Steroids for Treating Tuberculous Meningitis

Background: Even though corticosteroids have been used alongside antituberculosis drugs for tuberculous meningitis (TBM) since the 1950s their role remains controversial. Some believe corticosteroids improve outcome while others point to the lack of supportive evidence. In patients who are immunocompromised because of HIV infection the risks and benefits of steroids are unknown.

Objectives: To assess the effects of steroids on death and disability in patients with TBM.

Search Strategy: Electronic searching of MEDLINE, Cochrane Controlled Trials Register, and Cochrane Infectious Diseases Group Trials Register.

Selection Criteria: Randomised controlled trials of steroids in people on TB treatment for TBM.

Data Collection And Analysis: Two independent reviewers applied study selection criteria, assessed methodological quality and extracted data.

Main Results: Six trials of 595 patients met the inclusion criteria. No study described allocation concealment. Steroids were associated with fewer deaths (relative risk [RR] 0.79; 95% confidence interval [CI] 0.65 to 0.97) and a reduced incidence of death and severe residual disability (RR 0.58, 95% CI 0.38 to 0.88). Subgroup analysis suggests an effect on mortality in children (RR 0.77, 95% CI 0.62 to 0.96) but the results in a smaller number of adults are inconclusive (RR 0.96, 95% CI 0.50 to 1.84). There is little evidence that the severity of disease influences the effects of steroids on mortality.

Reviewer's Conclusions: Adjunctive steroids might be of benefit in patients with TBM. However, existing studies are small, and poor allocation concealment and publication bias may account for the positive results found in this review. No data are available on the use of steroids in HIV positive persons. Future placebo-controlled studies should include patients with HIV infection and should be large enough to assess both mortality and disability.