Goal directed therapy for suspected acute bacterial meningitis in adults and adolescents in sub-Saharan Africa.

Emma C Wall,Veronica S Mlozowa,Theresa J Allain,Malango Msukwa,Khumbo Kasambala,David G Lalloo,Brian Faragher,Brigitte Denis,Robert S Heyderman,Mavuto Mukaka,Mulinda Nyrienda,Ray Borrow

doi:10.1371/journal.pone.0186687

Abstract

BackgroundMortality from acute bacterial meningitis (ABM) in sub-Saharan African adults and adolescents exceeds 50%. We tested if Goal Directed Therapy (GDT) was feasible for adults and adolescents with clinically suspected ABM in Malawi.Materials and methodsSequential patient cohorts of adults and adolescents with clinically suspected ABM were recruited in the emergency department of a teaching hospital in Malawi using a before/after design. Routine care was monitored in year one (P1). In year two (P2), nurses delivered protocolised GDT (rapid antibiotics, airway support, oxygenation, seizure control and fluid resuscitation) to a second cohort. The primary endpoint was composite mean number of clinical goals attained. Secondary endpoints were individual goals attained and death or disability from proven or probable ABM at day 40.Results563 patients with suspected ABM were enrolled in the study; 273 were monitored in P1; 290 patients with suspected ABM received GDT in P2. 61% were male, median age 33 years and 90% were HIV co-infected. ABM was proven or probable in 132 (23%) patients. GDT attained more clinical goals compared to routine care: composite mean number of goals in P1 was 0·55 vs. 1·57 in P2 GDT (p<0·001); Death or disability by day 40 from proven or probable ABM occurred in 29/57 (51%) in P1 and 38/60 (63%) in P2 (p = 0·19).ConclusionNurse-led GDT in a resource-constrained setting was associated with improved delivery of protocolised care. Outcome was unaffected.Trial registrationwww.isrctn.com ISRCTN96218197

Highlights

Worldwide, acute bacterial meningitis (ABM) in adults and adolescents is associated with substantial mortality and morbidity [1,2,3,4]
563 patients with suspected ABM were enrolled in the study; 273 were monitored in P1; 290 patients with suspected ABM received Goal Directed Therapy (GDT) in P2. 61% were male, median age 33 years and 90% were HIV co-infected
GDT attained more clinical goals compared to routine care: composite mean number of goals in P1 was 0Á55 vs. 1Á57 in P2 GDT (p

Summary

Introduction

Acute bacterial meningitis (ABM) in adults and adolescents is associated with substantial mortality and morbidity [1,2,3,4]. Prompt treatment of suspected ABM with parenteral antibiotics is routinely recommended and is associated with improvements in outcome in Europe and the United States [5,6,7,8,9,10]. Improvements in outcome from sepsis using protocolised, goal directed therapy (GDT) have been reported [18, 19], leading to internationally accepted sepsis guidelines [20, 21]. Mortality from acute bacterial meningitis (ABM) in sub-Saharan African adults and adolescents exceeds 50%. We tested if Goal Directed Therapy (GDT) was feasible for adults and adolescents with clinically suspected ABM in Malawi

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Conclusion