With improved understanding of the pathophysiology of bacterial meningitis, a number of points in the deleterious inflammatory cascade have been identified as possible sites for modulation. Dexamethasone attenuates tissue injury by inhibiting host mediators at several steps in the inflammatory process. Dexamethasone therapy initiated just before or simultaneously with the first parenteral antibiotic dose is recommended for infants older than 6 weeks of age and children with bacterial meningitis. A beneficial effect of steroid therapy administered 12 to 24 hours or more after the first dose of parenteral antibiotics is unlikely. The consistent finding of improved overall neurologic outcome in infants and children with bacterial meningitis caused by the usual meningeal pathogens treated with dexamethasone is the basis for this recommendation, provided that the caveats discussed above are observed.