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SteroidforBacterialmeningitis李慧玲高雄市立小港醫院神經科臨床問題•P(patient):Becterialmeningitis•I(intervention):Steroid•C(comparison):Placebo•O(outcome):Efficacy背景說明•Steroid在臨床上已被廣泛地應用，它具有抗炎、止痛及減緩異常血腦障壁之微血管的通透，以及降低顱內壓等作用。•治療細菌性腦膜炎，雖然有著抗生素的介入治療，但卻仍具高死亡率，且造成嚴重的後遺症，，不僅是一個衝擊，也是我們要去突破的瓶頸。背景說明•感染性疾病有著強烈的地域性特色，在西方國家細菌性腦膜炎最常見到的致病菌是鏈球菌(StreptococcusPneumoniae)、李斯特菌(Listeriamonocytogenes)，或是奈瑟氏菌(Neisseriameningitids)；我國則是鏈球菌(StreptococcusPneumoniae)和取而代之的克雷伯氏菌(KlebsiellaPneumoniae)為主。•至於Steroid針對Bacterialmeningitis的使用，目前仍受爭議，至今尚無定論，但在有些病人身上是可以加速改善症狀，但對於減少後遺症則很難說。期待目標•提供有用的文獻資料，期待進一步釐清Steroid使用於Bacterialmeningitis的角色及療效。搜尋步驟-1•CochraneLibrary：KeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：【Reviews：1篇】【DARE：1篇】【CENTRAL：7篇】•Combine'bacterialmeningitis'AND'dexamethasone‘Found：【Reviews：1篇】【DARE：3篇】【CENTRAL：23篇】搜尋步驟-2•EBMR-ACPJournalClubKeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：0篇•Combine'bacterialmeningitis'AND'dexamethasone‘Found：2篇搜尋步驟-3•NGC（NationalGuidelineClearinghouse）KeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：1篇•Combine'bacterialmeningitis'AND'dexamethasone‘Found：1篇搜尋步驟-4•PubMedKeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：9篇•Combine'bacterialmeningitis'AND'dexamethasone‘Found：8篇搜尋步驟-5•MEDLINEKeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：10篇•Combine'bacterialmeningitis'AND'dexamethasone‘Found：8篇搜尋步驟-6•EBMONLINEKeyWord：•Combine‘bacterialmeningitis'AND'steroid‘Found：2篇•Combine'bacterialmeningitis'AND'dexamethasone‘Found：2篇結果摘要•Eighteenstudiesinvolving1853peoplewereincluded.•Overall,adjuvantcorticosteroidswereassociatedwithlowercasefatality(relativerisk(RR)0.76,95%condenceintervals(CI)0.59to0.98)andlowerratesofbothseverehearingloss(RR0.36,95%CI0.22to0.60)andlong-termneurologicalsequelae(RR0.66,95%CI0.44to0.99).•Inchildren,corticosteroidsreducedseverehearinglossinbacterialmeningitiscausedbyHaemophilusinfluenzae(RR0.31,95%CI0.15to0.62),aswellasinmeningitiscausedbyotherbacteriathanH.influenzae(RR0.42,95%CI0.20to0.89).vandeBeekD,deGansJ,McIntyreP,PrasadK.Corticosteroidsforacutebacterialmeningitis.TheCochraneDatabaseofSystematicReviews2003,Issue3.結果摘要•Inadults,therewasareductionincase-fatality(RR0.38,95%CI0.18to0.78),howevertherewerefewdata.•Adverseeventswerenotincreasedsignicantlywiththeuseofcorticosteroids.•Adjuvantcorticosteroidsarebenecialinthetreatmentofchildrenwithacutebacterialmeningitis.•Thelimiteddataavailableinadultsshowsatrendinfavourofadjuvantcorticosteroidsbutadeniterecommendationmustawaitmorestudies.vandeBeekD,deGansJ,McIntyreP,PrasadK.Corticosteroidsforacutebacterialmeningitis.TheCochraneDatabaseofSystematicReviews2003,Issue3.結果摘要•7RCTs（848p’tintotal）：1.InHaemophilusinfluenzaetypebmeningitis,dexamethasonereducedseverehearingloss.(pooledOR0.31,95%CI:0.14,0.69)2.Inpneumoccalmeningitis,thepooledoddsratioforseverehearinglosswas0.52.(95%CI:0.17,1.46)3.Limitingdexamethasonetherapyto2daysmaybeoptimal.結果摘要•7RCTs（848p’tintotal）：4.TheavailableevidenceonadjunctivedexamethasonetherapyconfirmsbenefitforHaemophilusinfluenzaetypebmeningitisand,ifcommencedwithorbeforeparenteralantibiotics,suggestsbenefitforpneumoccalmeningitisinchildhood.PBMcIntyre,CSBerkey,SMKing,UBSchaad,TKilpi,GYKanra,CMPerez.Dexamethasoneasadjunctivetherapyinbacterialmeningitis:ameta-analysisofrandomizedclinicaltrialssince1988(Structuredabstract).TheCochraneDatabaseofSystematicDARE.2000結果摘要•1RCT（301p’t）:1.EarlytreatmentwithdexamethasoneimprovestheoutcomeinadultswithacutebacterialmeningitisanddoesnotincreasetheriskofG-Ibleeding.•1doubleblindplacebocontrolstudy(40p’t):1.Dexamethasonewasgivenindoseof0.6mg/kg/dayindivideddose,forfirst4daysoftherapy.2.Firstdoseofdexamethasonewasgiven15minutespriortofirstdosedoseofceftriaxone.3.Neurologicalcomplicationsandhearinglossweremorecommonandsevereinplacebogroupascomparedtothedexamethasonegroup(p0.05).結果摘要•1ControlledClinicalTrial(68p’t):1.Dexamethasonewasgivenindoseof0.6mg/kg/dayindivideddose,forfirst4daysoftherapy.2.Mortalitywaslowerinthegrouptreatedwithdexamethasonebutthedifferencewasnotstatisticallysignificant.3.Dexamethasoneshouldbeadministeredtoalladultespatientswithacutebacterialmeningitis.Neonates•Atpresent,thereareinsufficientdatatomakearecommendationontheuseofadjunctivedexamethasoneinneonateswithbacterialmeningitis.(C-I)結果摘要結果摘要InfantsandChildren1.Despitesomevariabilityinresultofpublishedtrials,thePracticeGuidelineCommitteebelievestheavailableevidencesupportstheuseofadjunctivedexamethasoneininfantsandchildrenwithH.influenzaetypebmeningitis.(A-I)2.Dexamethasoneshouldbeinitiated10-20minpriorto,oratleastconcomitantwith,thefirstantimicrobialdose,at0.15mg/kgevery6hfor2-4days.結果摘要InfantsandChildren3.Adjunctivedexamethasoneshouldnotbegiventoinfantsandchildrenwhohavealreadyreceivedantimicrobialtherapy,becauseadministrationofdexamethasoneinthiscircumstanceisunlikelytoimprovepatientoutcome.(A-I)4.Ininfantsandchildrenwithpneumococcalmeningitis,thereiscontroversyconcerningtheuseofadjunctivedexamethasonetherapy.(C-II)結果摘要Adults1.ThePracticeGuidelineCommitteerecommendsuseofdexamethasone(