Neuro-Intensive Treatment Targeting Intracranial Hypertension Improves Outcome in Severe Bacterial Meningitis: An Intervention-Control Study

TLDR

The study aimed to assess whether early intracranial pressure–targeted therapy improves outcomes compared with standard intensive care in adults with community‑acquired acute bacterial meningitis and severe impaired consciousness. In a prospective intervention‑control comparison from 2004–2012, 52 adults received ICP‑targeted treatment—primarily cerebrospinal fluid drainage, osmotherapy, hyperventilation, cooling, steroids, and barbiturate sedation—to maintain ICP < 20 mmHg and CPP > 50 mmHg, while 53 controls received conventional ICU care. ICP‑targeted therapy reduced two‑month mortality from 30 % to 10 % (RR = 0.32) and increased full recovery at 2–6 months from 32 % to 54 % (RR = 1.69).

Abstract

Objective To evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness. Design A prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012. Patients Included patients were confirmed ABM-cases, aged 16–75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg. Measurements The primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2–6 months. Outcomes The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05). Conclusions Early neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.