儿童脑膜炎中的辅助性糖皮质激素治疗：当前证据、临床争议与未来方向

文献信息

中文摘要

背景： 尽管在疫苗接种、抗菌治疗和支持治疗方面取得了进展，儿童细菌性脑膜炎仍然是死亡和长期神经功能障碍的重要原因。由于宿主炎症对继发性神经元损伤有重要贡献，辅助性糖皮质激素已被研究作为减少炎症介导并发症的策略。本叙述性综述旨在批判性评估糖皮质激素治疗儿童脑膜炎的当前证据，特别关注急性细菌性脑膜炎、主要临床和神经学结局、治疗时机、病原体特异性效应以及疫苗接种后流行病学变化的影响。
方法： 对PubMed/MEDLINE、Scopus和Web of Science进行了结构化检索，检索截至2026年6月可获取的相关出版物。考虑了涉及0-18岁患者的随机对照试验、观察性研究、系统综述、荟萃分析和国际指南。证据以叙述性方式综合，重点关注死亡率、听力损失、神经学后遗症、长期结局、安全性、致病病原体和糖皮质激素给药时机。
结果： 辅助性地塞米松未显示出持续的死亡率获益，而关于住院时间、重症监护使用和医疗费用的证据仍然有限。其最可重复的获益是减少感音神经性听力损失，尤其是在b型流感嗜血杆菌（Hib）脑膜炎中。肺炎球菌脑膜炎中的获益较不一致，支持在脑膜炎球菌病中常规使用的证据仍然有限。当地塞米松在首剂抗生素之前或同时给药时疗效似乎最大，并且在疫苗接种后时代可能不那么明显。在结核性脑膜炎中，糖皮质激素可改善生存，而在无并发症的病毒性脑膜炎或隐球菌性脑膜炎中不支持常规使用。
结论： 辅助性地塞米松应在儿童脑膜炎中选择性使用，其最明确的获益是在早期治疗的Hib脑膜炎中保护听力。治疗决策应考虑病原体、时机和流行病学背景。

英文摘要

Background: Pediatric bacterial meningitis remains an important cause of death and long-term neurological disability despite advances in vaccination, antimicrobial therapy, and supportive care. Because host inflammation contributes substantially to secondary neuronal injury, adjunctive corticosteroids have been investigated as a strategy to reduce inflammation-mediated complications. This narrative review aims to critically evaluate the current evidence on corticosteroid therapy in pediatric meningitis, with particular emphasis on acute bacterial meningitis, major clinical and neurological outcomes, treatment timing, pathogen-specific effects, and the impact of changing post-vaccination epidemiology. Methods: A structured search of PubMed/MEDLINE, Scopus, and Web of Science was conducted for relevant publications available up to June 2026. Randomized controlled trials, observational studies, systematic reviews, meta-analyses, and international guidelines involving patients aged 0-18 years were considered. Evidence was synthesized narratively, focusing on mortality, hearing loss, neurological sequelae, long-term outcomes, safety, causative pathogen, and timing of corticosteroid administration. Results: Adjunctive dexamethasone has not demonstrated a consistent mortality benefit, while evidence concerning hospital stay, intensive care utilization, and healthcare costs remains limited. Its most reproducible benefit is a reduction in sensorineural hearing loss, particularly in Haemophilus influenzae type b (Hib) meningitis. Benefits in pneumococcal meningitis are less consistent, and evidence supporting routine use in meningococcal disease remains limited. Efficacy appears greatest when dexamethasone is administered before or with the first antibiotic dose and may be less pronounced in the post-vaccination era. In tuberculous meningitis, corticosteroids improve survival, whereas routine use is not supported in uncomplicated viral meningitis or cryptococcal meningitis. Conclusions: Adjunctive dexamethasone should be used selectively in pediatric meningitis, with its clearest benefit being hearing preservation in early-treated Hib meningitis. Treatment decisions should account for pathogen, timing, and epidemiological context.