Do new strategies in meningococcemia produce better outcomes?

Abstract

Meningococcal septic shock (MSS) has high mortality and morbidity rates. In addition to the traditional prompt antibiotics and respiratory and circulatory support, new treatment strategies have been proposed.

AGAINST THE INFLAMMATORY CASCADE:

Immunotherapy, such as antiserum to Escherichia coli J5 and human antilipid A monoclonal antibodies/centoxin (HA-1A), did not significantly alter the mortality rate of MSS; we are awaiting the results of the bactericidal/permeability-increasing protein multicenter trial. Two series reported the effects of hemofiltration and hemodiafiltration in MSS, but the true benefits remain unknown.

TO TREAT HEMOSTATIC ABNORMALITIES:

In MSS, heparin is still controversial and antithrombin concentrate use has been reported in only one child. Several case reports on protein C and recombinant tissue plasminogen activator have been published; the efficacy (improvement in shock and organ dysfunction and reduction in amputation rate) and safety (intracerebral hemorrhage with recombinant tissue plasminogen activator) of these treatments need further evaluation. Blood and plasma exchange appear to be safe and are supposed to reduce mortality, but it is difficult to draw firm conclusions from published studies. Finally, local application of medicinal leeches has been reported to improve purpuric lesions.

TO INDUCE VASODILATION:

Prostacyclin, or epoprostenol, infusion, sodium nitroprussiate infusion, sympathetic blockade, and topical nitroglycerin have been reported to improve distal perfusion; however, these reports are all anecdotal.

OTHER STRATEGIES:

Improvement in limb perfusion was achieved after hyperbaric oxygenation in patients with purpura fulminans caused by different pathogens. Most authors recommend monitoring of compartment pressures and performing fasciotomy as indicated. Finally, extracorporeal membrane oxygenation was recently proposed to support seven children with intractable MSS.

CONCLUSIONS:

There is no proof that unconventional treatments have a significant impact on outcome in MSS; prospective multicenter trials are needed. At present, early recognition of meningococcal sepsis and appropriate treatment seem to be the optimal methods of improving outcome. Efforts to find an effective meningococcal vaccine must be continued.

• Authors: F Leclerc, S Leteurtre, R Cremer, C Fourier, A Sadik
• Journal: Critical care medicine (Crit Care Med) Vol. 28 Issue 9 Suppl Pg. S60-3 (Sep 2000) ISSN: 0090-3493 [Print] United States
• PMID: 11007200 (Publication Type: Journal Article, Review)

Chemical References

• Vasodilator Agents

Topics

• Bacteremia (therapy)
• Hemofiltration
• Hemostasis (drug effects)
• Humans
• Hyperbaric Oxygenation
• Meningococcal Infections (therapy)
• Vasodilator Agents (therapeutic use)