Acute Bacterial Meningitis In Adults Research Articles

Clinical characteristics and outcomes of acute bacterial meningitis in adults at a tertiary university hospital in Thailand.

The epidemiology of acute bacterial meningitis varies among settings, areas, and times. This study aimed to determine the clinical characteristics, the causative organisms and their antibiotic susceptibility, and the outcomes of patients with acute bacterial meningitis in Thai adults. This retrospective study included hospitalized patients aged ≥18 years diagnosed with acute bacterial meningitis at Siriraj Hospital during January 2002-December 2016. Of 390 patients, the median age was 48 years, 51% were male, and 80% had at least 1 underlying illness. Over half (54%) of patients had community-acquired bacterial meningitis (CBM), and 46% had nosocomial bacterial meningitis (NBM). The triad of acute bacterial meningitis (fever, headache, and neck stiffness) was found in 46% of CBM and 15% of NBM (P < .001). The causative organisms were identified in about half (53%) of patients. Most study patients (73%) received antibiotic treatment before the CSF collection. Causative organisms were identified more frequently in CBM (P < .001). Gram-positive cocci were more prevalent in CBM (P < .001), whereas Gram-negative bacilli were more common in NBM (P < .001). Streptococcus agalactiae (29%), Streptococcus pneumoniae (12%), and Streptococcus suis (11%) were most common in CBM, and all of them were sensitive to third-generation cephalosporins. Acinetobacter baumannii (19%), Klebsiella pneumoniae (16%), and Staphylococcus aureus (11%) were the most common organisms in NBM, and antibiotic-resistant isolates were frequently found among these organisms. Ceftriaxone monotherapy and meropenem plus vancomycin were the most common empiric antibiotic in CBM and NBM, respectively. Mortality was 19% among CBM and 23% among NBM (P = .338). HIV infection, alcoholism, pneumonia, shock, and disseminated intravascular coagulation were independent predictors of mortality. Mortality remains high among adults with acute bacterial meningitis in Thailand. A clinical practice guideline for acute bacterial meningitis should be developed that is based on local epidemiology and microbiology data.

German guidelines on community-acquired acute bacterial meningitis in adults

IntroductionThe incidence of community-acquired acute bacterial meningitis has decreased during the last decades. However, outcome remains poor with a significant proportion of patients not surviving and up to 50% of survivors suffering from long-term sequelae. These guidelines were developed by the Deutsche Gesellschaft für Neurologie (DGN) under guidance of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) to guide physicians through diagnostics and treatment of adult patients with acute bacterial meningitis.RecommendationsThe most important recommendations are: (i) In patients with suspected acute bacterial meningitis, we recommend that lumbar cerebrospinal fluid (with simultaneous collection of serum to determine the cerebrospinal fluid-serum glucose index and blood cultures) is obtained immediately after the clinical examination (in the absence of severely impaired consciousness, focal neurological deficits, and/or new epileptic seizures). (ii) Next, we recommend application of dexamethasone and empiric antibiotics intravenously. (iii) The recommended initial empiric antibiotic regimen consists of ampicillin and a group 3a cephalosporin (e.g., ceftriaxone). (iv) In patients with severely impaired consciousness, new onset focal neurological deficits (e.g. hemiparesis) and/or patients with newly occurring epileptic seizures, we recommend that dexamethasone and antibiotics are started immediately after the collection of blood; we further recommend that —if the imaging findings do not indicate otherwise —a lumbar CSF sample is taken directly after imaging. (v) Due to the frequent occurrence of intracranial and systemic complications, we suggest that patients with acute bacterial meningitis are treated at an intensive care unit in the initial phase of the disease. In the case of impaired consciousness, we suggest that this is done at an intensive care unit with experience in the treatment of patients with severe CNS diseases.ConclusionsThe German S2k-guidelines give up to date recommendations for workup, diagnostics and treatment in adult patients with acute bacterial meningitis.

Addition of daptomycin for the treatment of pneumococcal meningitis: protocol for the AddaMAP study

BackgroundThe leading cause of acute bacterial meningitis in adults is Streptococcus pneumoniae. This infection is associated with high rates of mortality and morbidity related, among other factors, to the excessive...

Penicillin-Susceptible Streptococcus pneumoniae Meningitis in Adults: Does the Ceftriaxone Dosing Matter?

The recommended empiric ceftriaxone dosing regimen for acute bacterial meningitis in adults is 2 g every 12 h. After penicillin-susceptible Streptococcus pneumoniae is isolated as a causative microorganism, the ceftriaxone dose may be continued or reduced to a single dose of 2 g every 24 h, per institutional preference. There is no clear guidance that indicates the superiority of one regimen over the other. The objective of this study was to evaluate the susceptibility of S. pneumoniae in the cerebral spinal fluid (CSF) of patients with meningitis and the relationship between ceftriaxone dose and clinical outcomes. We identified 52 patients with S. pneumoniae meningitis with positive CSF cultures who were treated at the University Hospital, Bern, Switzerland, over a 19-year period. We collected clinical and microbiological data for evaluation. Broth microdilution and Etest methods were performed to test penicillin and ceftriaxone susceptibility. All isolates were susceptible to ceftriaxone. Ceftriaxone was empirically used in 50 patients, with a starting dosing regimen of 2 g every 24 h in 15 patients and 2 g every 12 h in 35 patients. In 32 patients started on a twice-daily regimen (91%), doses were reduced to once daily after a median of 1.5 (95% CI 1-2) days. The overall in-hospital mortality was 15.4% (n = 8), and 45.7% of patients reported at least one sequela of meningitis at the last follow-up (median 375, 95% CI 189-1585 days). We found no statistical difference in outcome between the 2 g every 24 h and the 2 g every 12 h ceftriaxone dosing regimens. A ceftriaxone total daily dose of 2 g may be associated with similar outcomes to a 4 g total daily dose, provided that the causative organism is highly susceptible to ceftriaxone. The persistence of neurological and infection sequelae at the last follow-up underscores the need for optimal treatment of these complex infections.

Accuracy of Meningitis Bacterial Score (MBS) as an indicator in establishing the diagnosis of acute bacterial meningitis in adults.

Bacterial meningitis persists as a worldwide threat contributing to high mortality and morbidity rate, where differentiating bacterial meningitis from aseptic meningitis is key for better management and outcomes. Hence, this study aimed to assess the Bacterial Meningeal Score (BMS) as a tool for early diagnosis of acute bacterial meningitis. This study employed a retrospective cross-sectional method using medical records of patients with meningitis and meningoencephalitis who were hospitalized at Dr. Soetomo Hospital, from January 2018 to September 2021. Data of demographics, clinical, laboratory and cerebrospinal fluid (CSF) profile and culture were collected. The diagnostic performance of the BMS in diagnosing acute bacterial meningitis was evaluated by its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR +) and negative likelihood ratio (LR -). A total of 128 patients who had been diagnosed with meningitis and meningoencephalitis were included. Out of total patients, 53 samples were diagnosed with acute bacterial meningitis as confirmed by CSF culture. The sensitivity and specificity of BMS with cutoff >2.5 in diagnosing acute bacterial meningitis were 92.4% and 92.0%, respectively with PPV 89.1% and NPV 94.5%. The area under the curve (AUC) of BMS in diagnosing of acute bacterial meningitis was 95.6% (95%CI: 92.3%, 99%). A BMS score of greater than 2.5 indicates a high likelihood of acute bacterial meningitis, whereas a score less than 2.5 indicates a low likelihood.

Meropenem Monotherapy is a Valid Alternative in Community Acquired Adult Acute Bacterial Meningitis (ABM)

Background: Meropenem (Merrem®, Meropenem®) is a broad-spectrum antibacterial carbapenem with indication for Acute Bacterial Meningitis (ABM). We wanted to specifically evaluate the effect of meropenem monotherapy, compared to standard recommended therapy. Method: A Swedish ongoing internet based quality register for ABM was started 1994 and covers the whole country with roughly 30 infectious disease clinics. After ethical approval data were extracted from the database and evaluated using conventional statistical methods (IBM SPSS Statistics 23). Results: The register contained 1708 patients altogether. All 770 patients (45%) given meropenem or cefotaxime/ampicillin were selected for this study. The age of the studied population was from 18-91 with a mean of 55 and median 60. Overall ABM mortality was 12.1% (197/1708). In the meropenem and cefotaxime/ampicillin subgroup 7.8% (60/770) died, p=0,035 and in the non-selected group 14,6 % (137/938), p&lt;0.001. For meningococci the mortality was only 2% and for pneumococci 9% (p=0,025) and are record low figures in this selected population. The mortality increased 1.3 times (Odd’s ratio 1.3, p&lt;0.001) with each decade of life and 1.5 times with each RLS stratification level (Odd’s ratio 1.5, p&lt;0.001). Conclusion: There was no statistical significance in mortality (p=0.67) or sequelae rate between meropenem and cefotaxime/ampicillin treatment. Favourable outcome depends on speedy and correct antibiotic therapy as well as inclusion of betamethasone. Age, RLS and bacterial species, are factors, which cannot be influenced. Meropenem is a valid antibiotic choice in the Swedish population (with limited resistance problems).

Evaluation of IL-8 level in cerebrospinal fluid in acute bacterial meningitis in adults

Background: Interleukin 8 increases in various types of meningitis, specifically acute bacterial meningitis inflammation, and it is important in the distinction between types of meningitis. The present paper aims at evaluation of the level of interleukin 8 in cerebrospinal fluid in acute adult bacterial meningitis. Methods: All adult patients’ with diagnosis of suspected meningitis with symptoms of fever, headache, neck stiffness, and consciousness disorder. Lumbar puncture was taken in between the third and fourth vertebra by a specialist physician for all patients suspected with meningitis. To determine the level of consciousness, the GCS of the patients was determined and the cerebrospinal fluid was cultured and sent to the laboratory for the analyses of cell count, diffraction, CSF fluid glucose, CSF fluid protein, LDH, or lactate dehydrogenase, and the level of interleukin 8. Results: The mean of IL-8 protein was 296.17±48.57Pg/ml in patients with aseptic meningitis and 1088.96±526.55Pg/ml in the group of patients with septic meningitis. There was a significant difference between the two groups in terms of the amount of interleukin 8 (p = 0.009). Cutoff was 297.6 Pg/ml for the detection of positive bacterial meningitis with a sensitivity of 92% and the specificity of 83.1% was 297.6 pg/ml. Conclusion: Interleukin 8 has a high sensitivity and specificity in the diagnosis of bacterial meningitis from aseptic meningitis, and along with the measurement of cerebrospinal fluid protein, it can be a good criterion for differentiation of bacterial from aseptic meningitis.

Etiology, clinical presentation, outcome and the effect of initial management in immunocompromised patients with community acquired bacterial meningitis

The aim was to analyze differences in clinical presentation, etiology, management, and outcome between immunocompromised and immunocompetent patients with acute bacterial meningitis (ABM). Data were extracted from 1056 adult ABM patients prospectively registered in the national Swedish quality register for ABM during 2008-2017. Primary endpoint was 30-day mortality and secondary endpoints 90-day mortality and unfavorable outcome. An immunocompromised state was observed in 352 (33%) of the 1056 patients. Streptococcus pneumoniae dominated in both immunocompromised and immunocompetent patients (53% in both groups), whereas L monocytogenes occurred in 11% and 2%, respectively. The unadjusted odds ratio (OR) for 30-day mortality in immunocompromised compared to immunocompetent patients was 1.68 (95% confidence interval (CI): 1.07-2.63). Adjusted for age, sex, and mental status on admission the OR was 1.34 (CI: 0.82-2.21). Adjusted also for time to antibiotic treatment and corticosteroids the OR was 1.10 (CI: 0.59-2.05), and in patients without Listeria meningitis 0.98 (CI: 0.50-1.90). Although, the ORs were higher for 90-day mortality and unfavorable outcome the effects of adjustments were similar. Mortality in immunocompromised patients with ABM is only moderately increased unless caused by Listeria. This difference is further reduced in patients given early antibiotic treatment and adjunctive corticosteroids. This work was supported by Stockholm County Council.

Community-acquired acute bacterial meningitis in adults: a clinical update.

Acute bacterial meningitis (ABM) in adults is associated with a mortality that may exceed 30%. Immunization programs have reduced the global burden; in the UK, declining incidence but persistently high mortality and morbidity mean that clinicians must remain vigilant. A systematic electronic literature search of PubMed was performed to identify all ABM literature published within the past 5years. Clinical features cannot reliably distinguish between ABM and other important infectious and non-infectious aetiologies. Prompt investigation and empirical treatment are imperative. Lumbar puncture (LP) and cerebrospinal fluid microscopy, biochemistry and culture remain the mainstay of diagnosis, but molecular techniques are increasingly useful. The 2016 UK joint specialist societies' guideline provides expert recommendations for the management of ABM, yet published data suggest clinical care delivered in the UK is frequently not adherent. Anxiety regarding risk of cerebral herniation following LP, unnecessary neuroimaging, underutilization of molecular diagnostics and suboptimal uptake of adjunctive corticosteroids compromise management. There is increasing recognition that current antibiotic regimens and adjunctive therapies alone are insufficient to reduce the mortality and morbidity associated with ABM. Research should be focused on optimization of vaccines (e.g. pneumococcal conjugate vaccines with extended serotype coverage), targeting groups at risk for disease and reservoirs for transmission; improving adherence to management guidelines; development of new faster, more accurate diagnostic platforms (e.g. novel point-of-care molecular diagnostics); and development of new adjunctive therapies (aimed at the host-inflammatory response and bacterial virulence factors).

Goal directed therapy for suspected acute bacterial meningitis in adults and adolescents in sub-Saharan Africa.

BackgroundMortality from acute bacterial meningitis (ABM) in sub-Saharan African adults and adolescents exceeds 50%. We tested if Goal Directed Therapy (GDT) was feasible for adults and adolescents with clinically suspected ABM in Malawi.Materials and methodsSequential patient cohorts of adults and adolescents with clinically suspected ABM were recruited in the emergency department of a teaching hospital in Malawi using a before/after design. Routine care was monitored in year one (P1). In year two (P2), nurses delivered protocolised GDT (rapid antibiotics, airway support, oxygenation, seizure control and fluid resuscitation) to a second cohort. The primary endpoint was composite mean number of clinical goals attained. Secondary endpoints were individual goals attained and death or disability from proven or probable ABM at day 40.Results563 patients with suspected ABM were enrolled in the study; 273 were monitored in P1; 290 patients with suspected ABM received GDT in P2. 61% were male, median age 33 years and 90% were HIV co-infected. ABM was proven or probable in 132 (23%) patients. GDT attained more clinical goals compared to routine care: composite mean number of goals in P1 was 0·55 vs. 1·57 in P2 GDT (p<0·001); Death or disability by day 40 from proven or probable ABM occurred in 29/57 (51%) in P1 and 38/60 (63%) in P2 (p = 0·19).ConclusionNurse-led GDT in a resource-constrained setting was associated with improved delivery of protocolised care. Outcome was unaffected.Trial registrationwww.isrctn.com ISRCTN96218197

Betamethasone and dexamethasone in adult community-acquired bacterial meningitis: a quality registry study from 1995 to 2014

Acute bacterial meningitis (ABM) is a highly lethal disease. Available data support the use of corticosteroids in high-income countries, but the effect on mortality is still controversial. The effects of corticosteroids on mortality and sequelae were evaluated in the national Swedish quality registry. In total, during 1995–2014 1746 adults with ABM were included, of whom 989 were treated with corticosteroids (betamethasone, n = 766; dexamethasone, n = 248; methylprednisolone, n = 2), 498 were not given corticosteroids and in 259 patients data for corticosteroids were missing. Fatal outcome was observed in 8.9% of the patients in the corticosteroid-treated group vs. 17.9% in the non-corticosteroid-treated group (p <0.001), resulting in an odds ratio (OR) of 0.57 with a 95% confidence interval (CI) of 0.40–0.81 adjusted for age, sex, mental status, and door-to-antibiotic time. In patients with meningitis caused by S. pneumoniae, mortality was 10.2% in the corticosteroid-treated group and 21.3% in the non-corticosteroid-treated group (p <0.001) with an adjusted OR of 0.50 (95% CI 0.31–0.80). In ABM patients with non-pneumococcal aetiology the adjusted OR was 0.71 (95% CI 0.40–1.26). Lower mortality was observed in the corticosteroid-treated group with impaired mental status, whereas no significant difference was found in patients with unaffected mental status. The adjusted ORs for betamethasone and dexamethasone were 0.49 (95% CI 0.28–0.84) and 0.61 (95% CI 0.37–1.01), respectively. Corticosteroid treatment decreases mortality in ABM and should be administered initially with antibiotics in adult ABM patients with impaired mental status regardless of presumed aetiology. Betamethasone seems to be at least as effective as dexamethasone.

Complications of Adult Bacterial Meningitis and their Neurocritical Care Management ? A Case Report and Short Review

Worldwide, bacterial meningitis is among the top ten causes of infection-related death. Although effective antimicrobial treatment is available and administered, fatality rates are still very high. Furthermore, 50% of affected patients suffer long-term sequelae due to severe complications, such as hydrocephalus, brain edema, cerebrovascular complications and ventriculitis. The following short review summarizes the most important complications and the neurocritical care management of acute bacterial meningitis in adults, illustrated by an instructive case report.

Prognosis of bacterial meningitis patients according to clinical criteriae and laboratory results on admission

Aim: The purpose of this study was to detect prognostic factors of acute bacterial meningitis on admission. Methods: Analysis of clinical and laboratory data of 60 adult acute bacterial meningitis patients admitted at Alexandria fever hospital between July 2014 to February 2015 including: age, sex, vital signs, conscious level, CSF findings, routine lab tests, metabolic acidosis, and causative organism was done initially on admission and then correlated with the patients' outcome on discharge which was either complete recovery (68.3%), recovery with sequelae (13.3%), or death (18.3%). Results: Factors associated with poor outcome were: Old age (P= 0.019), hypotension (p=0.003), low GCS (P=0.001), uremia (p=0.041), metabolic acidosis (P= 0.016), history of chronic hypertension (P= 0.018), Delayed referral &long duration of symptoms (P= 0.024). Conclusion: Acute bacterial meningitis patients having any of those poor prognostic criteria should be considered high risk patients and should have the priority for ICU admission and intensive monitoring.

Cerebral venous sinus thrombosis: update on diagnosis and management.

Cerebral venous thrombosis (CVT) is less frequent than ischemic stroke or intracerebral haemorrhage. Its incidence is comparable to that of acute bacterial meningitis in adults. Because of the increased use of magnetic resonance imaging (MR) for investigating patients with acute and subacute headaches and new onset seizures, CVT are now being diagnosed with increasing frequency. CVT have a more varied clinical presentation than other stroke types as they rarely present as a stroke syndrome. Their most frequent presentations are isolated headache, intracranial hypertension syndrome, seizures, a focal lobar syndrome and encephalopathy. The confirmation of the diagnosis of CVT relies on the demonstration of thrombi in the cerebral veins and/or sinuses by MR/MR venography or veno CT. The more frequent risk factors for CVT are prothrombotic conditions, either genetic or acquired, oral contraceptives, puerperium and pregnancy, infection and malignancy. The prognosis of CVT is in general favourable, as only around 15% of the patients remain dependent or die. The main intervention in the acute is anticoagulation with either low molecular weight or unfractionated heparin. In patients in severe condition on admission or who deteriorate despite anticoagulation, local thrombolysis or thrombectomy is an option. Decompressive surgery is life-saving in patients with large venous infarcts or haemorrhage. After the acute phase patients remain anticoagulated for a variable period of time, depending on their inherent thrombotic risk. CVT patients may experience recurrent seizures. Prophylaxis with antiepileptics is recommended after the first seizures, in particular in those with hemispheric lesions. There are several ongoing multicentre registries sand trials which will improve evidence-based management of CVT in the near future.

ACUTE BACTERIAL MENINGITIS MANAGEMENT IN ADULTS IS INADEQUATE: A MULTI–CENTRE AUDIT AND SURVEY

Acute bacterial meningitis (ABM) carries a 20–50% mortality rate with significant morbidity in survivors. Appropriate investigations and expeditious treatment (particularly antibiotics and often steroids) significantly improve outcomes. The National Institute...

Recognising and Treatment Seeking for Acute Bacterial Meningitis in Adults and Children in Resource-Poor Settings: A Qualitative Study

ObjectiveHigh mortality burden from Acute Bacterial Meningitis (ABM) in resource-poor settings has been frequently blamed on delays in treatment seeking. We explored treatment-seeking pathways from household to primary health care and referral for ABM in Malawi.DesignA cross-sectional qualitative study using narrative in-depth interviews, semi-structured interviews and focus group discussions.ParticipantsAdults and children with proven and probable acute bacterial meningitis and/or their carers; adults from urban and peri-urban communities; and primary health care workers (HCW).SettingQueen Elizabeth Central Hospital (QECH), urban and peri-urban private and government primary health centres and communities in Blantyre District, Malawi.ResultsWhilst communities associated meningitis with a stiff neck, in practice responses focused on ability to recognise severe illness. Misdiagnosis of meningitis as malaria was common. Subsequent action by families depended on the extent to which normal social life was disrupted by the illness and depended on the age and social position of the sufferer. Seizures and convulsions were considered severe symptoms but were often thought to be malaria. Presumptive malaria treatment at home often delayed formal treatment seeking. Further delays in treatment seeking were caused by economic barriers and perceptions of inefficient or inadequate primary health services.ConclusionsGiven the difficulties in diagnosis of meningitis where malaria is common, any intervention for ABM at primary level must focus on recognising severe illness, and encouraging action at the household, community and primary health levels. Overcoming barriers to recognition and social constraints at community level require broad community-based strategies and may provide a route to addressing poor clinical outcomes.

Early lumbar puncture in adult bacterial meningitis—rationale for revised guidelines

Current international guidelines recommend cerebral computerized tomography (CT) before lumbar puncture (LP) in many adults with suspected acute bacterial meningitis (ABM), due to concern about LP-induced cerebral herniation. Despite guideline emphasis on early treatment based on symptoms, performing CT prior to LP implies a risk of delayed ABM treatment, which may be associated with a fatal outcome. Firm evidence for LP-induced herniation in adult ABM is absent and brain CT cannot discard herniation. Thus, the recommendation to perform CT before LP may contribute to an avoidable delay of LP and ABM treatment. The inappropriate use of the diagnostic treatment sequence of brain CT scan, followed by LP, followed by antibiotics and corticosteroids should be avoided in adults with suspected ABM by omitting needless contraindications for LP, thus eliminating an unnecessary fear of immediate LP. Revised Swedish guidelines regarding early LP are presented, and the background documentation and reasons for omitting impaired consciousness, new onset seizures, and immunocompromised state as contraindications to LP are discussed.

Use of Corticosteroids and Other Adjunct Therapies for Acute Bacterial Meningitis in Adults

Acute bacterial meningitis is associated with high morbidity and mortality despite the availability of effective antibiotics. The inflammatory response induced by bacterial products in the subarachnoid space is responsible for neuronal injury. The use of adjuvant therapy in acute bacterial meningitis draws its rationale from the notion of arresting the inflammatory cascade at an early stage of the disease to improve clinical outcome. Corticosteroids have been studied extensively in these patients and seems effective in selective groups of patients, particularly those with pneumococcal meningitis. Glycerol appears harmful in adults with acute bacterial meningitis. Experimental models suggest promising role of newer anti-inflammatory drugs such as antioxidants, inhibitors of Tumor Necrosis Factor-α, poly-ADP-ribose inhibitors, caspase inhibitors, brain-derived neurotrophic factor etc.; however clinical trials are still lacking for these novel potential targets in acute bacterial meningitis. This review focuses on corticosteroids with comments on the role of other potential adjuvant therapy in adults with acute bacterial meningitis.

Acute bacterial meningitis in adults

A recent retrospective study including 125 adults with proven bacterial meningitis reported a 30% increase in unfavourable outcomes (defined as death or neurologic deficits resulting in an inability to return to work or school) for every hour that antimicrobial therapy was delayed.1 If lumbar

6．成人の細菌性髄膜炎の診断と治療―日本のガイドラインから

6．成人の細菌性髄膜炎の診断と治療―日本のガイドラインから