Detection and Management of Elevated Intracranial Pressure in the Treatment of Acute Community-Acquired Bacterial Meningitis: A Systematic Review

Abstract

Acute bacterial meningitis (ABM) is associated with severe morbidity and mortality. The most prevalent pathogens in community-acquired ABM are Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Other pathogens may affect specific patient groups, such as newborns, older patients, or immunocompromised patients. It is well established that ABM is associated with elevated intracranial pressure (ICP). However, the role of ICP monitoring and management in the treatment of ABM has been poorly described.An electronic search was performed in four electronic databases: PubMed, Web of Science, Embase, and the Cochrane Library. The search strategy chosen for this review used the following terms: Intracranial Pressure AND (management OR monitoring) AND bacterial meningitis. The search yielded a total of 403 studies, of which 18 were selected for inclusion. Eighteen studies were finally included in this review. Only one study was a randomized controlled trial. All studies employed invasive ICP monitoring techniques, whereas some also relied on assessment of ICP-based on clinical and/or radiological observations. The most commonly used invasive tools were external ventricular drains, which were used both to monitor and treat elevated ICP. Results from the included studies revealed a clear association between elevated ICP and mortality, and possibly improved outcomes when invasive ICP monitoring and management were used. Finally, the review highlights the absence of clear standardized protocols for the monitoring and management of ICP in patients with ABM. This review provides an insight into the role of invasive ICP monitoring and ICP-based management in the treatment of ABM. Despite weak evidence certainty, the present literature points toward enhanced patient outcomes in ABM with the use of treatment strategies aiming to normalize ICP using continuous invasive monitoring and cerebrospinal fluid diversion techniques. Continued research is needed to define when and how to employ these strategies to best improve outcomes in ABM.

Keywords: Acute bacterial meningitis; External ventricular drain; Intracranial hypertension management; Intracranial pressure monitoring; Outcomes.

Fig. 1

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers, and other sources. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Fig. 2

Logarithmic-scale histogram showing the sample size and number of patients treated with invasive monitoring in each of the included studies. ICP, intracranial pressure

Fig. 3

Suggested management of patients with suspicion of ABM based on available guidelines, with the addition of indications for invasive ICP monitoring and ICP-targeted therapy (based on low certainty evidence). ABM, acute bacterial meningitis, CT, computed tomography, EVD, external ventricular drain, GCS, Glasgow Coma Scale, ICP, intracranial pressure, ICU, intensive care unit, LP, lumbar puncture