Abstract
ObjectiveTo evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness.DesignA prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012.PatientsIncluded patients were confirmed ABM-cases, aged 16–75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg.MeasurementsThe primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2–6 months.OutcomesThe mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05).ConclusionsEarly neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.
Highlights
Acute bacterial meningitis (ABM) in adults is associated with a considerable risk of death and neurological deficits [1,2,3,4,5,6]
Early neuro-intensive care using intracranial pressure (ICP)-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission
Osmotherapy and ICP-targeted treatment can be considered in critical cases of ABM [7,22,23,24], and is well established in patients suffering from traumatic brain injury (TBI) [25]
Summary
Acute bacterial meningitis (ABM) in adults is associated with a considerable risk of death and neurological deficits [1,2,3,4,5,6]. The standard of care for acute bacterial meningitis includes initiation of adequate antibiotics and corticosteroids in meningitis doses within one hour of admission, and if impaired mental status or other signs of increased ICP, intensive care with proper analgesia and assisted mechanical ventilation. A neurocritical care approach using ICP-targeted treatment with favorable results has been reported in three relatively small and uncontrolled studies of ABM-patients presenting high ICP and severe impairment of consciousness [14,15,16], and promising results have recently been reported in a cohort study using lumbar drainage [23]. There is a lack of evidence supporting ICP-guided treatment in ABM [7,22]
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