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Fluid management of bacterial meningitis in developing countries
  1. Trevor Duke
  1. Goroka Base Hospital, PO Box 392, Goroka, Eastern Highlands Province, Papua New Guinea
  1. Dr Duke.

https://doi.org/10.1136/adc.79.2.181

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    Bacterial meningitis causes more than 100 000 deaths worldwide each year in infants and young children. It is predominantly a problem in developing countries, where there is an incidence of between 38 and 110 cases each year per 100 000 of the population aged less than 5 years, and a case fatality of 22–45%.1 2 Severe neurological sequelae occur in up to 50% of survivors. Fluid restriction in the initial management of meningitis in children has been widely advocated,3-5 but has now been challenged.6-8

    This review examines some theoretical and clinical evidence on which decisions about fluid management in bacterial meningitis could be made. There are currently no adequate controlled clinical trials to make definitive recommendations about the volume, composition, or the route of administration of fluids that could be empirically given to children with meningitis.

    Hyponatraemia, fluid volume status, and antidiuretic hormone

    The practice of fluid restriction is based on many reports of hyponatraemia, attributed to increased concentrations of circulating antidiuretic hormone (ADH): the so called “syndrome of inappropriate ADH secretion” (SIADH).9-12 Over 50% of children have hyponatraemia at the time of admission,13 and there are relations between the degree of hyponatraemia and the presence of seizures and severity of acute disease,14 and the degree of hyponatraemia and adverse neurodevelopmental outcomes.15

    Several workers have linked these findings and the high incidence of cerebral oedema in patients who die from acute bacterial meningitis,3 16 17 and have suggested that inappropriately increased concentrations of ADH lead to water retention, which in turn exacerbates cerebral swelling. Some have concluded that fluid restriction will avoid exacerbating cerebral oedema and may improve neurological outcome.18

    The percentage of children with meningitis in whom hyponatraemia can be attributed to “inappropriately” increased concentrations of ADH is uncertain. Estimates range from 7%10 to 88%.15 This discrepancy …

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