To Treat or Not to Treat Is the Nagging Question

Abstract

In a recent meeting, the issue of dexamethasone therapy for meningitis caused by Streptococcus pneumoniae was discussed. A member of the audience stated that he always gives dexamethasone to patients with this disease, and the speaker said, “You are correct [in doing so].” A while later, another audience member stated that she never uses dexamethasone for such patients, and the speaker responded, “You are correct [in doing so].” At this point, a third audience member asked, “How can you agree with these 2 opposing approaches? Isn't that confusing?” Without hesitation, the speaker responded, “You are correct, too.” Although this sequence of events may sound amusing, the fact is that the available data have not provided a definitive answer one way or the other. The controversy about dexamethasone therapy for S pneumoniae is well known, but we all believed that the role of dexamethasone in Haemophilus influenzae meningitis had been established. Yet, the data from a Peltola et al study,1 in this issue of Pediatrics , fail to demonstrate a benefit for dexamethasone in any bacterial meningitis (including H influenzae ) and raise questions about past beliefs. The authors suggest that dexamethasone may benefit some children with bacterial meningitis, but etiology is not the determining factor. Which children benefit, and why are these study's results different from those of previously reported studies? What features affect the response to adjunctive therapy for this serious infection? Why are the results from resource-poor countries (eg, Malawi) 2 discordant with those from studies … Address correspondence to Ram Yogev, MD, Children's Memorial Hospital, 2300 Children's Plaza, Box 155, Chicago, IL 60614. E-mail: ryogev{at}childrensmemorial.org