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Cochrane Database of Systematic Reviews

Fluid therapy for acute bacterial meningitis

Information

DOI:
https://doi.org/10.1002/14651858.CD004786.pub5Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 04 November 2016see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Acute Respiratory Infections Group

Copyright:
  1. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Ian K Maconochie

    Correspondence to: Department of Paediatrics A&E, St Mary's Hospital, London, UK

    [email protected]

  • Soumyadeep Bhaumik

    Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK

Contributions of authors

Ian Maconochie (IM) jointly (with Richmal Oates‐Whitehead (ROW)) conceptualised the review, commented on drafts of the protocol, was involved in selecting trials for inclusion in the review, performed independent data extraction and quality assessment of the included trials.

Soumyadeep Bhaumik (SB) led this 2016 update and was part of the 2014 update. For both updates he performed independent selection of trials for inclusion in the review, worked on the manuscript of the review. Both authors used the GRADE approach to interpret the findings of the study and commented on the drafts of the review.

Sources of support

Internal sources

  • Liverpool School of Tropical Medicine, UK.

  • Royal College of Paediatrics and Child Health, UK.

External sources

  • No sources of support supplied

Declarations of interest

Ian Maconochie ‐ no known conflicts of interest to declare.
Soumyadeep Bhaumik ‐ no known conflicts of interest to declare.

Acknowledgements

The review authors would like to acknowledge the major contribution of the late Richmal Oates‐Whitehead. She was the person who turned the idea of this review into a reality by doing much of the work for the first published version (Oates‐Whitehead 2005). Richmal died suddenly and was not therefore able to contribute to this version. She jointly (with IM) conceptualised the review, took the lead in writing the protocol and overall review, performed initial searches of databases for trials, was involved in selecting trials for inclusion, and performed independent data extraction and quality assessment of the included trials. The late Richmal is not included as an author on this update although she was the original contact reviewer in the first published version in 2005. Richmal died after the publication of that version.

Morwenna Stewart (MS) was an author on the original review and the 2008 update. Morwenna performed independent data extraction and quality assessment of the included trials, and commented on all drafts of the review.

Harry Baumer (HB) commented on drafts of the protocol and was involved in selecting trials for inclusion in the review; performed independent data extraction and quality assessment of the included trials; and commented on all drafts of the review. HB led the previous update.

The review authors would like to thank Dr Keith Powell and Dr Sunit Singhi for taking time to reply to requests for further information on their respective studies; Liz Dooley, Managing Editor of the Cochrane Acute Respiratory Infections (ARI) Group, Carol Wical, Ruth Foxlee and Sarah Thorning, former members of the ARI Group editorial team, for their help and support. Finally, we would like to thank the following people for commenting on drafts of this review: Hayley Edmonds, Robert Heyderman, Sree Nair, George Swingler and Diederik van de Beek.

Version history

Published

Title

Stage

Authors

Version

2016 Nov 04

Fluid therapy for acute bacterial meningitis

Review

Ian K Maconochie, Soumyadeep Bhaumik

https://doi.org/10.1002/14651858.CD004786.pub5

2014 May 05

Fluid therapy for acute bacterial meningitis

Review

Ian K Maconochie, Soumyadeep Bhaumik

https://doi.org/10.1002/14651858.CD004786.pub4

2008 Jan 23

Fluid therapy for acute bacterial meningitis

Review

Ian K Maconochie, J Harry Baumer

https://doi.org/10.1002/14651858.CD004786.pub3

2005 Jul 20

Fluid therapy for acute bacterial meningitis

Review

Richmal M Oates‐Whitehead, Ian K Maconochie, Harry Baumer, Morwenna Stewart

https://doi.org/10.1002/14651858.CD004786.pub2

2004 Apr 19

Fluid therapy for acute bacterial meningitis

Protocol

Richmal Marie Oates‐Whitehead, Ian K Maconochie, J H Baumer, Morwenna Stewart, Harry Baumer

https://doi.org/10.1002/14651858.CD004786

Differences between protocol and review

There were insufficient data to explore any of the subgroup analyses, with the exception of hypoperfusion at entry. One study subgrouped each participant group into those with hyponatraemia and those without hyponatraemia at enrolment (Singhi 1995). Therefore, we could only perform a subgroup analysis on this trial.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 1 Death.
Figures and Tables -
Analysis 1.1

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 1 Death.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 2 Severe neurological sequelae.
Figures and Tables -
Analysis 1.2

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 2 Severe neurological sequelae.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 3 Mild to moderate neurological sequelae.
Figures and Tables -
Analysis 1.3

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 3 Mild to moderate neurological sequelae.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 4 Hemiparesis/hemiplegia.
Figures and Tables -
Analysis 1.4

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 4 Hemiparesis/hemiplegia.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 5 Spasticity.
Figures and Tables -
Analysis 1.5

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 5 Spasticity.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 6 Seizures.
Figures and Tables -
Analysis 1.6

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 6 Seizures.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 7 Visual impairment.
Figures and Tables -
Analysis 1.7

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 7 Visual impairment.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 8 No response to sound.
Figures and Tables -
Analysis 1.8

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 8 No response to sound.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 9 Oedema.
Figures and Tables -
Analysis 1.9

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 9 Oedema.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 10 Total body water ‐ fall after 48 hours.
Figures and Tables -
Analysis 1.10

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 10 Total body water ‐ fall after 48 hours.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 11 Extracellular water ‐ fall after 48 hours.
Figures and Tables -
Analysis 1.11

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 11 Extracellular water ‐ fall after 48 hours.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 12 Serum sodium.
Figures and Tables -
Analysis 1.12

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 12 Serum sodium.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 13 Urinary sodium.
Figures and Tables -
Analysis 1.13

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 13 Urinary sodium.

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 14 Plasma osmolality ‐ change after 48 hours.
Figures and Tables -
Analysis 1.14

Comparison 1 Maintenance fluids versus restricted fluids, Outcome 14 Plasma osmolality ‐ change after 48 hours.

Summary of findings for the main comparison. Maintenance fluids versus restricted fluids for acute bacterial meningitis

Maintenance fluids versus restricted fluids for acute bacterial meningitis

Patient or population: paediatric patients with acute bacterial meningitis

Settings: hospital inpatient department

Intervention: maintenance fluids

Comparison: restricted fluids

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Restricted fluids

Maintenance fluids

Death ‐ all participants

Study population

RR 0.82

(0.53 to 1.27)

407
(2 studies)

⊕⊕⊝⊝
low1,2

186 per 1000

153 per 1000

(99 to 237)

Moderate risk population

213 per 1000

175 per 1000

(113 to 271)

Severe neurological sequelae ‐ acute (within the first 4 weeks)

Study population

RR 0.67
(0.41 to 1.08)

407
(2 studies)

⊕⊕⊝⊝
low1,2

176 per 1000

118 per 1000

(72 to 191)

Moderate risk population

252 per 1000

169 per 1000

(103 to 272)

Severe neurological sequelae ‐ chronic (after the first 4 weeks)

Study population

RR 0.42
(0.20 to 0.89)

351
(1 study)

⊕⊝⊝⊝
very low3,4

121 per 1000

51 per 1000

(24 to 108)

Moderate risk population

121 per 1000

51 per 1000

(24 to 108)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Total number of events is small and 95% CI around pooled estimate includes both appreciable benefit and harms.
2Duke 2002 and Singhi 1995 both were deemed to have high risk of bias for blinding. However, this would not have any effect on outcome assessment for the outcome of death and acute severe neurological sequelae. Singhi 1995 was deemed at high risk for reporting bias but we did not downgrade for risk of bias because sensitivity analyses did not change effect estimates significantly.
3Duke 2002 ‐ high risk of bias due to improper blinding would affect outcome assessment for chronic severe neurological sequelae.
4 Total number of events is not large enough for precision.

Figures and Tables -
Summary of findings for the main comparison. Maintenance fluids versus restricted fluids for acute bacterial meningitis
Comparison 1. Maintenance fluids versus restricted fluids

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 All participants

2

407

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.53, 1.27]

1.2 Participants with hyponatraemia

1

26

Risk Ratio (M‐H, Fixed, 95% CI)

0.15 [0.01, 2.50]

1.3 Participants without hyponatraemia

1

24

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.16, 3.90]

2 Severe neurological sequelae Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Acute (within the first 4 weeks)

2

407

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.41, 1.08]

2.2 Chronic (after the first 4 weeks)

1

351

Risk Ratio (M‐H, Fixed, 95% CI)

0.42 [0.20, 0.89]

2.3 Participants without hyponatraemia

1

24

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.13, 2.64]

2.4 Participants with hyponatraemia

1

26

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.34, 2.47]

3 Mild to moderate neurological sequelae Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Hemiparesis/hemiplegia Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5 Spasticity Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6 Seizures Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.1 Within the first 72 hours

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

6.2 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

7 Visual impairment Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

7.1 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

8 No response to sound Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

8.1 At 14 days

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9 Oedema Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

9.1 Acute facial oedema

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.2 Acute pulmonary oedema

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

9.3 Acute hydrocephalus

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10 Total body water ‐ fall after 48 hours Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

10.1 Participants without hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

10.2 Participants with hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

11 Extracellular water ‐ fall after 48 hours Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

11.1 Participants without hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

11.2 Participants with hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

12 Serum sodium Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

12.1 All participants (24 hours)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.2 Participants with hyponatraemia (48 hours)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.3 Participants without hyponatraemia (48 hours)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.4 Change from baseline at 48 hours ‐ without hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

12.5 Change from baseline at 48 hours ‐ with hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

13 Urinary sodium Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

13.1 Participants without hyponatraemia (48 hours)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.2 Participants with hyponatraemia (48 hours)

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.3 Change from baseline at 48 hours ‐ without hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

13.4 Change from baseline at 48 hours ‐ with hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

14 Plasma osmolality ‐ change after 48 hours Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

14.1 Participants without hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.2 Participants with hyponatraemia

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Maintenance fluids versus restricted fluids