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Algorithm from the British Infection Society represents current standard of care
The treatment of bacterial meningitis represents one of the success stories of modern medicine, particularly antibiotics. In the pre-antibiotic era bacterial meningitis was almost always fatal, but the prompt use of appropriate antibiotics together with supportive care can undoubtedly reduce the morbidity and the mortality of this condition substantially. And yet just 10 years ago a large study of acute bacterial meningitis in adults found a mortality of 25%.1 Why can't we do better than that?
Acute bacterial meningitis tends to present to non-specialist, and often
inexperienced, junior doctors. It is not very common
there
are about 1000 patients in the United Kingdom each yearand so
individual doctors will not see many patients. These are exactly
the circumstances in which a management algorithm can help. The
British Infection Society has recently published such an algorithm
for the initial management of adult patients with presumed bacterial
meningitis,2 and which represents an updated
version of the evidence based recommendations published by the
society four years ago.3 Key to the
success of algorithms such as this one is simplicity. The new
guidelines recommend a third generation cephalosporin such as
cefotaxime or ceftriaxone as the first line of treatment in most
patients, with the addition of ampicillin for older patients (to
cover the possibility of Listeria infection), and vancomycin
with or without rifampicin in case of a serious risk of infection due
to penicillin resistant pneumococci. Importantly, the society
recognises that a good outcome depends on factors other than the
choice of antibiotic alone. Awareness of the early clinical signs,
and prompt attention to oxygen requirements and circulatory support
are rightly stressed.
Algorithms are not intended to cover all circumstances. For example, in some parts of the world pneumococci remain predictably sensitive to penicillin, and this drug can remain a first line agent for presumed pneumococcal meningitis, but we do not know how long this will be true. Patients in special or high risk groups, such as immunocompromised people or small children, present particular problems, and expert advice needs to be sought immediately.
Some will argue with the detail. The authors state that a lumbar puncture should not be done in patients with septicaemic meningococcal disease and take a relatively conservative approach to lumbar puncture and the use of computed tomography scans in general. The evidence base for these assertions is not always clear. It needs to be acknowledged that because of a lack of systematic controlled clinical trials, many of the recommendations of the working party, including those on the use of antibiotics, are based on expert opinion and consensus driven guidelines rather than a secure evidence base. However, in the absence of better evidence most doctors accept that documents such as this generally represent the standard of care for a particular clinical condition. The problem is that despite this guidelines are often not followed. In a revealing study carried out in the Netherlands, van de Beek et al followed up 365 adult patients with bacterial meningitis.4 A year before the study began, a multiprofessional group of Dutch experts drew up guidelines for the empirical treatment of bacterial meningitis. These were agreed at a national consensus conference and were subsequently widely disseminated throughout the country. During their study, van de Beek et al found that only a third of patients received treatment in compliance with the guidelines. In patients over 60 years and those with other risk factors who were arguably at greater risk of a poor outcome if treatment was suboptimal the compliance rate was as low as 17%.
Although de Beek et al could not show any obvious clinical detriment as a
result of failure to comply with the approved regimen there are
important lessons here. Clearly, there are many reasons why the
uptake of such guidelines may be low. These include poor quality
advice (for example, not evidence based or not practical), and poor
dissemination of the information (targeting the wrong group of
doctors, for example). Guidelines for the use of antibiotics are
becoming increasingly popular as a means of improving the quality of
care, but if they are to be effective they need careful considerationnot
just of their content, but of how they are followed up and
implemented.5
An additional but less obvious benefit of the publication of such guidelines
is that they draw attention to changing practice in a rapidly moving
field. At the time of the last leading article in the BMJ
dealing with acute bacterial meningitis, just three years ago,6 the management of penicillin-resistant pneumococcal
infection was unclear and the role of corticosteroids debated.
In the current recommendations from the society a combination of
vancomycin and rifampicin is advised if resistance to penicillin is
considered likely. Notably the use of adjunctive corticosteroids has
changed after the recent publication of the European dexamethasone
meningitis study, which showed a significant reduction in mortality
in patients who were given dexamethasone 10 mg every six hours for
four days and started just before or at the same time as the first
dose of antibiotics.7 However, though bacterial
meningitis is a seemingly tractable infection, in this study the
mortality from pneumococcal meningitis was still 14%, even in the
group treated with steroids. There is still much to do.
Jonathan Cohen
Division of Medicine, Brighton and Sussex Medical School, Brighton BN1 9PH (j.cohen@bsms.ac.uk)
Footnotes
Competing interests: None declared.
| 1. | Durand ML, Calderwood SB, Weber DJ, Miller SI,
Southwick FS, Caviness Jr VS, et al. Acute bacterial meningitis in
adults. A review of 493 episodes. N Engl J Med 1993; 328:
21-28 |
| 2. | British Infection Society. Early management of suspected bacterial meningitis and meningococcal septicaemia in adults. In: London: BIS, 2003. www.britishinfectionsociety.org/meningitis.html. (Accessed 3 Mar 2003.) |
| 3. | Begg N, Cartwright KA, Cohen J, Kaczmarski EB, Innes JA, Leen CL, et al. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. British Infection Society Working Party. J Infect 1999; 39: 1-15[ISI][Medline]. |
| 4. | Van de Beek D, de Gans J, Spanjaard L, Vermeulen M,
Dankert J. Antibiotic guidelines and antibiotic use in adult
bacterial meningitis in the Netherlands. J Antimicrob Chemother
2002; 49: 661-666 |
| 5. | Brown EM. Guidelines for antibiotic usage in
hospitals. J Antimicrob Chemother 2002; 49: 587-592 |
| 6. | Møller K, Skinhøj P. Guidelines for managing acute
bacterial meningitis. BMJ 2000; 320: 1290 |
| 7. | De Gans J, van de BD. Dexamethasone in adults with
bacterial meningitis. N Engl J Med 2002; 347: 1549-1556 |
© 2003 BMJ
Publishing Group Ltd
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