激素在细菌性脑膜炎中的应用

激素在细菌性脑膜炎中的应用第1页，课件共29页，创作于2023年2月臨床問題P(patient):BecterialmeningitisI(intervention):SteroidC(comparison):PlaceboO(outcome):Efficacy第2页，课件共29页，创作于2023年2月背景說明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。第3页，课件共29页，创作于2023年2月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。

第4页，课件共29页，创作于2023年2月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。

第5页，课件共29页，创作于2023年2月搜尋步驟-1CochraneLibrary：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】第6页，课件共29页，创作于2023年2月搜尋步驟-2EBMR-ACPJournalClubKeyWord：

Combine‘bacterialmeningitis'AND'steroid‘Found：0篇

Combine'bacterialmeningitis'AND'dexamethasone‘Found：2篇第7页，课件共29页，创作于2023年2月搜尋步驟-3NGC（NationalGuidelineClearinghouse）

KeyWord：Combine‘bacterialmeningitis'AND'steroid‘Found：1篇Combine'bacterialmeningitis'AND'dexamethasone‘Found：1篇第8页，课件共29页，创作于2023年2月搜尋步驟-4PubMedKeyWord：

Combine‘bacterialmeningitis'AND'steroid‘Found：9篇

Combine'bacterialmeningitis'AND'dexamethasone‘Found：8篇

第9页，课件共29页，创作于2023年2月搜尋步驟-5MEDLINEKeyWord：

Combine‘bacterialmeningitis'AND'steroid‘Found：10篇

Combine'bacterialmeningitis'AND'dexamethasone‘Found：8篇第10页，课件共29页，创作于2023年2月搜尋步驟-6EBMONLINEKeyWord：Combine‘bacterialmeningitis'AND'steroid‘Found：2篇Combine'bacterialmeningitis'AND'dexamethasone‘Found：2篇第11页，课件共29页，创作于2023年2月結果摘要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.第12页，课件共29页，创作于2023年2月結果摘要Inadults,therewasareductionincase-fatality(RR0.38,95%CI0.18to0.78),howevertherewerefewdata.Adverseeventswerenotincreasedsignicantlywiththeuseofcorticosteroids.Adjuvantcorticosteroidsarebenecialinthetreatmentofchildrenwithacutebacterialmeningitis.Thelimiteddataavailableinadultsshowsatrendinfavourofadjuvantcorticosteroidsbutadeniterecommendationmustawaitmorestudies.vandeBeekD,deGansJ,McIntyreP,PrasadK.Corticosteroidsforacutebacterialmeningitis.TheCochraneDatabaseofSystematicReviews2003,Issue3.第13页，课件共29页，创作于2023年2月結果摘要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.第14页，课件共29页，创作于2023年2月結果摘要7RCTs（848p’tintotal）：4.TheavailableevidenceonadjunctivedexamethasonetherapyconfirmsbenefitforHaemophilusinfluenzaetypebmeningitisand,ifcommencedwithorbeforeparenteralantibiotics,suggestsbenefitforpneumoccalmeningitisinchildhood.PBMcIntyre,CSBerkey,SMKing,UBSchaad,TKilpi,GYKanra,CMPerez.Dexamethasoneasadjunctivetherapyinbacterialmeningitis:ameta-analysisofrandomizedclinicaltrialssince1988(Structuredabstract).TheCochraneDatabaseofSystematicDARE.2000第15页，课件共29页，创作于2023年2月結果摘要1RCT（301p’t）:1.EarlytreatmentwithdexamethasoneimprovestheoutcomeinadultswithacutebacterialmeningitisanddoesnotincreasetheriskofG-Ibleeding.1doubleblindplacebocontrolstudy(40p’t):1.Dexamethasonewasgivenindoseof0.6mg/kg/dayindivideddose,forfirst4daysoftherapy.2.Firstdoseofdexamethasonewasgiven15minutespriortofirstdosedoseofceftriaxone.3.Neurologicalcomplicationsandhearinglossweremorecommonandsevereinplacebogroupascomparedtothedexamethasonegroup(p<0.05).第16页，课件共29页，创作于2023年2月結果摘要1ControlledClinicalTrial(68p’t):1.Dexamethasonewasgivenindoseof0.6mg/kg/dayindivideddose,forfirst4daysoftherapy.2.Mortalitywaslowerinthegrouptreatedwithdexamethasonebutthedifferencewasnotstatisticallysignificant.3.Dexamethasoneshouldbeadministeredtoalladultespatientswithacutebacterialmeningitis.第17页，课件共29页，创作于2023年2月NeonatesAtpresent,thereareinsufficientdatatomakearecommendationontheuseofadjunctivedexamethasoneinneonateswithbacterialmeningitis.(C-I)

結果摘要第18页，课件共29页，创作于2023年2月結果摘要InfantsandChildren1.Despitesomevariabilityinresultofpublishedtrials,thePracticeGuidelineCommitteebelievestheavailableevidencesupportstheuseofadjunctivedexamethasoneininfantsandchildrenwithH.influenzaetypebmeningitis.(A-I)2.Dexamethasoneshouldbeinitiated10-20minpriorto,oratleastconcomitantwith,thefirstantimicrobialdose,at0.15mg/kgevery6hfor2-4days.第19页，课件共29页，创作于2023年2月結果摘要InfantsandChildren3.Adjunctivedexamethasoneshouldnotbegiventoinfantsandchildrenwhohavealreadyreceivedantimicrobialtherapy,becauseadministrationofdexamethasoneinthiscircumstanceisunlikelytoimprovepatientoutcome.(A-I)4.Ininfantsandchildrenwithpneumococcalmeningitis,thereiscontroversyconcerningtheuseofadjunctivedexamethasonetherapy.(C-II)第20页，课件共29页，创作于2023年2月結果摘要Adults1.ThePracticeGuidelineCommitteerecommendsuseofdexamethasone(0.15mg/kgevery6hfor2-4dayswiththefirstdoseadministered10-20minbefore,oratleastconcomitantwith,thefirstdoseofantimicrobialtherapy)inadultswithsuspectedorprovenpneumococcalmeningitis.

(A-I)2.Someexpertswouldonlyadministeradjunctivedexamethasoneifthepatienthadmoderate-to-severedisease(GlasgowComaScalescore<11).第21页，课件共29页，创作于2023年2月結果摘要Adults3.However,thePracticeGuidelineCommitteethinksthatadjunctivedexamethasoneshouldbeinitiatedinalladultpatientswithsuspectedorprovenpneumococcalmeningitis,becauseassessmentofthescoremaydelayinitiationofappropriatetherapy.4.DexamethasoneshouldonlybecontinuediftheCSFGramstainrevealsgram-positivediplococci,orifbloodorCSFculturesarepositiveforS.pneumoniae.第22页，课件共29页，创作于2023年2月結果摘要Adults4.Adjunctivedexamethasoneshouldnotbegiventoadultpatientswhohavealreadyreceivedantimicrobialtherapy,becauseadministrationofdexamethasoneinthiscircumstanceisunlikelytoimprovepatientoutcome.(A-I)5.Thedataareinadequatetorecommendadjunctivedexamethasonetoadultswithmeningitiscausedbyotherbacterialpathogens,althoughsomeauthoritieswouldinitiatedexamethasoneinalladults,becausetheetiologyofmeningitisisnotalwaysascertainedatinitialevaluation.

(B-III)第23页，课件共29页，创作于2023年2月結果摘要PneumococcalMeningitis1.ThePracticeGuidelineCommitteerecommendsthatadjunctivedexamethasonebeadministeredtoalladultpatientswithpneumococcalmeningitis,eveniftheisolateissubsequentlyfoundtobehighlyresistanttopenicillinandcephalosporins(B-III).2.Carefulobservationandfollow-uparecriticaltodeterminewhetherdexamethasoneisassociatedwithadverseclinicaloutcome.第24页，课件共29页，创作于2023年2月結果摘要PneumococcalMeningitis

3.Fordataonoutcomeinpatientswithmeningitiscausedbyresistantpneumococcalisolates,casereportsandsmallcaseseriesmayhelpascertainwhetherdexamethasoneisharmfultothesepatients.4.Furthermore,inpatientswithsuspectedpneumococcalmeningitiswhoreceiveadjunctivedexamethasone,additionofrifampintotheempiricalcombinationofvancomycinplusathird-generationcephalosporinmaybereasonablependingcultureresultsandinvitrosusceptibilitytesting(B-III).第25页，课件共29页，创作于2023年2月後記TheavailableevidencesupportstheuseofadjunctivedexamethasoneininfantsandchildrenwithH.influenzaetypebmeningitis.(0.15mg/kgevery