Early Goal Directed Therapy for Acute Bacterial Meningitis in Malawian Adults
Acute bacterial meningitis (ABM) in sub-Saharan African adults occurs in young, HIV co-infected people, is predominately caused by S. pneumoniae, and mortality exceeds 50%. We tested if nurse-led Early Goal Directed Therapy (EGDT) was feasible for ABM in a resource-limited hospital in Malawi.
We prospectively recruited patients with suspected ABM in the emergency department of a Malawian referral hospital in a before/after design. EGDT was adapted from surviving sepsis guidelines, targets were set using outcome predictors from historical meningitis data. Routine care for suspected ABM was monitored in year one (Phase 1), study nurses delivered EGDT in year two (Phase 2). Protocolised care included rapid antibiotics, airway support, oxygenation, seizure control and fluid resuscitation for shock. Primary endpoints were proportions of clinical targets achieved, the secondary endpoint was outcome measured as death or disability (modified Rankin Score of =>2) at 40 days. ISRCTN96218197.
273 adults with suspected ABM were monitored in Phase 1 (P1), 71 with ABM were followed to day 40. 290 patients received EGDT in Phase 2 (P2), 61 had confirmed ABM. 61% were male, median age was 33 years, 75% were HIV co-infected.
In the feasibility comparison of EGDT, significantly more clinical targets were met in cases of proven ABM in P2 compared to P1. Of patients requiring one target, 81% achieved that target in P1, compared to 112% in P2. 36% achieved two targets in P1 compared to 110% in P2, 0% achieved three targets in P1 compared to 91% in P2, and 0% achieved four targets in P1 compared to 12.5% in P2. The overall composite mean target difference between P1 and P2 was highly significant p<0.001
EGDT substantially reduced time to antibiotics (1hr 55 mins in P1 v 1hr 13 mins in P2 p<0.001), IV fluids and blood were more frequently given to shocked patients; airway placement in coma was more likely. No significant difference was seen in outcome at 40 days; death or disability occurred in 29/57 (51%) in P1 and 38/60 (63%) in P2 p=0.19.
Nurse led EGDT was feasible for adults with ABM in Malawi and led to important improvements in clinical care delivery. Mortality remains high and testing EGDT for ABM in a large randomised trial is now required.
V. Mlozowa, None
M. Msukwa, None
M. Mukaka, None
T. Allain, None
M. Nyirenda, None
B. Faragher, None
R. Heyderman, None
D. Lalloo, None