Bacterial Meningitis Clinical Findings at Admission Predict Outcome

Abstract

Source: Roine I, Peltola H, Fernández J, et al. Influence of admission findings on death and neurological outcome from childhood bacterial meningitis. Clin Infect Dis. 2008;46(8):1248–1252; doi:10.1086/533448Investigators from South America and Finland previously reported on admission and outcome data from 654 cases of childhood bacterial meningitis in a prospective, randomized, double-blind study.1In the current report they present the results of a post hoc analysis to determine independent predictors of outcome. Of the 654 patients in the study, 86 (13%) died and 556 (98%) of the 568 surviving patients were available for analysis. Degree of neurological deficit was predefined. Severe neurological deficits were identified in 44 (8%) and mild neurological deficits in 102 (18%) patients.Admission data were analyzed for three categories: death, death and severe neurological sequelae, and death and any neurological sequelae. By univariate analysis, young age, convulsions, delay in presentation, Glasgow Coma Score (GCS) below 13, slow capillary-filling time, low CSF glucose and high protein concentrations, low blood leukocyte count, low blood hemoglobin, and pneumococcal etiology were each associated with an increased risk of all three outcome categories. In multiple logistic regression analysis only GCS was an independent predictor for all three outcomes.There was a nine-fold increased risk of death with a GCS of ≤6 compared with a GCS of 13–15 (P=.002). The relationship of lower GCS with death or severe neurological sequelae was even stronger. As compared with a GCS of 13–15, the risk of death or severe neurological sequelae increased 3.51 times with a GCS of 10–12 (95% CI, 1.49–8.25), increased 10.64 times when GCS was 7–9, and increased 28.83 times with a GCS ≤6.For children with GCS of 13–15, risk of death was almost five times higher among those with Streptococcus pneumoniae than those with Haemophilus influenzae type b (Hib) meningitis. However, for those with GCS ≤12 the risk of death was predicted by GCS and not the etiologic agent. The authors conclude that the child’s level of consciousness at the time of hospitalization was the most important predictor of outcome in bacterial meningitis.Dr. Rathore has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.With the introduction of Hib and S. pneumoniae conjugate vaccines for infants, the prevalence of childhood bacterial meningitis has decreased significantly in the US. However, bacterial meningitis still occurs and is one of the most common reasons for litigation when the outcome is poor.2Previous studies have primarily focused on etiology of meningitis and CSF glucose concentration as predictors of outcome. The results of this study indicate that these are important predictors but that etiology was important only when the level of consciousness was close to normal (risk of death was higher in patients with pneumococcus when GCS was 13–15), and low CSF glucose was significant only when milder neurological sequelae were included in the analysis. This finding is of obvious benefit in under-resourced areas of the world where childhood meningitis is common, sophisticated evaluation techniques are lacking, and treatment and intervention decisions have to be made based on rationed availability of resources.In addition, as the authors suggest, one must be careful in reaching conclusions about treatment interventions in childhood bacterial meningitis by combining studies from populations that differ considerably in clinical conditions and available resources. The inherent weaknesses of any post hoc analysis limit the interpretation of the results of this study. Until prospective studies validate its findings, the present study should assist physicians in the US and other developed nations in discussing meningitis outcomes with families.