Duration of anti-seizure medicines started for acute symptomatic seizures due to acute meningitis: a systematic review and meta-analysis.

BACKGROUND

Acute symptomatic seizures (ASS), a frequent complication of meningitis, are potentially life-threatening and are a predictor of epilepsy if not managed appropriately. The optimal duration of anti-seizure medicines (ASM) in these patients remains unclear. This systematic review evaluates the evidence for earlier versus later cessation of ASM in patients with meningitis who experience ASS.

METHODS

A comprehensive literature search was conducted across Medline via OVID, Embase via OVID, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov. Eligible studies included randomized controlled trials and cohort studies that compared ASM cessation within 3 months of initiation of treatment to cessation beyond 3 months. Pooled estimates for outcomes including epilepsy development, seizure recurrence, and adverse events were calculated using random-effects meta-analysis. The certainty of evidence was assessed using the GRADE methodology.

RESULTS

Out of 4283 records screened for eligibility, none were found to provide direct evidence in people with meningitis. Two studies on people with encephalitis were included in the meta-analysis as indirect evidence. A randomized controlled trial (RCT) compared 4 weeks versus 12 weeks of ASM in children with acute encephalitis syndrome, while a cohort study investigated ASM duration in adults, including a subset with bacterial meningitis. Both studies found no significant difference in seizure recurrence between earlier and later cessation groups. The pooled risk ratio for seizure recurrence was 1.14 (95% CI, 0.26-5.01). The certainty of the evidence was very low due to indirectness and imprecision. Indirect evidence from other causes of ASS was inconclusive with regard to the duration of ASM.

CONCLUSIONS

The available evidence is inconclusive with regard to the difference between early and late ASM cessation in reducing seizure recurrence. Due to very low certainty of evidence, individualized clinical judgment remains crucial. Further research, specifically targeting bacterial meningitis, is needed to clarify optimal ASM duration in this population.