Pre-admission antibiotics for suspected cases of meningococcal disease

Pre-admission antibiotics for suspected cases of meningococcal disease

BACKGROUND

Meningococcal disease can lead to death or disability within hours after onset. Pre-admission antibiotics aim to reduce the risk of serious disease and death by preventing delays in starting therapy before confirmation of the diagnosis.

OBJECTIVES

To study the effectiveness and safety of pre-admission antibiotics versus no pre-admission antibiotics or placebo, and different pre-admission antibiotic regimens in decreasing mortality, clinical failure, and morbidity in people suspected of meningococcal disease.

SEARCH METHODS

We searched CENTRAL (6 January 2017), MEDLINE (1966 to 6 January 2017), Embase (1980 to 6 January 2017), Web of Science (1985 to 6 January 2017), LILACS (1982 to 6 January 2017), and prospective trial registries to January 2017. We previously searched CAB Abstracts from 1985 to June 2015, but did not update this search in January 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotics versus placebo or no intervention, in people with suspected meningococcal infection, or different antibiotics administered before admission to hospital or confirmation of the diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data from the search results. We calculated the risk ratio (RR) and 95% confidence interval (CI) for dichotomous data. We included only one trial and so did not perform data synthesis. We assessed the overall quality of the evidence using the GRADE approach.

MAIN RESULTS

We found no RCTs comparing pre-admission antibiotics versus no pre-admission antibiotics or placebo. We included one open-label, non-inferiority RCT with 510 participants, conducted during an epidemic in Niger, evaluating a single dose of intramuscular ceftriaxone versus a single dose of intramuscular long-acting (oily) chloramphenicol. Ceftriaxone was not inferior to chloramphenicol in reducing mortality (RR 1.21, 95% CI 0.57 to 2.56; N = 503; 308 confirmed meningococcal meningitis; 26 deaths; moderate-quality evidence), clinical failures (RR 0.83, 95% CI 0.32 to 2.15; N = 477; 18 clinical failures; moderate-quality evidence), or neurological sequelae (RR 1.29, 95% CI 0.63 to 2.62; N = 477; 29 with sequelae; low-quality evidence). No adverse effects of treatment were reported. Estimated treatment costs were similar. No data were available on disease burden due to sequelae.

AUTHORS' CONCLUSIONS

We found no reliable evidence to support the use pre-admission antibiotics for suspected cases of non-severe meningococcal disease. Moderate-quality evidence from one RCT indicated that single intramuscular injections of ceftriaxone and long-acting chloramphenicol were equally effective, safe, and economical in reducing serious outcomes. The choice between these antibiotics should be based on affordability, availability, and patterns of antibiotic resistance.Further RCTs comparing different pre-admission antibiotics, accompanied by intensive supportive measures, are ethically justified in people with less severe illness, and are needed to provide reliable evidence in different clinical settings.

Pre-admission antibiotics for suspected cases of meningococcal disease

BACKGROUND

Meningococcal disease can lead to death or disability within hours after onset. Pre-admission antibiotics aim to reduce the risk of serious disease and death by preventing delays in starting therapy before confirmation of the diagnosis.

OBJECTIVES

To study the effectiveness and safety of pre-admission antibiotics versus no pre-admission antibiotics or placebo, and different pre-admission antibiotic regimens in decreasing mortality, clinical failure and morbidity in people suspected of meningococcal disease.

SEARCH METHODS

We updated searches of CENTRAL (2013, Issue 4), MEDLINE (1966 to April week 4, 2013), EMBASE (1980 to May 2013), Web of Science (1985 to May 2013), CAB Abstracts (1985 to May 2013), LILACS (1982 to May 2013) and prospective trials registries to May 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotics versus placebo or no intervention, in people with suspected meningococcal infection, or different antibiotics administered before admission to hospital or confirmation of the diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data from the search results. We calculated the risk ratio (RR) and 95% confidence interval (CI) for dichotomous data. We included only one trial so data synthesis was not performed. We assessed the overall quality of the evidence using the GRADE approach.

MAIN RESULTS

We found no RCTs that compared pre-admission antibiotics versus no pre-admission antibiotics or placebo. One open-label, non-inferiority RCT, conducted during an epidemic in Niger, evaluated a single dose of intramuscular ceftriaxone versus a single dose of intramuscular long-acting (oily) chloramphenicol. Ceftriaxone was not inferior to chloramphenicol in reducing mortality (RR 1.2, 95% CI 0.6 to 2.6; N = 503; 308 confirmed meningococcal meningitis; 26 deaths; moderate-quality evidence), clinical failures (RR 0.8, 95% CI 0.3 to 2.2; N = 477, 18 clinical failures; moderate-quality evidence) or neurological sequelae (RR 1.3, 95% CI 0.6 to 2.6; N = 477; 29 with sequelae; low-quality evidence). No adverse effects of treatment were reported. Estimated treatment costs were similar. No data were available on disease burden due to sequelae.

AUTHORS' CONCLUSIONS

We found no reliable evidence to support or refute the use of pre-admission antibiotics for suspected cases of non-severe meningococcal disease. Evidence of moderate quality from one RCT indicated that single intramuscular injections of ceftriaxone and long-acting chloramphenicol were equally effective, safe and economical in reducing serious outcomes. The choice between these antibiotics would be based on affordability, availability and patterns of antibiotic resistance.Further RCTs comparing different pre-admission antibiotics, accompanied by intensive supportive measures, are ethically justifiable in participants with severe illness, and are needed to provide reliable evidence in different clinical settings.

Osmotic therapies added to antibiotics for acute bacterial meningitis

BACKGROUND

Every day children and adults throughout the world die from acute community-acquired bacterial meningitis, particularly in low-income countries. Survivors are at risk of deafness, epilepsy and neurological disabilities. Osmotic therapies have been proposed as an adjunct to improve mortality and morbidity from bacterial meningitis. The theory is that they will attract extra-vascular fluid by osmosis and thus reduce cerebral oedema by moving excess water from the brain into the blood. The intention is to thus reduce death and improve neurological outcomes.

OBJECTIVES

To evaluate the effects on mortality, deafness and neurological disability of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults.

SEARCH METHODS

We searched CENTRAL 2012, Issue 11, MEDLINE (1950 to November week 3, 2012), EMBASE (1974 to November 2012), CINAHL (1981 to November 2012), LILACS (1982 to November 2012) and registers of ongoing clinical trials (April 2012). We also searched conference abstracts and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results and selected trials for inclusion. We collected data from each study for mortality, deafness, seizures and neurological disabilities. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not.

MAIN RESULTS

Four trials were included comprising 1091 participants. All compared glycerol (a water-soluble sugar alcohol) with a control; in three trials this was a placebo, and in one a small amount of 50% dextrose. Three trials included comparators of dexamethasone alone or in combination with glycerol. As dexamethasone appeared to have no modifying effect, we aggregated results across arms where both treatment and control groups received corticosteroids and where both treatment and control groups did not.Compared to placebo, glycerol may have little or no effect on death in people with bacterial meningitis (RR 1.09, 95% confidence interval (CI) 0.89 to 1.33, 1091 participants, four trials, low-quality evidence); or on death and neurological disability combined (RR 1.04, 95% CI 0.86 to 1.25).Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30, 909 participants, three trials, low-quality evidence).Glycerol may reduce the risk of subsequent deafness (RR 0.60, 95% CI 0.38 to 0.93, 741 participants, four trials, low-quality evidence).

AUTHORS' CONCLUSIONS

The only osmotic diuretic to have undergone randomised evaluation is glycerol. Data from trials to date have not demonstrated benefit on death, but it may reduce deafness. Osmotic diuretics, including glycerol, should not be given to adults and children with bacterial meningitis unless as part of carefully conducted randomised controlled trial.

Meningococcal meningitis

OPINION STATEMENT

Meningococcal meningitis (MM) is the most common presentation of meningococcal disease and an important cause of morbidity and mortality worldwide. When MM is associated with shock, early recognition and treatment of shock is essential. No investigation should delay starting antibiotics once the diagnosis is suspected. Corticosteroids can be started at the same time as the antibiotics or just before, but this is not a specific recommendation for MM. Low-dose steroids should be used in meningococcal disease with refractory shock. Altered blood flow, cerebral edema, and raised intracranial pressure are problems that should be considered in all patients with MM and decreased consciousness level. When mechanical ventilation is required, the target carbon dioxide level is 4.0 to 4.5 kPa, with avoidance of hypocapnia. Seizures, although not frequent, can occur in MM and require prompt treatment. Other treatments, such as mannitol and activated protein C, should be avoided. Potential new treatments requiring further investigation include neuroprotection with hypothermia or glycerol.

Pathophysiology and treatment of bacterial meningitis

Bacterial meningitis is a medical emergency requiring immediate diagnosis and immediate treatment. Streptococcus pneumoniae and Neisseria meningitidis are the most common and most aggressive pathogens of meningitis. Emerging antibiotic resistance is an upcoming challenge. Clinical and experimental studies have established a more detailed understanding of the mechanisms resulting in brain damage, sequelae and neuropsychological deficits. We summarize the current pathophysiological concept of acute bacterial meningitis and present current treatment strategies.

Pre-admission antibiotics for suspected cases of meningococcal disease

BACKGROUND

Meningococcal disease begins suddenly and death can follow within hours. Pre-admission antibiotic therapy aims to prevent delay in starting therapy that occurs if bacterial confirmation is sought before instituting therapy.

OBJECTIVES

To study the effectiveness and safety of pre-admission antibiotics versus no pre-admission antibiotics or placebo and of different pre-admission antibiotic regimens in decreasing mortality and morbidity in people suspected of meningococcal disease.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, Issue 1), MEDLINE (1966 to February 2007) and EMBASE (1980 to February 2007).

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) or quasi-RCTs, of all people with suspected meningococcal infection. We compared antibiotic treatment versus placebo or no intervention, or different antibiotic treatments administered before admission to hospital or confirmation of the diagnosis.

DATA COLLECTION AND ANALYSIS

Two author authors independently assessed quality and extracted data from included trials. We calculated the relative risk (RR) and 95% confidence interval (CI) for dichotomous data. As only one trial fulfilled inclusion criteria, data synthesis was not performed.

MAIN RESULTS

No RCTs were found that compared pre-admission antibiotics versus no pre-admission antibiotics or placebo. One open-label RCT evaluated a single dose of intramuscular ceftriaxone versus a single dose of intramuscular long acting (oily) chloramphenicol. Interventions did not differ significantly in mortality (RR 1.2, 95% CI 0.5 to 2.6; N = 510; 349 confirmed meningococcal meningitis; 26 deaths), nor in proportions of survivors who developed neurological sequelae (RR 1.2, 95% CI 0.6 to 2.2; N = 488; 36 with neurological sequelae), or that were classified as clinical failures (RR 0.8, 95% CI 0.4 to 1.8; N = 488, 25 clinical failures). No adverse effects of treatment were seen. No data were available for our secondary outcomes.

AUTHORS' CONCLUSIONS

We found no reliable evidence to support or refute the use of pre-admission antibiotics for suspected cases of meningococcal disease. Evidence from one RCT-during an epidemic of meningococcal meningitis, indicated that single intramuscular injections of ceftriaxone and long-acting chloramphenicol were equally effective and safe in preventing mortality and morbidity. The choice between these antibiotics would be based on affordability, availability, and patterns of antibiotic resistance.Further RCTs comparing different pre-admission antibiotics, including penicillin, including participants with severe illness are ethically justifiable and are needed to provide reliable evidence to clinicians in differing clinical settings.