Efficacy and safety of drug therapies for treating tuberculous meningitis: a network meta-analysis

Introduction The optimal treatment for tuberculous meningitis (TBM) remains inconclusive. This study intends to compare the efficacy and safety of available drug therapies for treating TBM from the perspective of mortality, neurological events, and adverse events. Methods PubMed (21/6/2025), Cochrane (21/6/2025), Embase (21/6/2025), and Web of Science (21/6/2025) were searched for randomized controlled trials (RCTs) of TBM. Risk of Bias 2.0 was used for the quality assessment of the included studies. R4.2.3 "gemtc" package was used for data analysis, and Stata 15.0 was utilized to assess publication bias. Odds ratios (ORs) with 95% credible intervals (95% CrIs) were calculated as effect sizes. Results Twenty-nine RCTs involving 4,640 TBM patients were included. The results showed that when combined with the standard treatment, prednisone might reduce TBM mortality [OR (95% CrI) = 0.26 (0.07, 0.78)]; both methylprednisolone [OR (95% CrI) = 0.13 (0, 0.98)] and prednisone [OR (95% CrI) = 0.18 (0.02, 0.76)] were likely to reduce the incidence of tuberculoma and other extracranial tuberculosis; prednisolone might increase the risk of neurological events [OR (95% CrI) = 5.98 (2.03, 20.7)], while standard-dose rifampicin was less likely to cause neurological events [OR (95% CrI) = 0.25 (0.06, 0.78)]; dexamethasone might increase the incidence of gastrointestinal events [OR (95% CrI) = 1.72 (1.04, 2.91)]; levofloxacin was more likely to cause hepatic events [OR (95% CrI) = 1.79 (1.05, 3.14)]. Conclusions Prednisone, levofloxacin, and linezolid, rather than high-dose rifampicin, may reduce TBM mortality compared with standard-dose rifampicin. Prednisolone increases the risk of neurological events.