Cochrane review: Fluid therapy for acute bacterial meningitis

Abstract

AbstractBackgroundAcute bacterial meningitis remains a disease with high mortality and morbidity rates. However, with prompt and adequate antimicrobial and supportive treatment, the chances for survival have improved, especially in infants and children. Careful management of fluid and electrolyte balance is an important supportive therapy. Both over‐ and under‐hydration are associated with adverse outcomes.ObjectivesTo evaluate differing volumes of fluid given in the initial management of bacterial meningitis.Search strategyWe searched the Cochrane Acute Respiratory Infection Group's trials register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), and CINAHL (1982 to February 2007).Selection criteriaRandomised controlled trials of differing volumes of fluid given in the initial management of bacterial meningitis were eligible for inclusion.Data collection and analysisSix trials were identified in the initial search. On careful inspection three of these met the inclusion criteria. Data were extracted and trials were assessed for quality by all four of the original review authors (one author, R.O.W. has died since the original review, see acknowledgements). Data were combined for meta‐analysis using relative risks for dichotomous data or weighted mean difference for continuous data. A fixed‐effect statistical model was used.Main resultsThe largest of the three trials was conducted in settings with high mortality rates. The meta‐analysis found no significant difference between the maintenance‐fluid and restricted‐fluid groups in number of deaths (RR 0.82, 95% CI 0.53 to 1.27); acute severe neurological sequelae (RR 0.67, 95% CI 0.41 to 1.08); or in mild to moderate sequelae (RR 1.24, 95% CI 0.58 to 2.65). However, when neurological sequelae were defined further, there was a statistically significant difference in favour of the maintenance‐fluid group in regard to spasticity (RR 0.50, 95% CI 0.27 to 0.93), seizures at both 72 hours (RR 0.59, 95% CI 0.42 to 0.83) and 14 days (RR 0.19, 95% CI 0.04 to 0.88), and chronic severe neurological sequelae at three‐months follow up (RR 0.42, 95% CI 0.20 to 0.89).Authors' conclusionsSome evidence supports maintaining intravenous fluids rather than restricted them in the first 48 hours, in settings with high mortality rates and where patients present late. However, where children present early and mortality rates are lower there is insufficient evidence to guide practice.Plain language summaryThere is some evidence to support not restricting fluids for people in developing countries where death rates are high and where people often seek help lateBacterial meningitis is an infection of the fluid in the spinal cord and surrounding the brain. Antibiotics are prescribed as treatment. Supportive care (especially of brain swelling and shock), requires other drugs and intravenous fluid management. There has been disagreement as to whether fluids should be restricted as hormones secreted by very ill patients reduce normal fluid excretion. The review found some evidence to support not restricting fluids in countries where death rates are high and where patients seek help late. However, there are no trials in other settings.