Bacterial meningitis in infants less 3 months may no longer be commonplace thanks to vaccinations, but when this illness occurs, it can be devastating. Treatment targeted to the right organism is critical, but so is the duration of treatment to ensure complications of lingering infection do not occur or the primary infection itself does not recur. Yet when it comes to determining the right duration of treatment for bacterial meningitis, do we really have an evidence-based approach that will treat sufficiently but not overtreat?
Given the rarity of this disorder, Van Hentenryck from Stanford and colleagues evaluated this question with a systematic review of the peer-reviewed literature (10.1542/peds.2022-057510). The authors identified 32 studies that met study criteria. Of these only 1 was a randomized controlled trial (RCT) and of the cohort studies reviewed, only 1 specifically along with the RCT specifically looked at the relationship between duration of parenteral therapy and outcomes. Both studies found that longer courses of therapy were not associated with improved outcomes. In addition, they were limited in generalizability since patients who got shorter treatments did not experience CSF-culture positive meningitis from briefer treatment. The remaining studies in this systematic review were small, did not stratify by duration of therapy, and had moderate to high risk of bias. The authors conclude that there was insufficient evidence regarding the optimal parenteral treatment duration. They highlight the important need for comparative effectiveness research to resolve this issue.
While this sounds like a reasonable approach, an accompanying commentary by infectious disease expert Dr. Sheldon Kaplan from Texas Children’s Hospital raises feasibility questions even conducting a comparative effectiveness study given the rarity of bacterial meningitis in young children (10.1542/peds.2022-058164). Dr. Kaplan’s commentary begins with a look back at how we got to a range of 10 to 21 days of antibiotics for various bacterial pathogens which is interesting unto itself. Tap into both this study and commentary and you’ll get a great perspective on how weak evidence has led to a range in duration of treatments that probably will result in good outcomes whether we treat for 10 or up to 21 days as long as we stay vigilant in our monitoring for complications of this cerebral infection.