Fluid therapy for acute bacterial meningitis

 

Abstract

Background

Acute 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 among 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.

Objectives

To evaluate differing volumes of fluid given in the initial management of bacterial meningitis.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1966 to Week 4, July 2010); EMBASE (1980 to August 2010); and CINAHL (1982 to August 2010).

Selection criteria

Randomised controlled trials (RCTs) of differing volumes of fluid given in the initial management of bacterial meningitis were eligible for inclusion.

Data collection and analysis

The initial search identified six trials; 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, ROW, has died since the original review, see acknowledgements). We combined data for meta-analysis using risk ratios (RR) for dichotomous data or mean difference (MD) for continuous data. We used a fixed-effect statistical model.

Main results

The 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 (risk ratio (RR) 0.82, 95% confidence interval (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' conclusions

Some evidence supports maintaining intravenous fluids rather than restricting 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 summary

Fluids for people with acute bacterial meningitis

Bacterial meningitis is an infection of the fluid in the spinal cord and surrounding the brain. Antibiotics are prescribed as treatment. Supportive care includes other drugs and the regulation of fluid intake. Despite treatment, there is a risk of death or long-term complications from the infection, especially in the youngest and oldest patients.

There has been disagreement as to whether fluids should be restricted (hormones secreted by very ill patients reduce normal fluid output by the body). There are potential risks from giving too much fluid (especially brain swelling) as well as too little fluid (especially shock). Three trials involving over 400 children (over 350 of which were in a single trial) were included. All trials were set in countries where death rates are high and where patients seek help late.

Analysis of available trials found no significant differences in death rates or overall effects on brain function, either immediately or later. However, one study found a significantly lower rate of seizures and spasticity (abnormal body tone) in children receiving normal amounts of fluid compared to those receiving restricted fluids.

An adverse effect in children with restricted fluid intake was that they were less likely to have low levels of sodium in their blood and therefore, they would experience greater reductions in body fluids.

An adverse effect of unrestricted fluid administration was reported in one study as short-term fluid swelling of the face and low sodium levels in the blood one to two days after fluids were started, although the largest study found no difference in sodium levels in the blood.

The review found limited evidence from these trials in support of not restricting fluids in settings with high death rates. As there were no trials in other settings, there is no evidence to guide clinicians where children present early and mortality rates are lower.

 

摘要

背景

急性細菌性腦膜炎的輸液療法

急性細菌性腦膜炎至今仍會造成高死亡率以及嚴重的併發症，而良好的抗生素與支持性療法可增進存活率，尤其對於嬰幼兒病人來說更是如此。嚴謹地調控體液與電解質平衡是支持性療法中很重要的一環，而輸液過度與不足均可能導致副作用的產生。

目標

評估不同輸液量在細菌性腦膜炎的初期處置上之成效差別。

搜尋策略

我們搜尋了Cochrane Acute Respiratory Infection Group's Specialised Register、Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library2007, issue 1)、MEDLINE (1966年至2007年3月)、EMBASE (1980年至2007年3月)，以及CINAHL (1982 年至2007年2月)。

選擇標準

我們收錄了比較不同輸液量在細菌性腦膜炎的初期處置上之成效差別的Randomised controlled trials。

資料收集與分析

一開始的搜尋發現了6個試驗，但只有其中3個符合收錄的標準。共有4位作者(其中1位作者R.O.W在第1次的文章回顧後即過世)評估試驗品質並擷取資料；這些數據被合併以進行Metaanalysis，我們計算了二元資料的relative risks以及連續性資料的weighted mean difference，並使用Fixedeffect statistical model。

主要結論

其中規模最大的3個試驗均針對高死亡率的病人進行研究。經過Metaanalysis後發現無論是維持或限制輸液，對於死亡人數(RR 0.82，95% CI 0.53 – 1.27)、急性嚴重神經學後遺症(RR 0.67，95% CI 0.41 – 1.08)，或是輕到中度的神經學後遺症(RR 1.24，95% CI 0.58 – 2.65) 等均沒有影響。然而若是針對神經學症狀細分的話，則會發現維持輸液療法可以減少痙攣(RR 0.50，95% CI 0.27 – 0.93)、前72小時 (RR 0.59，95% CI 0.42 – 0.83) 與前14天的癲癇(RR 0.19，95% CI 0.04 – 0.88)，以及3個月後的慢性嚴重神經學後遺症(RR 0.42，95% CI 0.20 – 0.89)。

作者結論

對於高死亡率及較晚就醫的病人來說，有證據證實維持前48小時的靜脈輸液，會比限制輸液還要來得有利。然而對於較早就醫的病童及死亡率較低的患者來說，則沒有足夠的證據可供參考。

翻譯人

本摘要由慈濟醫院鄭育容翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於死亡率較高及可能延遲就醫的開發中國家人民來說，有部分證據支持不限制輸液的作法。細菌性腦膜炎是一種包覆在腦與脊髓中液體的感染，抗生素是治療的重點，而支持性療法(尤其針對腦腫脹與休克的病人) 則需要其他的藥物或輸液；持相反意見的人認為重症患者會因內分泌調控而減少體液排除，所以應當限制輸液給予的量。對於死亡率較高及可能延遲就醫的開發中國家人民來說，這篇回顧性文章發現了一些支持不限制輸液作法的證據；然而對於其他狀況的病人來說，目前仍缺乏相關的研究。