Systemic meningococcal infection: which children may benefit from adjuvant haemostatic therapy? Results from an observational study.

UNLABELLED

The potential benefits of haemostatic therapy (heparin, antithrombin (AT) concentrate, fresh frozen plasma (FFP)) in severe systemic meningococcal infections (SMI) are controversial. A reduction of the still high case fatality rate would be an important indicator for potential benefits of adjuvant haemostatic therapy in children with SMI. Observational data from nationwide, active surveillance for SMI in children under 16 years in all German paediatric hospitals over a one-year period were used to assess whether potentially beneficial effects of haemostatic therapy are related to the severity of disease. The Neisseria sepsis index (NESI), which grades the severity of SMI from 0 to 8 and has proven to be a reliable tool for predicting the outcome of children with SMI, was used as an indicator of the severity of SMI. During the study period from July 1994 to June 1995, 305 children met the case definition; for 176 of these, complete data sets providing information on parameters underlying the NESI index and regarding the specific haemostatic therapy were available. As all recorded children with NESI 0-2 (n = 129; 73%) survived, a potential impact of haemostatic therapy (given to 45 of them) on survival would be undetectable in this group. A NESI between 3 and 8 was found in 47/176 patients (24%), 35 of whom received some kind of haemostatic therapy. The survival rates were 80% in children with haemostatic therapy (n = 35) and 50% in those without (n = 12) (odds ratio 0.25; 95% confidence interval 0.06-0.98). A subgroup analysis of patients with NESI 3-5 versus those with NESI scores above 5 showed that the beneficial effect of haemostatic therapy was almost confined to children in the NESI 3-5 subgroup. In this subgroup there were 28/31 (90%) survivors with, and 6/11 (55%) survivors without adjuvant haemostatic therapy, whereas none of the patients (n = 5) with a NESI of 6-8 survived, although 4 had received adjuvant haemostatic therapy.

CONCLUSION

Studies on the impact of adjuvant haemostatic therapy on survival in children with SMI should focus on those with NESI scores 3-5. The data from this population-based, observational study suggests that haemostatic therapy might reduce the case fatality rate in these children. The optimal dosage and choice of preparations remains to be established. Alternative adjuvant therapeutic strategies may be required in children with SMI and NESI scores > 5.