激素在细菌性脑膜炎中的应用.ppt

SteroidforBacterialmeningitis 李慧玲高雄市立小港醫院神經科 臨床問題 P patient BecterialmeningitisI intervention SteroidC comparison PlaceboO 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 p 0 05 結果摘要 1ControlledClinicalTrial 68p t 1 Dexamethasonewasgivenindoseof0 6mg kg dayindivideddose forfirst4daysoftherapy 2 Mortalitywaslowerinthegrouptreatedwithdexamethasonebutthedifferencewasnotstatisticallysignificant 3 Dexamethasoneshouldbeadministeredtoalladultespatientswithacutebacterialmeningitis NeonatesAtpresent 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 0 15mg kgevery6hfor2 4dayswiththefirstdoseadministered10 20minbefore oratleastconcomitantwith thefirstdoseofantimicrobialtherapy inadultswithsuspectedorprovenpneumococcalmeningitis A I 2 Someexpertswouldonlyadministeradjunctivedexamethasoneifthepatienthadmoderate to severedisease GlasgowComaScalescore 11 結果摘要 Adults3 However thePracticeGuidelineCommitteethinksthatadjunctivedexamethasoneshouldbeinitiatedinalladultpatientswithsuspectedorprovenpneumococcalmeningitis becauseassessmentofthescoremaydelayinitiationofappropriatetherapy 4 DexamethasoneshouldonlybecontinuediftheCSFGramstainrevealsgram positivediplococci orifbloodorCSFculturesarepositiveforS pneumoniae 結果摘要 Adults4 Adjunctivedexamethasoneshouldnotbegiventoadultpatientswhohavealreadyreceivedantimicrobialtherapy becauseadministrationofdexamethasoneinthiscircumstanceisunlikelytoimprovepatientoutcome A I 5 Thedataareinadequatetorecommendadjunctivedexamethasonetoadultswithmeningitiscausedbyotherbacterialpathogens althoughsomeauthoritieswouldinitiatedexamethasoneinalladults becausetheetiologyofmeningitisisnotalwaysascertainedatinitialevaluation B III 結果摘要 PneumococcalMeningitis1 ThePracticeGuidelineCommitteerecommendsthatadjunctivedexamethasonebeadministeredtoalladultpatientswithpneumococcalmeningitis eveniftheisolateissubsequentlyfoundtobehighlyresistanttopenicillinandcephalosporins B III 2 Carefulobservationandfollow uparecriticaltodeterminewhetherdexamethasoneisassociatedwithadverseclinicaloutcome 結果摘要 PneumococcalMeningitis3 Fordataonoutcomeinpatientswithmeningitiscausedbyresistantpneumococcalisolates casereportsandsmallcaseseriesmayhelpascertainwhetherdexamethasoneisharmfultothesepatients 4 Furthermore inpatientswithsuspectedpneumococcalmeningitiswhoreceiveadjunctivedexamethasone additionofrifampintotheempiricalcombinationofvancomycinplusathird generationcephalosporinmaybereasonablependingcultureresultsandinvitrosusceptibilitytesting B III 後記 TheavailableevidencesupportstheuseofadjunctivedexamethasoneininfantsandchildrenwithH influenzaetypebmeningitis 0 15mg kgevery6hfor2