Abstract
We studied occurrence, presentation, disease course, effect of adjunctive dexamethasone, and prognosis of bacterial meningitis in patients using immunosuppressive medication. Patients were selected from our nationwide, prospective cohort on community-acquired bacterial meningitis performed from March 1, 2006 through October 31, 2014. Eighty-seven of 1447 episodes (6 %) of bacterial meningitis occurred in patients using immunosuppressive medication, and consisted of corticosteroids in 82 %. Patients with bacterial meningitis using immunosuppressive medication were less likely to present with headache (P = 0.02) or neck stiffness (P = 0.005), as compared those not on immunosuppressive medication. In 46 % of episodes CSF leukocyte count was below 1000/mm3. CSF cultures revealed S. pneumoniae in 41 % and L. monocytogenes in 40 % of episodes. Outcome was unfavorable in 39 of 87 episodes (45 %) and death occurred in 22 of 87 episodes (25 %). Adjunctive dexamethasone was administered in 52 of 87 (60 %) episodes, and mortality tended to be lower in those on adjunctive dexamethasone therapy as compared to those without dexamethasone therapy (10 of 52 [19 %] vs 12 of 35 [34 %], P = 0.14). We conclude that bacterial meningitis in patients using immunosuppressive medication is likely to present with atypical clinical and laboratory features, and is often caused by atypical bacteria, mainly L. monocytogenes. Adjunctive dexamethasone is widely prescribed in these patients and was not associated with harm in this study.
Highlights
Community-acquired bacterial meningitis is a severe infectious disease with high morbidity and mortality rates (Brouwer et al 2010), and is most commonly caused by Streptococcus pneumoniae
Adjunctive dexamethasone is widely prescribed for patients using immunosuppressive medication who are admitted with bacterial meningitis and is not associated with harm
Guidelines advise the use of a third generation cephalosporin combined with ampicillin or amoxicillin if L. monocytogenes is suspected (Chaudhuri et al 2008; Tunkel et al 2004)
Summary
Community-acquired bacterial meningitis is a severe infectious disease with high morbidity and mortality rates (Brouwer et al 2010), and is most commonly caused by Streptococcus pneumoniae (van de Beek et al 2004b). Acquired immunodeficiency previously has been associated with an increased risk of bacterial meningitis (Adriani et al 2013; van Veen et al 2016; Weisfelt et al 2010). One of the most common acquired conditions causing immunodeficiency is the use of immunosuppressive medication, including corticosteroids. The proposed mechanisms by which corticosteroids cause immunosuppression are decreased production, function and migration of inflammatory cells and decreased antibody production (Fardet et al 2007). The use of immunosuppressive medication has been reported to be an important predisposing factor for infections with Listeria monocytogenes (Yildiz et al 2007). Glucocorticoids can mask the symptoms of infection and delay treatment because patients present at an advanced stage of disease (Fardet et al 2007)
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