Bacterial Meningitis In Adults Research Articles

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

Clinical Practice Guidelines for the Management of Bacterial Meningitis in Adults in Korea

Clinical Practice Guidelines for the Management of Bacterial Meningitis in Adults in Korea

Bacterial Meningitis in Adults

Abstract Bacterial meningitis is a life threatening infection of the central nervous system with significant morbidity and mortality. Clinicians are challenged with using patient history, physical ...

Meningitis fulminante por Streptococcus pyogenes

Streptococcus pyogenes, or group A Streptococcus, rarely causes bacterial meningitis in adults but has a high mortality rate if untreated. This bacterium has become more aggressive and shows greater invasive capacity, increasing the incidence and severity of infections. These observations have led to the hypothesis of a more virulent strain. We report the case of a healthy 54-year-old woman with neck pain and rapid neurological and hemodynamic worsening despite appropriate antibiotic and corticosteroid treatment who died 5 hours after admission.

CSF interleukin 6 – a useful biomarker of meningitis in adults?/Liquor Interleukin 6 – ein sinnvoller Biomarker für die Meningitis beim Erwachsenen

Abstract Background: Bacterial meningitis in adults is a rapid progressive and life threatening condition. Monitoring of cytokines such as interleukin (IL) 6 by automated chemiluminescence poses an attractive alternative to monitoring of conventional biomarkers. Methods: In a prospective setting, we studied 523 consecutive neurological patients within a 6 month period. 419 complete datasets could be included the analysis. Results: In control patients (with neurological disease excluded), the 95. percentile of cerebrospinal fluid (CSF) IL-6 was 7.0 pg/mL and the ratio of CSF IL-6 /serum IL-6 was <2.67. In our population, acute inflammation of the central nervous system was observed in 5.7% of the patients only. In all patients with bacterial meningitis, very high concentrations of CSF IL-6 were observed. In viral meningitis, the concentration of CSF IL-6 was heterogeneous. In acute meningitis, the performance of CSF IL-6 was similar to the performance of CSF lactate. Very high CSF IL-6 concentrations in otherwise normal CSF were observed in few patients with seizures. Conclusions: In adults, CSF IL-6 cannot differentiate between bacterial and viral meningitis. Low concentrations of CSF IL6 do not exclude viral meningitis but might be a helpful biomarker to exclude acute bacterial inflammation of the central nervous system. However, given the very low incidence of bacterial meningitis in our adult neurological population, our study does not indicate a better targeted use of antibiotic therapy when IL-6 is added to the routine CSF analysis panel.

Risk Factors of Streptococcus suis Infection in Vietnam. A Case-Control Study

Background Streptococcus suis infection, an emerging zoonosis, is an increasing public health problem across South East Asia and the most common cause of acute bacterial meningitis in adults in Vietnam. Little is known of the risk factors underlying the disease.Methods and FindingsA case-control study with appropriate hospital and matched community controls for each patient was conducted between May 2006 and June 2009. Potential risk factors were assessed using a standardized questionnaire and investigation of throat and rectal S. suis carriage in cases, controls and their pigs, using real-time PCR and culture of swab samples. We recruited 101 cases of S. suis meningitis, 303 hospital controls and 300 community controls. By multivariate analysis, risk factors identified for S. suis infection as compared to either control group included eating “high risk” dishes, including such dishes as undercooked pig blood and pig intestine (OR1 = 2.22; 95%CI = [1.15–4.28] and OR2 = 4.44; 95%CI = [2.15–9.15]), occupations related to pigs (OR1 = 3.84; 95%CI = [1.32–11.11] and OR2 = 5.52; 95%CI = [1.49–20.39]), and exposures to pigs or pork in the presence of skin injuries (OR1 = 7.48; 95%CI = [1.97–28.44] and OR2 = 15.96; 95%CI = [2.97–85.72]). S. suis specific DNA was detected in rectal and throat swabs of 6 patients and was cultured from 2 rectal samples, but was not detected in such samples of 1522 healthy individuals or patients without S. suis infection.ConclusionsThis case control study, the largest prospective epidemiological assessment of this disease, has identified the most important risk factors associated with S. suis bacterial meningitis to be eating ‘high risk’ dishes popular in parts of Asia, occupational exposure to pigs and pig products, and preparation of pork in the presence of skin lesions. These risk factors can be addressed in public health campaigns aimed at preventing S. suis infection.

Glycerol adjuvant therapy in adults with bacterial meningitis in a high HIV seroprevalence setting in Malawi: a double-blind, randomised controlled trial

Southern Africa has a high incidence of bacterial meningitis in adults, often associated with HIV co-infection. Mortality exceeds 50%, even with appropriate antibiotic therapy, and is not improved with corticosteroids. Glycerol adjuvant therapy reduces long-term morbidity in bacterial meningitis in children, and its use is being promoted. We aimed to assess the effectiveness of glycerol as an adjuvant therapy for adults with bacterial meningitis in Africa. The study was done in two phases. First, in an open-label dose-finding study, 45 adult patients with symptoms, signs, and cerebrospinal fluid findings consistent with bacterial meningitis received either 50 mL, 75 mL, or 100 mL of glycerol four times a day for 4 days. We then did a randomised, double-blind, placebo-controlled trial of oral glycerol in adults with bacterial meningitis. Patients with clinical and cerebrospinal fluid findings suggestive of bacterial meningitis were randomly assigned in blocks of 12 by use of a random number list produced by an independent statistician to receive either glycerol or an equivalent volume of sugar solution. Glycerol and placebo were indistinguishable by colour or taste. The primary outcome was mortality at 40 days, with secondary outcomes including disability and mortality restricted to pneumococcal disease. All patients were analysed for the primary outcome excluding those who were lost to follow-up. This trial is registered at controlled-trials.com, number ISRCTN70121840. 75 mL glycerol four times a day was the highest tolerated dose, and was used for the main study. 265 patients were assigned treatment: 137 glycerol and 128 placebo. The trial was stopped early on the advice of the data and safety monitoring board after a planned interim analysis. By day 40, 61 (49%) of 125 patients in the placebo group and 86 (63%) of 136 in the glycerol group had died (adjusted odds ratio 2.4, 95% CI 1.3-4.2, p=0.003). There was no benefit from glycerol for death and disability by day 40, and glycerol did not improve death and disability by day 40 or death at day 40 in patients with proven bacterial disease or pneumococcal disease. Two serious adverse events occurred that were possibly due to the study drug. Oral glycerol therapy cannot be recommended as an adjuvant therapy in adults with bacterial meningitis in resource-poor settings with a high HIV prevalence. Meningitis Research Foundation.

The antimicrobial resistance patterns and associated determinants in Streptococcus suisisolated from humans in southern Vietnam, 1997-2008

BackgroundStreptococcus suis is an emerging zoonotic pathogen and is the leading cause of bacterial meningitis in adults in Vietnam. Systematic data on the antimicrobial susceptibility profiles of S. suis strains isolated from human cases are lacking. We studied antimicrobial resistance and associated resistance determinants in S. suis isolated from patients with meningitis in southern Vietnam.MethodsS. suis strains isolated between 1997 and 2008 were investigated for their susceptibility to six antimicrobial agents. Strains were screened for the presence and expression of tetracycline and erythromycin resistance determinants and the association of tet(M) genes with Tn916- like transposons. The localization of tetracycline resistance gene tet(L) was determined by pulse field gel electrophoresis and Southern blotting.ResultsWe observed a significant increase in resistance to tetracycline and chloramphenicol, which was concurrent with an increase in multi-drug resistance. In tetracycline resistance strains, we identified tet(M), tet(O), tet(W) and tet(L) and confirmed their expression. All tet(M) genes were associated with a Tn916-like transposon. The co-expression of tet(L) and other tetracycline resistance gene(s) encoding for ribosomal protection protein(s) was only detected in strains with a minimum inhibitory concentration (MIC) of tetracycline of ≥ 64 mg/LConclusionsWe demonstrated that multi-drug resistance in S. suis causing disease in humans in southern Vietnam has increased over the 11-year period studied. We report the presence and expression of tet(L) in S. suis strains and our data suggest that co-expression of multiple genes encoding distinct mechanism is required for an MIC ≥ 64 mg/L to tetracycline.

Clinical and bacteriological spectrum of community-acquired acute bacterial meningitis in adults at a tertiary care hospital in northern India

Objective : To evaluate the clinical and bacteriological spectrum of community-acquired acute bacterial meningitis (ABM) in an adult population at Lok Nayak Hospital, New Delhi, a tertiary care hospital in northern India. Materials and Methods: Cerebrospinal fluid (CSF) samples from 120 clinically suspected cases of pyogenic meningitis were processed for cell counts, differential counts, bacterial stain and culture, antibiotic susceptibility test, and bacterial antigen detection by latex agglutination test (LAT) in CSF, serum and urine. Results : CSF LAT was positive in 56/120 cases of ABM. Streptococcus pneumoniae was the predominant pathogen in 41 of these 120 cases i.e. 34.0% of all cases. Neisseria meningitidis accounted for 24 cases i.e. 20% of all cases. Staphylococcus aureus was isolated in one case. Bacterial cultures were positive in 22 (18.3%) cases only. Conclusions: Evidence for presence of microbial activity could be detected in 44.1% cases by LAT, whereas a direct microbiological confirmation could be documented in only 22 cases i.e. 18.3%. Streptococcus pneumoniae remains the major etiological agent of ABM in our study. Penicillin resistance was detected in 50% of cases among the isolates which came positive by culture. Neisseria meningitidis was detected in 24 cases. But since none were cultured, sensitivity patterns could not be correlated. LAT is a convenient and rapid test to support bacterial etiology in ABM. In remote situations, their use in serum or urine needs to be considered after evaluation in longer studies. Further research should focus on the preventable aspects of ABM, especially pneumococcal and meningococcal vaccines, to potentially protect susceptible groups.

Acute Epidural Abscess Complicating Pneumococcal Meningitis in Adult

Acute spinal epidural abscesses rarely complicate bacterial meningitis in adults. We report an uncommon case of advanced pneumococcal meningitis complicated by acute lumbar epidural abscess in an adult. A 35-year-old man was admitted to the medical intensive care unit with pneumococcal meningitis. On the eighth day of hospitalization, he presented a cauda equine syndrome with flaccid paraplegia, saddle anesthesia, and bladder and bowel dysfunction. Magnetic resonance imaging (MRI) of the spine demonstrated a suppurative collection at L2-L3. Surgical decompression was performed, and antibiotherapy was followed for eight weeks. Clinical improvement was progressive over eight months. New onset neurologic deficits in a patient with pneumococcal meningitis should raise suspicion of acute epidural abscess.

Meningitis bacteriana asociada a analgesia y anestesia espinal

Introduction Although rare, infectious complications from spinal analgesia and anaesthesia (SA) can have serious morbidity and mortality. This study describes the clinical features and outcome of SA-associated bacterial meningitis in adults seen in a hospital over a 25 yearperiod. Methods We reviewed the charts of all patients (aged ≥14 years) diagnosed with SA-associated bacterial meningitis between 1982 and 2006. Results Eight cases of SA-associated bacterial meningitis were diagnosed (3.3% bacterial meningitis), with a median age of 62 years (range, 35-80). SA procedures were: morphine infusion pumps with epidural (3 cases) or intrathecal (3) catheters, spinal cord stimulation with epidural neuroelectrode (1), and epidural anesthesia (1). Site of spinal insertion was: cervical (2 cases), thoracic (3), and lumbar (3). The median time to onset of meningitis was 26 days (range, 7-101) after AE. The most common clinical findings were fever (8 cases, 100%), headache (7 cases, 87.5%), and neck stiffness (4 cases, 50%). CSF abnormalities were pleocytosis (8 cases, 100%), elevated protein level (8 cases, 100%), and hypoglycorrhachia (5 cases, 62.5%). The causative organisms were Staphylococcus epidermidis (2 cases), Staphylococcus aureus (2), Enterococcus faecalis (1), Streptococcus milleri (1), and S. epidermidis and Pseudomonas fluorescens (1); one patient had a negative CSF culture. Treatment included antibiotics and to remove the analgesia device in all patients. There was one death (12.5%). Conclusions SA is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting.

Clinical Features and Independent Prognostic Factors for Acute Bacterial Meningitis in Adults

Clinical recognition of acute bacterial meningitis (ABM) and its early prognostication would guide the degree of intensive treatment required. We aimed to study the clinical features and factors associated with death in patients with community acquired ABM. Adult patients with clinically suspected community acquired ABM (CAABM) were studied between July 2004 to September 2008 (retrospective and prospective). Detailed history, clinical examination, cerebrospinal fluid (CSF) analysis, and laboratory investigations were performed and noted. The complications with which the patient presented or developed during hospital course were also noted. The outcome noted was at the time of discharge. In multivariate logistic regression, independent factors associated with death were rural area of residence, presentation after >24 h, total leukocyte count (TLC) of <15000, CSF neutrophils <75%, low GCS at the time of admission, and a high creatinine level. In the present study, most of the factors predicting death were identified at the time of admission. Identification of these factors could help prioritizing patients needing intensive care facilities, especially in resource poor setting.

Changing etiology of community-acquired bacterial meningitis in adults: a nationwide multicenter study in Korea

Epidemiologic data on the etiologic organisms is important for appropriate empirical antibiotic treatment of bacterial meningitis. We identified the etiologies of community-acquired bacterial meningitis in Korean adults and the associated epidemiological factors. A retrospective, multicenter nationwide study was carried out. Patients 18 years of age or older with community-acquired bacterial meningitis with a confirmed pathogen were enrolled. Demographic, clinical, and microbiological data were collected. One hundred and ninety-five cases were collected. Streptococcus pneumoniae was the most common pathogen (50.8%), followed by Staphylococcus aureus (10.3%), Klebsiella pneumoniae (7.7%), Listeria monocytogenes (6.7%), and group B Streptococcus (3.1%). The penicillin resistance rate of the S. pneumoniae was 60.3%; 40.0% of the organisms were not susceptible to third-generation cephalosporins. The combination of third-generation cephalosporin with vancomycin was used in 76.3% of cases. Steroids were given before or with the first dose of antibiotics in 37.4% of patients. The 30-day mortality rate was 20.5% and neurological sequelae developed in 15.6% of cases. S. pneumoniae was the most common organism identified in community-acquired bacterial meningitis among Korean adults. S. aureus, K. pneumoniae, L. monocytogenes, and group B Streptococcus were also common. S. pneumoniae had high rates of resistance to penicillin and third-generation cephalosporins.

NOD2 mediates CNS inflammatory responses of primary murine glia in streptococcal meningitis (136.34)

Abstract Resident cells of the central nervous system (CNS) such as microglia and astrocytes initiate and/or augment inflammation following trauma or infection. We have previously demonstrated that glia constitutively express nucleotide-binding oligomerization domain-2 (NOD2), a member of the novel nucleotide-binding domain leucine-rich repeat region-containing family of proteins (NLR) that functions as an intracellular receptor for a minimal motif present in all bacterial peptidoglycans. We have also shown that this NLR is essential for glial responses to Gram-negative pathogens and the subsequent in vivo CNS inflammation. In the present study, we have established that intact Streptococcus pneumoniae, the major causative agent for Gram-positive bacterial meningitis in adults, is a potent stimulus for the activation of the pivotal inflammatory transcription factor NF-kB and production of inflammatory cytokines in primary murine microglia and astrocytes. We demonstrate that NOD2 is essential for the maximal responses of these cells to intact S. pneumoniae but not cellular lysates. Finally, we have shown that NOD2 is required for the elevated inflammatory mediator levels, astrogliosis, and demyelination, following in vivo administration of this Gram-positive CNS pathogen. As such, we suggest that NOD2 plays a critical role in the establishment of the lethal inflammation associated with streptococcal meningitis.

Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults

IntroductionBacterial meningitis is a medical emergency, the outcome of which is improved by prompt antibiotic treatment. For patients with suspected meningitis and no features of severe disease, the British Infection...

Cerebrospinal Fluid Ferritin for Differentiation of Aseptic and Bacterial Meningitis in Adults

Problem statement: Bacterial meningitis is one of the most important causes of mortality and morbidity. Rapid diagnosis of bacterial cause is very important and critical, because early antibiotic therapy prevents complications; different tests have been developed for rapid diagnosis of bacterial meningitis. One of them is CSF ferritin, which is evaluated in this study. Approach: During cross sectional study from 2008-2009 for 2 years, CSF was collects from 61 adults suspected to have meningitis. These patients admitted to Emam Reza and Sina hospitals of Tabriz. CSF was analyzed for ferritin, glucose, protein, cell count, culture and gram stains. Clinical data's were collected for all patients. Collected data's were analyzed by SPSS software. Results: From 61 specimens, 19 cases had bacterial, 19 cases had aseptic meningitis and 23 cases had no criteria for diagnosis of meningitis. CSF ferritin in bacterial meningitis was 231.63 ± 61.26 ng dL −1 that was significantly higher, than that of aseptic meningitis group. Cut off value for ferritin was estimated 155ng dL −1 with sensitivity of 94% and specificity of 21.7% in this study. Symptoms such as levels of consciousness, fever and seizure were not considered as a criteria for diagnosis of bacterial meningitis (p>0.05). But symptoms such as headache, nausa, vomiting and neck stefness were significantly higher in bacterial and aseptic groups than no meningitis group (p<0.05). Conclusion: In this study CSF ferritin in bacterial meningitis group was significantly higher than aseptic meningitis group. But due to low specificity of CSF ferritin for differentiation of bacterial from aseptic meningitis, we don't recommend performance of this test in early phase of meningitis course.

Acute Bacterial Meningitis in Adults: a Hospital Based Study in Yemen

Acute bacterial meningitis is an important cause of mortality and morbidity with high rates of long-term neurological sequelae. To determine the clinical presentation, complications, and outcome of acute meningitis in Yemen, a retrospective study in patients 15 years or older with acute bacterial meningitis who were admitted into Al-Thawra Teaching Hospital in Sana'a from January 2006 to December 2007 was carried out. There were 121 patients with acute bacterial meningitis. Lumbar puncture was performed in 112 (92.6%). The most common pathogen was Streptococcus pneumoniae found in 47.4% of positive cultures, Neisseria meningitidis in 33.9%, and Haemophilus influenzae in 10.2%. The classical triad of acute bacterial meningitis was found in 65% of cases. The mortality rate was 22.3%, with 27 patients dying during hospitalization. S. pneumoniae had a case fatality rate of 35.7%. Frequent complications were impaired consciousness, recurrent convulsion, and chest infection, which occurred in 30.6, 16.5, and 10.7% of the patients, respectively. Risk factors for death among those with acute bacterial meningitis included older age (>or=45 years), altered mental status, chest infection, and S. pneumoniae infection. This study highlights the importance of bacterial meningitis as a serious disease of adults in Yemen and the need for effective methods to prevent its complications.

NOD2 mediates inflammatory responses of primary murine glia to Streptococcus pneumoniae

It is now widely accepted that resident central nervous system (CNS) cells such as microglia and astrocytes initiate and/or augment inflammation following trauma or infection. However, the mechanisms by which glial cells perceive microbial challenges are only now becoming apparent. We have recently demonstrated that microglia and astrocytes constitutively express nucleotide-binding oligomerization domain-2 (NOD2), a member of the novel nucleotide-binding domain leucine-rich repeat region-containing family of proteins (NLR) that functions as an intracellular receptor for a minimal motif present in all bacterial peptidoglycans. Furthermore, we have shown that this NLR is essential for glial responses to gram-negative pathogens and in vivo CNS inflammation elicited by these organisms. In the present study, we have established that intact Streptococcus pneumoniae, the major causative agent for gram-positive bacterial meningitis in adults, is a potent stimulus for the activation of the pivotal inflammatory transcription factor NF-kB and production of inflammatory cytokines in primary murine microglia and astrocytes. We demonstrate that NOD2 is essential for the maximal responses of these cells to intact S. pneumoniae but not cellular lysates. Finally, we have shown that this cytosolic pattern recognition receptor is required for the elevated inflammatory mediator levels, astrogliosis, and demyelination, following in vivo administration of this gram-positive CNS pathogen. As such, we suggest that NOD2 plays a critical role in the establishment of the lethal inflammation associated with streptococcal meningitis.

Bacterial meningitis secondary to spinal analgesia and anaesthesia

Introduction Although rare, infectious complications from spinal analgesia and anaesthesia (SA) can have serious morbidity and mortality. This study describes the clinical features and outcome of SA-associated bacterial meningitis in adults seen in a hospital over a 25 yearperiod. Methods We reviewed the charts of all patients (aged ≥14 years) diagnosed with SA-associated bacterial meningitis between 1982 and 2006. Results Eight cases of SA-associated bacterial meningitis were diagnosed (3.3% bacterial meningitis), with a median age of 62 years (range, 35–80). SA procedures were: morphine infusion pumps with epidural (3 cases) or intrathecal (3) catheters, spinal cord stimulation with epidural neuroelectrode (1), and epidural anesthesia (1). Site of spinal insertion was: cervical (2 cases), thoracic (3), and lumbar (3). The median time to onset of meningitis was 26 days (range, 7–101) after AE. The most common clinical findings were fever (8 cases, 100%), headache (7 cases, 87.5%), and neck stiffness (4 cases, 50%). CSF abnormalities were pleocytosis (8 cases, 100%), elevated protein level (8 cases, 100%), and hypoglycorrhachia (5 cases, 62.5%). The causative organisms were Staphylococcus epidermidis (2 cases), Staphylococcus aureus (2), Enterococcus faecalis (1), Streptococcus milleri (1), and S. epidermidis and Pseudomonas fluorescens (1); one patient had a negative CSF culture. Treatment included antibiotics and to remove the analgesia device in all patients. There was one death (12.5%). Conclusions SA is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting.

Focal parenchymal lesions in community-acquired bacterial meningitis in adults: a clinico-radiological study

Here, we analyzed the frequency, morphological pattern, and imaging characteristics of focal lesions as a consequence of community-acquired bacterial meningitis. We hypothesized that diffusion-weighted imaging combined with contrast-enhanced imaging, serial scanning, and multimodal vascular studies would provide further insight into the pathological basis of such parenchymal lesions in bacterial meningitis. We reviewed clinical and imaging data (i.e., magnetic resonance tomography, magnetic resonance angiography, computed tomography angiography, digital subtraction angiography) of 68 adult patients admitted to our neurological intensive care unit between March 1998 and February 2009 with the diagnosis of community-acquired bacterial meningitis. We identified seven patients with parenchymal lesions. These lesions could be attributed to four morphological patterns: (1) territorial cerebral ischemia, (2) perforating vessels ischemia, (3) ischemia of presumed cardiac origin, and (4) isolated cortical lesions. Whereas the patterns (1) and (2) were associated with vasculopathy of large- and medium-sized vessels (as shown by cerebral vascular imaging), vessel imaging in (3) and (4) did not show abnormal findings. Our study implies that parenchymal lesions in acute bacterial meningitis are mainly ischemic and due to involvement of large-, medium-, and small-sized arteries of the brain. Diffusion-weighted imaging combined with conventional, CT-, or MR-based cerebral angiography revealed the underlying pathophysiological mechanisms in the majority of patients. Furthermore, we detected two patients with isolated bilateral cortical involvement and normal vessel imaging. These lesions might represent ischemia due to the involvement of small pial and intracortical arteries.