Early goal directed therapy for adult meningitis in Malawi

Wall, Emma
Early goal directed therapy for adult meningitis in Malawi. PhD thesis, University of Liverpool.

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Introduction: Mortality from acute bacterial meningitis (ABM) in sub-Saharan adults is 50-60%, twice that in well-resourced settings. To date, interventions designed to impact on outcome have been ineffective in this setting. This thesis addressed the hypothesis that high mortality is due in part to delayed or inappropriate care, and that this may be improved by goal directed resuscitation. Methods: Clinical and laboratory surveillance data from a large central hospital in Malawi were analysed. Clinical predictors of poor outcome were synthesised into the Malawi Adult Meningitis Score (MAMS). To assess feasibility and outcome, patients with suspected ABM were recruited in the emergency department and observed in year one under routine clinical care (Phase 1), and then managed with a meningitis-specific EGDT clinical care bundle in year two (Phase 2). Laboratory data were tested for outcome associations. Results: A significant decline in the total number of CSF isolates over 12 years was noted, entirely in children under 5 years of age coinciding with Hib vaccination. Adult meningitis incidence remained unchanged, despite significant ART provision. Analysis of 715 historical meningitis episodes showed that the mortality rate was 54% at day 40; HIV seroprevalence was 87% and treatment delays were marked. Coma, seizures, tachycardia and anaemia but not HIV were significantly associated with mortality. The MAMS predicted outcome with good agreement, estimated sensitivity was 74%, specificity was 55%. EGDT was found to be feasible, more clinical targets were met using EGDT including reduced time to antibiotics, iv fluids, blood transfusion and airway placement. There was no significant difference in outcome at 40 days between the two cohorts. Neither high pneumococcal load nor the presence of EBV co-infection in the CSF were associated with poor outcome. CSF white cell counts were lower in non-survivors, other markers of inflammation were not associated with outcome. Conclusion: The incidence of bacterial meningitis is not falling in adults in Malawi. Important clinical predictors were identified and synthesised into a prediction tool. EGDT for meningitis is feasible in adult patients in Malawi; a larger trial is required to test the impact on outcome. Further work to improve pre-hospital care and identify novel adjunctive treatments is necessary.

Item Type: Thesis (PhD)
Additional Information: Date: 2014-08 (completed)
Depositing User: Symplectic Admin
Date Deposited: 09 Sep 2015 14:51
Last Modified: 17 Dec 2022 01:34
DOI: 10.17638/02005919
URI: https://livrepository.liverpool.ac.uk/id/eprint/2005919