Do new strategies in meningococcemia produce better outcomes?

Meningococcal septic shock (MSS) has high mortality and morbidity rates. In addition to the traditional prompt antibiotics and respiratory and circula tory support, new treatment strategies have been proposed. Against the inflammatory Cascade: Immunotherapy, such as antiserum to Esche richia coli J5 and human antilipid A monoclonal antibodies/centoxin (HA-1A) , did not significantly alter the mortality rate of MSS; we are awaiting th e results of the bactericidal/permeability-increasing protein multicenter t rial. Two series reported the effects of hemofiltration and hemodiafiltrati on in MSS, but the true benefits remain unknown. To Treat Hemostatic Abnormalities: In MSS, heparin is still controversial a nd antithrombin concentrate use has been reported in only one child. Severa l case reports on protein C and recombinant tissue plasminogen activator ha ve been published; the efficacy (improvement in shock and organ dysfunction and reduction in amputation rate) and safety (intracerebral hemorrhage wit h recombinant tissue plasminogen activator) of these treatments need furthe r evaluation. Blood and plasma exchange appear to be safe and are supposed to reduce mortality, but it is difficult to draw firm conclusions from publ ished studies. Finally, local application of medicinal leeches has been rep orted to improve purpuric lesions. To Induce Vasodilation: Prostacyclin, or epoprostenol, infusion, sodium nit roprussiate infusion, sympathetic blockade, and topical nitroglycerin have been reported to improve distal perfusion; however, these reports are all a necdotal. Other Strategies: Improvement in limb perfusion was achieved after hyperbar ic oxygenation in patients with purpura fulminans caused by different patho gens. Most authors recommend monitoring of compartment pressures and perfor ming 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 signif icant impact on outcome in MSS; prospective multicenter trials are needed. At present, early recognition of meningococcal sepsis and appropriate treat ment seem to be tbe optimal methods of improving outcome. Efforts to find a n effective meningococcal vaccine must be continued.