Management of meningitis in children with oral fluid restriction or intravenous fluid at maintenance volumes: a randomised trial

Global Case Fatality of Bacterial Meningitis During an 80-Year Period: A Systematic Review and Meta-Analysis

Importance

The impact of vaccination, antibiotics, and anti-inflammatory treatment on pathogen distribution and outcome of bacterial meningitis over the past century is uncertain.

Objective

To describe worldwide pathogen distribution and case fatality ratios of community-acquired bacterial meningitis.

Data Sources

Google Scholar and MEDLINE were searched in January 2022 using the search terms bacterial meningitis and mortality.

Study Selection

Included studies reported at least 10 patients with bacterial meningitis and survival status. Studies that selected participants by a specific risk factor, had a mean observation period before 1940, or had more than 10% of patients with health care-associated meningitis, tuberculous meningitis, or missing outcome were excluded.

Data Extraction and Synthesis

Data were extracted by 1 author and verified by a second author. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Random-effects models stratified by age (ie, neonates, children, adults), Human Development Index (ie, low-income or high-income countries), and decade and meta-regression using the study period's year as an estimator variable were used.

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

This review included 371 studies performed in 108 countries from January 1, 1935, to December 31, 2019, describing 157 656 episodes. Of the 33 295 episodes for which the patients' sex was reported, 13 452 (40%) occurred in females. Causative pathogens were reported in 104 598 episodes with Neisseria meningitidis in 26 344 (25%) episodes, Streptococcus pneumoniae in 26 035 (25%) episodes, Haemophilus influenzae in 22 722 (22%), other bacteria in 19 161 (18%) episodes, and unidentified pathogen in 10 336 (10%) episodes. The overall case fatality ratio was 18% (95% CI, 16%-19%), decreasing from 32% (95% CI, 24%-40%) before 1961 to 15% (95% CI, 12%-19%) after 2010. It was highest in meningitis caused by Listeria monocytogenes at 27% (95% CI, 24%-31%) and pneumococci at 24% (95% CI, 22%-26%), compared with meningitis caused by meningococci at 9% (95% CI, 8%-10%) or H influenzae at 11% (95% CI, 10%-13%). Meta-regression showed decreasing case fatality ratios overall and stratified by S pneumoniae, Escherichia coli, or Streptococcus agalactiae (P < .001).

Conclusions and Relevance

In this meta-analysis with meta-regression, declining case fatality ratios of community-acquired bacterial meningitis throughout the last century were observed, but a high burden of disease remained.

Intravenous maintenance fluid therapy in acutely and critically ill children: state of the evidence

Intravenous maintenance fluid therapy (IV-MFT) is one of the most prescribed, yet one of the least studied, interventions in paediatric acute and critical care settings. IV-MFT is not typically treated in the same way as drugs with specific indications, contraindications, compositions, and associated adverse effects. In the last decade, societies in both paediatric and adult medicine have issued evidence-based practice guidelines for the use of intravenous fluids in clinical practice. The main objective of this Viewpoint is to summarise and compare the rationales on which these international expert guidelines were based and how these recommendations affect IV-MFT practices in paediatric acute and critical care. Although these guidelines recommend the use of isotonic fluids as a standard in IV-MFT, some discrepancies and uncertainties remain regarding the systematic use of balanced fluids, glucose and electrolyte requirements, and appropriate fluid volume. IV-MFT should be considered in the same way as any other prescription drug and none of the components of IV-MFT prescription should be overlooked (ie, choice of drug, dosing rate, duration of treatment, and de-escalation). Furthermore, most evidence that was used to inform the guidelines comes from high-income countries. Although some principles of IV-MFT are universal, the direct relevance to and feasibility of implementing the guidelines in low-income and middle-income countries is uncertain.

Antimicrobial Resistance in Papua New Guinea: A Narrative Scoping Review

Antimicrobial-resistant bacterial infections are a known threat to the public health of low-income countries and are undercharacterized in Papua New Guinea. A scoping literature review of scientific peer-reviewed publications on antimicrobial resistance in Papua New Guinea was conducted, and their results were summarized. Many of the available data on resistant bacteria in Papua New Guinea have come from Port Moresby and Goroka and have been focused on Staphylococcus aureus, as well as important pediatric pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. Progressive resistance to the commonly used antibiotics penicillin and chloramphenicol among most clinically important bacterial pathogens has prompted healthcare workers to adopt expensive broad-spectrum antibiotics. There is already evidence of resistance to newly adopted antibiotics among several Gram-negative organisms. Drivers of antimicrobial resistance in Papua New Guinea include a high burden of infectious diseases, inappropriate antibiotic prescription practices, poor regulation of antibiotics, incomplete adherence, substandard drug quality, and overcrowding of healthcare facilities. There is a lack of information on antimicrobial resistance among priority pathogens and from several important regions of Papua New Guinea.

ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis

PURPOSE

Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid.

METHODS

A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds.

RESULTS

56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations.

CONCLUSIONS

Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance.

Isotonic versus Hypotonic Intravenous Maintenance Fluids in Children: A Randomized Controlled Trial

OBJECTIVE

To compare the incidence of hyponatremia during the first 48 h in hospitalized children receiving normal saline vs. N/2 saline as maintenance intravenous fluid.

METHODS

This open label, randomized controlled trial to compare the incidence of hyponatremia in hospitalized children receiving normal saline (0.9% sodium chloride in 5% dextrose) vs. N/2 saline (0.45% sodium chloride in 5% dextrose) as maintenance fluid was conducted from December 2014 through November 2015 in a tertiary care teaching hospital. Children between 1 mo and 18 y requiring maintenance intravenous fluids were randomized to receive normal saline with 5% dextrose (n = 75) or N/2 saline with 5% dextrose (n = 75).

RESULTS

Both groups were comparable for demographic variables and illness severity at baseline. Incidence of hyponatremia at 24 h of hospitalization was comparable between normal saline and N/2 saline group, 3(4%) vs. 6(8%) cases, respectively; p value 0.494. Mean serum sodium levels were marginally higher in normal saline group (138.3 ± 6.0 mEq/L) as compared with N/2 saline group (135.1 ± 4.4 mEq/L) (p value <0.01) at 24 h of hospitalization. Incidence of hyponatremia at 48 h and hypernatremia at 24 and 48 h was comparable in two groups.

CONCLUSIONS

The use of either N/2 saline or normal saline in sick children at standard maintenance fluid rates is associated with low but comparable incidence of hypo or hypernatremia in first 24 h of hospitalization. Both types of fluids appear acceptable in hospitalized sick children.

Fluid therapy for acute bacterial meningitis

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. This is the latest update of a review first published in 2005 and updated in 2008 and 2014.

OBJECTIVES

To evaluate treatment of acute bacterial meningitis with differing volumes of initial fluid administration (up to 72 hours after first presentation) and the effects on death and neurological sequelae.

SEARCH METHODS

For this 2016 update we searched the following databases up to March 2016: the Cochrane Acute Respiratory Infections Group's Specialised Register, CENTRAL, MEDLINE, CINAHL, Global Health, and Web of Science.

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

All four of the original review authors extracted data and assessed trials for quality in the first publication of this review (one author, ROW, has passed away since the original review; see Acknowledgements). The current authors combined data for meta-analysis using risk ratios (RRs) for dichotomous data or mean difference (MD) for continuous data. We used a fixed-effect statistical model. We assessed the overall quality of evidence using the GRADE approach.

MAIN RESULTS

We included three trials with a total of 420 children; there were no trials in adult populations. The largest of the three trials was conducted in settings with high mortality rates and was judged to have low risk of bias for all domains, except performance bias which was high risk. The other two smaller trials were not of high quality.The meta-analysis found no significant difference between the maintenance-fluid and restricted-fluid groups in number of deaths (RR 0.82, 95% confidence interval (CI) 0.53 to 1.27; 407 participants; low quality of evidence) or acute severe neurological sequelae (RR 0.67, 95% CI 0.41 to 1.08; 407 participants; low quality of evidence). However, when neurological sequelae were defined further, there was a statistically significant difference in favour of the maintenance-fluid group for spasticity (RR 0.50, 95% CI 0.27 to 0.93; 357 participants); and seizures at both 72 hours (RR 0.59, 95% CI 0.42 to 0.83; 357 participants) and 14 days (RR 0.19, 95% CI 0.04 to 0.88; 357 participants). There was very low quality of evidence favouring maintenance fluid over restrictive fluid for chronic severe neurological sequelae at three months follow-up (RR 0.42, 95% CI 0.20 to 0.89; 351 participants).

AUTHORS' CONCLUSIONS

The quality of evidence regarding fluid therapy in children with acute bacterial meningitis is low to very low and more RCTs need to be conducted. There is insufficient evidence to guide practice as to whether maintenance fluids should be chosen over restricted fluids in the treatment of acute bacterial meningitis.

The Golden Hours in Paediatric Septic Shock—Current Updates and Recommendations

Introduction: Paediatric sepsis is a global health problem. It is the leading cause of mortality in infants and children worldwide. Appropriate and timely initial management in the first hours, often termed as the “golden hours”, has great impact on survival. The aim of this paper is to summarise the current literature and updates on the initial management of paediatric sepsis. Materials and Methods: A comprehensive literature search was performed via PubMed using the search terms: ‘sepsis’, ‘septic shock’, ‘paediatric’ and ‘early goal-directed therapy’. Original and review articles were identified and selected based on relevance to this review. Results: Early recognition, prompt fluid resuscitation and timely administration of antibiotics remain key in the resuscitation of the septic child. Use of steroids and tight glycaemic control in this setting remain controversial. Conclusion: The use of early goal-directed therapy has had significant impact on patient outcomes and protocolised resuscitation of children in septic shock is recommended. Key words: Child, Early goal-directed therapy, Emergency, Sepsis

Fluid therapy for acute bacterial meningitis

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 treatment of acute bacterial meningitis with differing volumes of initial fluid administration (up to 72 hours after first presentation) and the effects on death and neurological sequelae.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), MEDLINE (1966 to October week 5, 2013), EMBASE (1980 to November 2013), CINAHL (1981 to November 2013), LILACS (1982 to November 2013) and Web of Science (2010 to 2013).

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

For this update we identified two abstracts, but after obtaining full texts we excluded them. Previous searches had identified six trials; on careful inspection three trials (415 children) met the inclusion criteria. All four of the original review authors extracted data and assessed trials for quality (one author, ROW, has died since the original review; see Acknowledgements). We combined data for meta-analysis using risk ratios (RRs) for dichotomous data or mean difference (MD) for continuous data. We used a fixed-effect statistical model. We assessed overall evidence quality using the GRADE approach.

MAIN RESULTS

There were no trials in adult populations. All included trials were on paediatric patient groups. 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 (RR 0.82, 95% confidence interval (CI) 0.53 to 1.27; 407 participants) (moderate trial quality); acute severe neurological sequelae (RR 0.67, 95% CI 0.41 to 1.08; 407 participants) (very low trial quality); or in mild to moderate sequelae (RR 1.24, 95% CI 0.58 to 2.65; 357 participants) (moderate trial quality). However, when neurological sequelae were defined further, there was a statistically significant difference in favour of the maintenance-fluid group for spasticity (RR 0.50, 95% CI 0.27 to 0.93; 357 participants); seizures at both 72 hours (RR 0.59, 95% CI 0.42 to 0.83; 357 participants) and 14 days (RR 0.19, 95% CI 0.04 to 0.88; 357 participants); and chronic severe neurological sequelae at three months follow-up (RR 0.42, 95% CI 0.20 to 0.89; 351 participants).

AUTHORS' CONCLUSIONS

The quality of evidence regarding fluid therapy in children with acute bacterial meningitis is not high-grade and there is a need for further research. Some evidence supports maintaining intravenous fluids rather than restricting them in the first 48 hours in settings with high mortality rates and where children present late. However, where children present early and mortality rates are lower, there is insufficient evidence to guide practice.

Alternative rehydration methods: a systematic review and lessons for resource-limited care

OBJECTIVE

Dehydration is a significant threat to the health of children worldwide and a major cause of death in resource-scarce settings. Although multiple studies have revealed that oral and intravenous (IV) methods for rehydration in nonsevere dehydration are nearly equally effective, little is known about effectiveness beyond these 2 techniques. With this systematic review we analyzed the effectiveness of nonoral and nonintravenous methods of rehydration.

METHODS

The Medline, Cochrane, Global Health, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for articles on intraosseous (IO), nasogastric (NG), intraperitoneal (IP), subcutaneous (hypodermoclysis), and rectal (proctoclysis) rehydration through December 2009. Only human pediatric studies that included data on the effectiveness or complications of these methods were included.

RESULTS

The search identified 38 articles that met the inclusion criteria: 12 articles on NG, 16 on IO, 7 on IP, 3 on subcutaneous, and none on rectal rehydration. NG rehydration was as effective as IV rehydration for moderate-to-severe dehydration. IO rehydration was effective and easy to obtain, although only 1 randomized trial was identified. IP rehydration had some benefit for moderate dehydration, although none of the trials had control groups. Limited data were available on subcutaneous rehydration, and only 1 case series showed benefit.

CONCLUSIONS

NG rehydration should be considered second-line therapy, after oral rehydration, particularly in resource-limited environments. IO rehydration seems to be an effective alternative when IV access is not readily obtainable. Additional evidence is needed before IP and subcutaneous rehydration can be endorsed.

Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol

OBJECTIVE

Several studies have evaluated dexamethasone for prevention of hearing loss in childhood bacterial meningitis, but results have varied. We compared dexamethasone and/or glycerol recipients with placebo recipients, and measured hearing at 3 threshold levels.

METHODS

Children aged 2 months to 16 years with meningitis were treated with ceftriaxone but were double-blindly randomly assigned to receive adjuvant dexamethasone intravenously, glycerol orally, both agents, or neither agent. We used the Glasgow coma scale to grade the presenting status. The end points were the better ear's ability to detect sounds of >40 dB, >or=60 dB, and >or=80 dB, with these thresholds indicating any, moderate-to-severe, or severe impairment, respectively. All tests were interpreted by an external audiologist. Influence of covariates in the treatment groups was examined by binary logistic regression.

RESULTS

Of the 383 children, mostly with meningitis caused by Haemophilus influenzae type b or Streptococcus pneumoniae, 101 received dexamethasone, 95 received dexamethasone and glycerol, 92 received glycerol, and 95 received placebo. Only the presenting condition and young age predicted impairment independently through all threshold levels. Each lowering point in the Glasgow scale increased the risk by 15% to 21% (odds ratio: 1.20, 1.21, and 1.15 [95% confidence interval: 1.06-1.35, 1.07-1.37, and 1.01-1.31]; P = .005, .003, and .039) for any, moderate-to-severe, or severe impairment, respectively. Each increasing month of age decreased the risk by 2% to 6% (P = .0001, .0007, and .041, respectively). Neither dexamethasone nor glycerol prevented hearing loss at these levels regardless of the causative agent or timing of antimicrobial agent.

CONCLUSIONS

With bacterial meningitis, the child's presenting status and young age are the most important predictors of hearing impairment. Little relief is obtained from current adjuvant medications.

[Adjunctive therapies (excluding corticosteroids). Site of initial management]

Bacterial meningitis is still a serious disease with a high risk of mortality and sequels. The progress in antibiotic treatment has not improved the prognosis. Thus, optimizing the initial care and the treatment of the most severe cases should improve the outcome. No study has compared the outcome according to the level of care at the admission site. There is evidence that the most severe cases should be managed by critical care units. It seems reasonable to recommend initial admission of common cases to units able to provide intensive care. Most people now agree that fluid restriction has not demonstrated its efficiency, furthermore it might have deleterious effects. However, a fluid overload should be avoided. Maintaining cerebral perfusion is a key issue in the treatment of bacterial meningitis and requires monitoring both arterial blood pressure and intracranial pressure. Intracranial pressure monitoring is probably useful to optimize the treatment of the most severe cases. The aggressive treatments of cerebral edema have not been evaluated but seem, in some limited series, able to improve some life threatening situations. The benefit of systematic glycerol administration needs confirmation. Seizures should be treated with the usual medications. However, drugs with potentially deleterious effects on hemodynamics should be avoided. There is no sufficient evidence to support the administration of a systematic prophylactic treatment. Fever should be treated when above 39.5 degrees C/40 degrees C and in the case of intracranial hypertension. There is no clinical study to explore the modifications of fever on bacterial growth or on inflammation as observed in some experimental studies.

Treatment of bacterial meningitis: an overview of Cochrane systematic reviews

BACKGROUND

Acute bacterial meningitis (ABM) is a rapidly developing acute inflammation of leptomeninges and underlying subarachnoid cerebrospinal fluid (CSF). ABM is caused by bacteria and has a case fatality rate of 20-30%. Most prevalent causes of ABM are Neisseria meningitis, Streptococcus pneumoniae and Haemophilus influenzae. The aim of this paper is to summarize the main findings from Cochrane systematic reviews that have considered the evidence for treatments of ABM.

METHODS

We searched the Cochrane Library (issue 1, 2007) for relevant reviews using 'meningitis' as a search term. The titles of all the search results were examined to select reviews on treatment of ABM. The full text of each of the selected reviews was studied to summarize the evidence available in Cochrane systematic reviews.

RESULTS

We found three Cochrane reviews that focused specifically on the treatment of ABM, addressing empiric antibiotic therapy, fluid therapy and effects of adjuvant corticosteroids respectively. No statistically significant difference was found between third generation cephalosporins and conventional antibiotics in the combined endpoint of death or deafness (risk difference (RD) -1%, 95% CI -4% to +2%). However, culture positivity of CSF at 10-48 h was significantly higher in the conventional antibiotic group and diarrhoea was significantly more common in the cephalosporin group. When third generation cephalosporins are not available, ampicillin-chloramphenicol combination may be used as an alternative empiric treatment, however both resistance pattern as well as availability should be considered while prescribing empiric therapy of community acquired ABM. The fluid therapy review found too few studies to provide any robust conclusion. In settings with high mortality rates and where patients present late, use of intravenous maintenance fluids seems preferable to a restricted fluid intake. The efficacy of adjuvant corticosteroids varied between high- and low-income countries suggesting greater mortality reduction in high-income countries (RR 0.74, 95% CI 0.52-1.05) than in low-income countries (RR 0.87, 95% CI 0.72-1.05) and a beneficial effect on severe hearing loss in high-income countries (RR 0.32, 95% CI 0.18-0.57), whereas, sparse data in low-income countries (RR 1.04, 95% CI 0.66-1.63). A four-day regimen of dexamethasone should be given preferably before or with the first dose of antibiotics for cases of ABM from high-income countries.

CONCLUSION

In presence of sensitive organisms, third generation cephalosporins and conventional antibiotics lead to similar outcomes. More studies are needed to determine the antimicrobial resistance pattern against various antibiotics in rural and remote areas of developing as well as developed countries. To assess the effectiveness of either restricting or maintenance fluids in populations where patients present early and on death and disability when mortality rates are low, large trials should be conducted. More trials are needed to assess the use of adjuvant dexamethasone for ABM in low-income countries.

Randomised controlled trial of intravenous maintenance fluids

AIM

Traditional paediatric intravenous maintenance fluids are prescribed using hypotonic fluids and the weight-based 4:2:1 formula for administration rate. However, this may cause hyponatraemia in sick and post-operative children. We studied the effect of two types of intravenous maintenance fluid and two administration rates on plasma sodium concentration in intensive care patients.

METHODS

A Factorial-design, double-blind, randomised controlled trial was used. We randomised 50 children with normal electrolytes without hypoglycaemia who needed intravenous maintenance fluids for >12 h to 0.9% saline (normal saline) or 4% dextrose and 0.18% saline (dextrose saline), at either the traditional maintenance fluid rate or 2/3 of that rate. The main outcome measure was change in plasma sodium from admission to 12-24 h later.

RESULTS

Fifty patients (37 surgical) were enrolled. Plasma sodium fell in all groups: mean fall 2.3 (standard deviation 4.0) mmol/L. Fluid type (P = 0.0063) but not rate (P = 0.12) was significantly associated with fall in plasma sodium. Dextrose saline produced a greater fall in plasma sodium than normal saline: difference 3.0, 95% confidence interval 0.8-5.1 mmol/L. Full maintenance rate produced a greater fall in plasma sodium than restricted rate, but the difference was small and non-significant: 1.6 (-0.7, 3.9) mmol/L. Fluid type, but not rate, remained significant after adjustment for surgical status. One patient, receiving normal saline at restricted rate, developed asymptomatic hypoglycaemia.

CONCLUSION

Sick and post-operative children given dextrose saline at traditional maintenance rates are at risk of hyponatraemia.

Increase in serum osmolality is possible mechanism for the beneficial effects of glycerol in childhood bacterial meningitis

BACKGROUND

Oral glycerol reduces severe neurologic sequelae in childhood bacterial meningitis, but the mechanism awaits elucidation. We conducted a prospective, randomized, double-blind study in which the effects of glycerol and intravenous dexamethasone were compared with placebo recipients in an intensive care setting in India.

METHODS

Thirty-six children at age 2 months to 12 years with meningitis were treated with ceftriaxone and were randomized to receive also either dexamethasone intravenously, or glycerol orally, or both agents, or neither. The illness was monitored with preset criteria. The primary outcome measures were the changes in plasma osmolality and in urine output.

RESULTS

Nine children received glycerol, 8 dexamethasone, 11 both agents, and 8 only placebo. The leading agents identified were Streptococcus pneumoniae, Haemophilus influenzae type b, and Staphylococcus aureus. Only the glycerol recipients increased plasma osmolality by up to 3% from the mean baseline of 294 mOsm/kg in the glycerol and 295 mOsm/kg in the glycerol-dexamethasone group. This change occurred within 6 hours, the critical period of treatment, and lasted <24 hours. Blood pressure was not affected, nor did urine output increase. The dexamethasone-only and placebo-only recipients showed immediate decrease in serum osmolality.

CONCLUSIONS

Because excretion of the cerebrospinal fluid is inversely associated with plasma osmolality, we suggest that the glycerol-induced osmolality increase reduce the volume of cerebrospinal fluid, enhanced water movement back to the plasma by osmosis, increased cerebral blood flow, and thus, improved brain oxygenation.

The diagnosis and management of acute bacterial meningitis in resource-poor settings

Acute bacterial meningitis is more common in resource-poor than resource-rich settings. Survival is dependent on rapid diagnosis and early treatment, both of which are difficult to achieve when laboratory support and antibiotics are scarce. Diagnostic algorithms that use basic clinic and laboratory features to distinguish bacterial meningitis from other diseases can be useful. Analysis of the CSF is essential, and simple techniques can enhance the yield of diagnostic microbiology. Penicillin-resistant and chloramphenicol-resistant bacteria are a considerable threat in resource-poor settings that go undetected if CSF and blood can not be cultured. Generic formulations of ceftriaxone are becoming more affordable and available, and are effective against meningitis caused by penicillin-resistant or chloramphenicol-resistant bacteria. However, infection with Streptococcus pneumoniae with reduced susceptibility to ceftriaxone is reported increasingly, and alternatives are either too expensive (eg, vancomycin) or can not be widely recommended (eg, rifampicin, which is the key drug to treat tuberculosis) in resource-poor settings. Additionally, improved access to affordable antibiotics will not overcome the problems of poor access to hospitals and the fatal consequences of delayed treatment. The future rests with the provision of effective conjugate vaccines against S pneumoniae, Haemophilus influenzae, and Neisseria meningitides to children in the poorest regions of the world.

Fluid therapy for acute bacterial meningitis

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 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.

OBJECTIVES

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

SEARCH STRATEGY

We 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 CRITERIA

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

DATA COLLECTION AND ANALYSIS

Six 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 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 (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' CONCLUSIONS

Some 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.

Hypotonic versus isotonic maintenance intravenous fluid therapy in hospitalized children: a systematic review

A systematic review of studies comparing hypotonic versus isotonic intravenous maintenance fluids in hospitalized children was conducted to determine whether hypotonic solutions increase the risk of acute hyponatremia. Studies were identified from electronic databases and hand-searched reference lists. A total of 283 abstracts were reviewed, 55 full-text articles were retrieved, and 3 studies were included. All studies were observational and were overall inconclusive. All authors cautioned against the routine use of hypotonic maintenance fluids, but hypotonic fluid administration did not always explain the development of acute hyponatremia. Further evidence is required as to the appropriate maintenance solution for hospitalized children.

Adjuvant glycerol and/or dexamethasone to improve the outcomes of childhood bacterial meningitis: a prospective, randomized, double-blind, placebo-controlled trial

BACKGROUND

Despite favorable meta-analyses, no study involving third-generation cephalosporins for the treatment of childhood bacterial meningitis has documented a benefit of adjuvant dexamethasone therapy if the outcomes are examined individually.

METHODS

We conducted a prospective, randomized, double-blind trial comparing adjuvant dexamethasone or glycerol with placebo in children aged from 2 months through 16 years in Latin America. Ceftriaxone was administered to all children; children were randomized to also receive dexamethasone intravenously, glycerol orally, both agents, or neither agent. Primary end points were death, severe neurological sequelae, or deafness, with the first 2 end points forming a composite end point. A subgroup analysis for Haemophilus influenzae type b meningitis was undertaken. Intention-to-treat analysis was performed using binary logistic regression models.

RESULTS

H. influenzae type b, pneumococci, and meningococci were the main agents found among 654 patients; dexamethasone was given to 166, dexamethasone and glycerol were given to 159, glycerol was given to 166, and placebo was given to 163. No adjuvant therapy significantly affected death or deafness. In contrast, glycerol and dexamethasone plus glycerol reduced severe neurological sequelae, compared with placebo; the odds ratios were 0.31 (95% confidence interval [95% CI], 0.13-0.76; P=.010) and 0.39 (95% CI, 0.17-0.93; P=.033), respectively. For neurological sequelae and death, the odds ratios were 0.44 (95% CI, 0.25-0.76; P=.003) and 0.55 (95% CI, 0.32-0.93; P=.027), respectively. Dexamethasone therapy prevented deafness in patients with H. influenzae type b meningitis only if patients were divided grossly into dexamethasone recipients and nonrecipients and if timing between dexamethasone and ceftriaxone administration was not taken into account (odds ratio, 0.27; 95% CI, 0.09-0.77; P=.014).

CONCLUSION

Oral glycerol therapy prevents severe neurological sequelae in patients with childhood meningitis. Safety, availability, low cost, and oral administration also add to its usefulness, especially in resource-limited settings.

Hypotonic versus isotonic saline in hospitalised children: a systematic review

BACKGROUND

The traditional recommendations which suggest that hypotonic intravenous (i.v.) maintenance fluids are the solutions of choice in paediatric patients have not been rigorously tested in clinical trials, and may not be appropriate for all children.

AIMS

To systematically review the evidence from studies evaluating the safety of administering hypotonic versus isotonic i.v. maintenance fluids in hospitalised children.

DATA SOURCES

Medline (1966-2006), Embase (1980-2006), the Cochrane Library, abstract proceedings, personal files, and reference lists. Studies that compared hypotonic to isotonic maintenance solutions in children were selected. Case reports and studies in neonates or patients with a pre-existing history of hyponatraemia were excluded.

RESULTS

Six studies met the selection criteria. A meta-analysis combining these studies showed that hypotonic solutions significantly increased the risk of developing acute hyponatraemia (OR 17.22; 95% CI 8.67 to 34.2), and resulted in greater patient morbidity.

CONCLUSIONS

The current practice of prescribing i.v. maintenance fluids in children is based on limited clinical experimental evidence from poorly and differently designed studies, where bias could possibly raise doubt about the results. They do not provide evidence for optimal fluid and electrolyte homoeostasis in hospitalised children. This systematic review indicates potential harm with hypotonic solutions in children, which can be anticipated and avoided with isotonic solutions. No single fluid rate or composition is ideal for all children. However, isotonic or near-isotonic solutions may be more physiological, and therefore a safer choice in the acute phase of illness and perioperative period.

Fluid therapy for acute bacterial meningitis

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 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.

OBJECTIVES

The objective of this review was to evaluate differing volumes of fluid given in the initial management of bacterial meningitis.

SEARCH STRATEGY

We searched the Cochrane Acute Respiratory Infection Group's trials register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to March 2005), EMBASE (1980 to December 2004), and CINAHL (1982 to February 2005). References from relevant articles were searched and authors contacted where necessary. In addition, we contacted experts in the field for unpublished works.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Six 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 reviewers. 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 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 (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' CONCLUSIONS

There is some evidence to support the use of intravenous maintenance fluids in preference to restricted fluid intake 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.

Hypotonic vs isotonic saline solutions for intravenous fluid management of acute infections

BACKGROUND

Hypotonic saline is commonly used as maintenance fluid in the management of acute infections. In recent years use of a hypotonic saline has been associated with adverse outcomes. To reduce the rates of adverse outcomes, use of isotonic saline as maintenance fluid has been suggested.

OBJECTIVES

To asses adverse events and benefits associated with infusion of hypotonic saline compared to isotonic saline solutions in the management of acute infections.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, The Cochrane Controlled Trials Register, current controlled trials and the Specialised register of the Injuries Group.

SELECTION CRITERIA

Randomised trials comparing hypotonic saline to isotonic saline in the management of acute infections.

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated all potentially relevant articles, examined each study for possible inclusion and assessed the methodology quality using the Cochrane guidelines.

MAIN RESULTS

No trials met our inclusion criteria.

REVIEWERS' CONCLUSIONS

We found no randomised controlled evidence to show that use of isotonic saline as a maintenance fluid instead of a hypotonic saline will lead to an improvement in outcomes. Randomised trials with adequate design and sample sizes are needed to evaluate the possible advantages and risks of using isotonic saline as maintenance fluid.

The management of bacterial meningitis in children

Bacterial meningitis is still a major cause of death and disability in children worldwide. With the advent of conjugate vaccines against the three major pathogens, the burden of disease is increasingly concentrated in developing countries that cannot afford the vaccines. Antibiotic resistance is an increasing problem; in developed countries, high-level resistance to beta-lactams among Streptococcus pneumoniae necessitates the addition of vancomycin to third-generation cephalosporins. In many developing countries, the problems are more fundamental. Increasing resistance of S. pneumoniae to penicillin and chloramphenicol and of Haemophilus influenzae to chloramphenicol means that many children with bacterial meningitis receive ineffective treatments, as third-generation cephalosporins are often unavailable or unaffordable. Case fatality rates are as high as 50% and neurological sequelae occur in one-third of survivors. The use of corticosteroids in meningitis is controversial; the evidence that they protect against neurological complications of childhood meningitis (particularly severe hearing loss) is strongest when: meningitis is caused by H. influenzae type b; dexamethasone is given before the first dose of antibiotics; a bactericidal antibiotic such as a third-generation cephalosporin is used; and in the early stages of the infection. There are few controlled clinical trials on which to base recommendations about other adjuvant therapy for meningitis. Avoidance of secondary brain injury from hypoxia, hypotension, hypo-osmolarity and cerebral oedema, hypoglycaemia or convulsions is essential for a good outcome. The problem of bacterial meningitis will only be solved if protein-conjugate vaccines (or other effective vaccine strategies) against S. pneumonia, H. influenzae and epidemic strains of Neisseria meningitidis are available to all the world's children. Making third-generation cephalosporins affordable in the developing world is also a necessary intervention, but better antibiotics will not overcome the problems of poor access to hospitals and late presentation with established brain injury, and will inevitably bring further pressure for antimicrobial resistance.

Diagnosis and treatment of bacterial meningitis

This review focuses on recent advances of topical interest regarding the diagnosis and treatment of common causes of bacterial meningitis occurring in children beyond the neonatal period. Tuberculous meningitis is beyond the scope of this review.

Bacterial meningitis in children

This review comprises aspects of the epidemiology, microbiology, pathophysiology, clinical manifestations, diagnosis, management, prognosis, and prevention of bacterial meningitis, with emphasis on the paediatric population. The beginning of this millennium has witnessed the virtual disappearance of Haemophilus invasive disease in some countries, emergence of pneumococcal strains that are resistant to multiple antibiotics, isolation of pneumococci with tolerance to vancomycin, outbreaks and clusters of meningococcal meningitis in several geographical areas, and intense research in development of effective conjugate pneumococcal and meningococcal vaccines. Bacterial meningitis has become an uncommon disease in the developed world. Unfortunately, because of limited economic resources and poor living conditions, many developing countries are still affected by the devastating consequences of this life-threatening systemic infection. Basic and clinical research is needed to discover new antimicrobial and anti-inflammatory agents to improve outcome from disease. Novel strategies are needed to distribute and implement effective vaccines worldwide to prevent bacterial meningitis.

Chloramphenicol or ceftriaxone, or both, as treatment for meningitis in developing countries?

AIMS

To determine in children with meningitis whether there is any difference in mortality and neurological sequelae using chloramphenicol as first line treatment, with a change to ceftriaxone if chloramphenicol resistance is shown in vitro, compared to using ceftriaxone as first line treatment, with a change to chloramphenicol if there is no evidence of in vitro resistance.

METHODS

An observational study with a retrospective control group nested within a randomised trial of fluid management for bacterial meningitis where clinical care was standardised. Chloramphenicol is standard treatment for bacterial meningitis in Papua New Guinea. In the first 150 cases we used chloramphenicol and only changed treatment to ceftriaxone if chloramphenicol resistance for cerebrospinal fluid isolates was proved. After finding 20% of Haemophilus influenzae were resistant to chloramphenicol, and that most affected children had poor outcomes, we changed to an alternative strategy. In the next 196 cases first line treatment was ceftriaxone and treatment was changed to chloramphenicol if the isolated bacteria were found to be susceptible.

RESULTS

When chloramphenicol was used as first line treatment for meningitis followed by ceftriaxone when in vitro resistance was shown, there was invariably a very poor outcome in chloramphenicol resistant disease (71% of children died or had severe neurological complications). Using ceftriaxone as first line treatment was effective in reducing mortality and neurological sequelae from chloramphenicol resistant Haemophilus influenzae type (71% v 9%, relative risk 0.13; 95% CI 0.02 to 0.87; p = 0.013). Changing to chloramphenicol if there was no evidence of in vitro resistance was less than half the cost of empirical use of ceftriaxone for a full course for all children with meningitis.

CONCLUSIONS

Using a third generation cephalosporin as first line treatment is effective in dealing with the problem of poor outcomes from meningitis due to Haemophilus influenzae that is resistant to chloramphenicol, and a strategy of changing to chloramphenicol if in vitro susceptibility is shown will reduce the use of expensive third generation cephalosporins without comprising on clinical outcomes. This highlights the urgent need to reduce the costs of third generation cephalosporins, to improve bacteriological services in developing countries, and to introduce effective and affordable vaccines against H influenzae and Streptococcus pneumoniae.