Terapi cecair untuk meningitis bakteria akut
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. 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.
PICO
Plain language summary
Cecair untuk orang yang menghidap meningitis bakteria akut
Soalan ulasan
Mengapakah kesan pemberian pelbagai isipadu cecair awal ke atas kematian dan akibat‐akibat neurologi dalam kalangan orang yang menghidap meningitis bakteria akut penting?
Latarbelakang
Meningitis bakteria adalah infeksi cecair dalam kord spina dan keliling otak. Antibiotik diberikan sebagai rawatan. Penjagaan sokongan melibatkan ubatan lain dan kawalan pengambilan cecair. Terdapat percanggahan samada cecair perlu dihadkan atau tidak dihadkan memandangkan potensi risiko pemberian terlalu banyak cecair (otak bengkak) dan juga terlalu sedikit cecair (renjatan).
Ciri kajian
Bukti adalah terkini sehingga Mac 2016. Kami tidak menjumpai sebarang kajian dalam populasi dewasa dan memasukkan tiga kajian melibatkan 420 kanak‐kanak. Kesemua kajian dijalankan di negara‐negara di mana kadar kematian akibat meningitis adalah tinggi. Dalam satu kajian, sumber dana tidak dinyatakan. Dua kajian selebihnya dibiaya bersama oleh farmaseutikal berkaitan dengan agensi kerajaan dan agensi amal.
Keputusan‐keputusan utama
Tiada kajian yang melaporkan hasil penjagaan kesihatan misalnya tempoh tinggal di hospital, kenaikan tekanan intrakranial, atau status epileptikus. Satu kesan buruk dalam kalangan kanak‐kanak yang mempunyai pengambilan cecair terhad adalah kemungkinan aras natrium dalam darah yang rendah dan oleh itu mengalami lebih pengurangan cecair badan. Kesan buruk pemberian cecair tidak terhad dilaporkan dalam satu kajian sebagai bengkak muka untuk jangkamasa pendek dan aras natrium dalam darah yang rendah satu hingga dua hari selepas cecair diberikan, walaupun kajian terbesar tidak menjumpai perbezaan aras‐aras natrium darah.
Ulasan ini mendapati bukti terbatas daripada kajian‐kajian tersebut untuk menyokong pemberian cecair yang tidak terhad dalam persekitaran yang mempunyai kadar mortaliti tinggi. Tidak terdapat sebarang bukti bagi membantu klinisian mengenai terapi cecair dalam kalangan pesakit dewasa dengan meningitis bakteria akut. Kajian lanjutan diperlukan berkenaan aspek ini di masa hadapan
.Kualiti bukti
Analisis kajian sedia ada mendapati bukti berkualiti rendah berkenaan perbezaan tidak ketara di antara rejimen pengekalan berbanding rejimen cecair terhad untuk hasil kematian dan komplikasi‐komplikasi neurologi akut yang teruk. Terdapat juga sedikit bukti yang menyokong terapi cecair pengekalan berbanding cecair terhad untuk komplikasi neurologikal teruk yang kronik pada tiga bulan susulan, tetapi kualiti bukti adalah rendah.
