Fluid therapy for acute bacterial meningitis

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.

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.

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).

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

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.

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).

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.