the study. All of the patients were HIV-negative.

Sixty-nine percent of patients had confirmed bacterial meningitis, 28.3% had probable
meningitis, and 2.8% had an alternative diagnosis.

In the overall analysis, dexamethasone therapy did not reduce mortality at 1 month or
the risk of death or disability at 6 months. When the analysis was confined to patients
with confirmed bacterial meningitis, however, use of the drug reduced 1-month
mortality by 57% and the 6-month risk of death or disability by 44%.

As noted, use of dexamethasone for probable bacterial meningitis appeared to

increase the risk of death at 1 month. The researchers believe that this is because
many of the cases of probable bacterial meningitis actually had TB meningitis, which
responded adversely to the drug.

"From this study, if you have an adult patient who is HIV-negative, in whom you
confirm acute bacterial meningitis, you should give steroids, even if the patient has
had antibiotics before coming to the hospital," Dr. Farrar said. "It also shows how
important good diagnostic laboratories are and that by having good laboratories
making a quick diagnosis, you can reduce death by a half."

In the second study, which was centered in Blantyre, Malawi, Dr. Matthew
Scarborough, also from the John Radcliffe Hospital in Oxford, UK, and colleagues
assessed the outcomes of 465 patients who were admitted with bacterial meningitis
and randomized to receive intravenous dexamethasone or placebo in combination
with intramuscular or intravenous ceftriaxone. In contrast to the first study, 90% of
the subjects were HIV-positive.

Dexamethasone therapy did not reduce morbidity or mortality in the study group.
Ceftriaxone efficacy was not significantly influenced by its route of administration.

SOURCE: http://www.rehabpub.com/reuters_article.asp?id=20071213clin001.html
CURRENT TREND

Many times meningeal infections can be prevented, especially when the infecting
pathogen is H. influenzae, S. pmeumoniae, or N. meningitidis. The current
immunization guidelines endorsed by the Advising Committee on Immunization
Practices and American Academy of Pediatrics are that all children be immunized
against H. Influenzae. The role of the government is very crucial in times of outbreaks
and life threatening diseases. The government engages in research activities,
continuous proper management and initial treatment such as immunization, which is
the concern of everyone. While the treatment and prevention of bacterial meningitis
has greatly improved over the past decade. Significant therapeutic challenges still
exist. Controversies include the choice of empiric antimicrobial agents and the
administration of corticosteroids; the introduction of pneumococcal vaccines and the
new antibiotics have changed the epidemiology of meningitis. Together, the
availability of antibiotics has contributed to the emergence of resistant organisms.
One of the activities of the government is to respond to this dilemma, according to
Carlos, et al, through a study entitled “Antimicrobial Resistance Surveillance Program
in the Philippines” which was held last 2000, and was about the resistance of H.
influenzae to cotrimoxazole, ampicillin and chloramphenicol whereas it is concluded
the three drugs are still recommended to use for H. influenzae. In addition to this,
scientists believe they may have found a way to protect people against every strain of
meningitis. The most current study that was published, “Vaccine could beat
meningitis”, talks about the new approach towards management of meningitis. It
shows that a vaccine against A and C strain of the disease exists, however there is no
job against the lethal B strain. Scientists use genetic engineering technology to create
a strain of meningitis B that is incapable of causing for disease, after injecting the
strains of the disease the finding suggested that it may be possible to create a single
vaccine to protect against each strain. The unique thing about this research is that it
provides hope for a complete vaccine protecting people against all types of
meningococcal bacteria, the most common cause of meningitis worldwide. (Carlos,
2004)
 Successful eradication of CSF infection will rely on the continued development of
new antibiotics and vaccines as well as judicious use of those antibiotics currently
available. Routine immunization of young adolescent will help prevent the rare but
serious infection of the disease. In addition, the absence of specific clinical findings
makes diagnosis of meningitis more difficult. As stated by Lincoln, whether its
making sure that families have access to quality health care and child care, in making
sure that the children receive the best educational opportunities we can give them, we
must remain committed to these needs because our children are our future. Embracing
the vital role of the government in creating barriers against the disease, the initiative
and braveness of the stat to fight for the children against the disease is like struggling
for a better economy. (Sarah Yuan, 2004)

STATISTICS OF TB MENINGITIS

There has been a steady increase in the number of notified cases of TB

meningitis over recent years, from 6,300 cases in 2000 to 8,400 cases in 2007. In
2007, there were over 300 reported cases of TB meningitis.

Source: http://www.meningitis-trust.org/images/pdfs/TB-Meningitis.pdf
University of Perpetual Help – Dr. Jose G. Tamayo Medical
University
Sto. Niño, Biñan, Laguna

COLLEGE OF NURSING

TRENDS IN TB MENINGITIS

Submitted By:
Matute, Lora Mae O.
BSN III-K, GROUP #45

Submitted To:
Ms. Teresa Bonza