Effects of corticosteroids on adults with tuberculous meningitis admitted to intensive care unit: a propensity score analysis

The beneficial effect of corticosteroids has been well established, particularly in patients free of infection with the human immunodeficiency virus. In intensive care units, the high risks of infection to which patients are exposed specifically could offset the neurological benefit of corticosteroids. The purpose of the study was to assess the effects of corticosteroids in adult patients with tuberculous meningitis admitted to intensive care unit. Retrospective cohort study including all adult patients admitted to intensive care unit for tuberculous meningitis between January 1993 and December 2005. A propensity score case matching was performed using a multivariable logistic regression model, and matched pairs were examined for baseline characteristics and outcome by using conditional regression model. A multivariate Cox's proportional hazard model was used to assess the effects of corticosteroids in all patients adjusting for propensity score. The primary outcome was mortality at 60 days and the secondary outcome was the density of incidence of nosocomial infections. Two hundred and seventy patients were included. The mean age was 38+/-17 years, and the Glasgow coma scale was 12+/-3. The overall mortality was 43.3%. Ninety-four patients who had received corticosteroids were matched to 94 patients untreated with corticosteroids by the propensity score. The baseline characteristics were similar in the two groups except for hydrocephalus, which was more frequent in the group corticosteroids. The mortality rate was 47.9% in group Corticosteroids and 52.1% in group No corticosteroids (P=0.77). The case fatality rate in stage III patients, according to the British Medical Research Council criteria, was 61.5% in the group Corticosteroids versus 74.1% in the group No corticosteroids (P=0.33). Nosocomial infections were observed in 19.1 by 1000 days patient in group Corticosteroids versus 16.1 by 1000 days patient in group No corticosteroids (P=0.4). The outcome in all patients after adjusting for propensity score showed the same results. This study found no significant improvement in survival in adult patients with tuberculous meningitis admitted to intensive care who received dexamethasone. However, the confidence interval was in accordance with the 0.78 relative risk estimated by the meta-analysis Cochrane version 2008. There was no significant difference for nosocomial infections between the group Corticosteroids and the group No corticosteroids. A probable