Community-acquired Bacterial Meningitis In Adults Research Articles

Otitis in patients with Community-Acquired Bacterial Meningitis: A Nationwide Prospective Cohort Study.

Otitis is commonly associated with community-acquired bacterial meningitis but role of ear surgery as treatment is debated. In this study, we investigated the impact of otitis and ear surgery on outcome of adults with community-acquired bacterial meningitis. We analyzed episodes of adults with community-acquired bacterial meningitis from a nationwide prospective cohort study in the Netherlands, between March 2006 to July 2021. A total of 2,548 episodes of community-acquired bacterial meningitis were evaluated. Otitis was present in 696 episodes (27%). In these patients the primary causative pathogen was Streptococcus pneumoniae (615 of 696 [88%]), followed by Streptococcus pyogenes (5%) and Haemophilus influenzae (4%). In 519 of 632 otitis episodes (82%) an ear-nose-throat specialist was consulted, and surgery was performed in 287 of 519 (55%). The types of surgery performed were myringotomy with ventilation tube insertion in 110 of 287 episodes (38%), mastoidectomy in 103 of 287 (36%) and myringotomy alone in 74 of 287 (26%). Unfavorable outcome occurred in 210 of 696 episodes (30%) and in 65 of 696 episodes was fatal (9%). Otitis was associated with a favorable outcome in a multivariable analysis (odds ratio 0.74; 95% CI 0.59-0.92; p =0.008). There was no association between outcome and ear surgery. Otitis is a common focus of infection in community-acquired bacterial meningitis in adults, with S. pneumoniae being the most common causative pathogen. Presence of otitis is associated with a favorable outcome. Ear surgery's impact on the outcome of otogenic meningitis patients remains uncertain.

Group B Streptococcus Meningitis in an Adult Woman with Type 2 Diabetes and Ethmoid Roof Defect. Impact on "frontal" Cognitive Functions.

Community-acquired bacterial meningitis in adults represents one of the most severe infectious diseases worldwide with potentially life-threatening medical complications. Several infectious agents can cause acute meningitis. Although group B Streptococcus is more prevalent in newborns, infection can also lead to meningitis in older adults, particularly those with underlying health issues. A 53-year-old woman with a body mass index of 28.7 kg/m2, type 2 diabetes mellitus, and dyslipidaemia presented to the emergency department of Santa Maria della Stella Hospital (Orvieto, Italy) with confusion, low-grade fever, echolalia, and hyperglycaemia. Computed tomography scans of the brain revealed a hypodensity in the left anterior frontal lobe and an osteodural defect of the rhinobase. Meningitis was suspected and empiric broad-spectrum antibiotic therapy with corticosteroids and insulin were administered while the results of the cerebrospinal fluid analysis confirmed the diagnosis of group B Streptococcus meningitis. Repeat imaging at 48 hours revealed enlargement of the hypodense lesion. The frontal assessment battery indicated deficits in executive functions. Prompt treatment led to rapid clinical improvement. Following the restoration of euglycemic status and hemodynamic stabilization, a follow-up magnetic resonance imaging confirmed the ischaemic lesion and showed cerebrospinal fluid in the sella turcica. The patient was then transferred to neurorehabilitation. The complex interactions among multiple risk factors resulted in an atypical clinical case of group B Streptococcus meningitis, which was promptly treated with empiric antibiotic therapy to mitigate neurocognitive deficits. Group B Streptococcus can cause meningitis in adults with poorly controlled type 2 diabetes mellitus and should be promptly treated with empiric broad-spectrum antibiotics.An osteodural defect of the ethmoid roof together with idiopathic intracranial hypertension may result in empty sella turcica and CSF rhinorrhoea, promoting the dissemination of the pathogen.Meningitis patients with pre-existing diabetic cerebral vasculopathy may develop cerebrovascular complications and cognitive impairments.

Persistent headaches one year after bacterial meningitis: prevalence, determinants and impact on quality of life.

Little is known on headaches long-term persistence after bacterial meningitis and on their impact on patients' quality of life. In an ancillary study of the French national prospective cohort of community-acquired bacterial meningitis in adults (COMBAT) conducted between February 2013 and July 2015, we collected self-reported headaches before, at onset, and 12months (M12) after meningitis. Determinants of persistent headache (PH) at M12, their association with M12 quality of life (SF 12), depression (Center for Epidemiologic Studies Depression Scale) and neuro-functional disability were analysed. Among the 277 alive patients at M12 87/274 (31.8%), 213/271 (78.6%) and 86/277 (31.0%) reported headaches before, at the onset, and at M12, respectively. In multivariate analysis, female sex (OR: 2.75 [1.54-4.90]; p < 0.001), pre-existing headaches before meningitis (OR: 2.38 [1.32-4.30]; p < 0.01), higher neutrophilic polynuclei percentage in the CSF of the initial lumbar puncture (OR: 1.02 [1.00-1.04]; p < 0.05), and brain abscess during the initial hospitalisation (OR: 8.32 [1.97-35.16]; p < 0.01) were associated with M12 persistent headaches. Neither the responsible microorganism, nor the corticoids use were associated with M12 persistent headaches. M12 neuro-functional disability (altered Glasgow Outcome Scale; p < 0.01), M12 physical handicap (altered modified Rankin score; p < 0.001), M12 depressive symptoms (p < 0.0001), and M12 altered physical (p < 0.05) and mental (p < 0.0001) qualities of life were associated with M12 headaches. Persistent headaches are frequent one year after meningitis and are associated with quality of life alteration. NCT01730690.

Haemophilus influenzae meningitis: A rare etiology of bacterial meningitis in adults! A case report

Invasive Haemophilus influenzae infections can occur as a sepsis, an invasive pneumonia, an epiglottitis and an acute bacterial meningitis. H. influenzae meningitis accounts for about 4% of community-acquired bacterial meningitis in adults. We report a case of Haemophilus influenzae serotype b (Hib) meningitis in a 37-year-old patient having an osteomeningeal breach as a predisposing factor. The diagnosis was established by lumbar puncture. The course was satisfactory with antibiotic treatment. The systematic search for an osteomeningeal breach as well as other risk factors is crucial in any adult patient presenting with an episode of confirmed H. influenzae meningitis. The quick performance of bacteriological samples is primordial in order to obtain an early diagnosis and to ensure a good clinical outcome.

NLRP3 in the Cerebrospinal Fluid as a Potential Biomarker for the Diagnosis and Prognosis of Community-Acquired Bacterial Meningitis in Adults.

ObjectiveTo discover the levels of NLR family pyrin domain-containing 3 (NLRP3) in the cerebrospinal fluid (CSF) from adult patients with community-acquired bacterial meningitis (CABM).MethodsWe enrolled 34 patients with CABM, 20 patients with viral meningitis (VM), and 25 patients with non-inflammatory neurological disease. Data on standard clinical parameters, scores, and outcomes were obtained from clinical records, and inflammasome levels in the CSF were measured by an enzyme-linked immunosorbent assay. The area under the receiver operating characteristic curve (AUROC) was used to quantify the diagnostic and prognostic performance of CSF NLRP3 as a biomarker of CABM.ResultsThe levels of NLRP3 were elevated in the CSF of patients with CABM, but levels for ASC, caspase-1, or other inflammasomes did not vary significantly. CSF NLRP3 was positively correlated with clinical severity and with the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte count, albumin quotient (Qalb), and immunoglobulin G quotient (QIgG). Patients with unfavorable outcomes had higher levels of NLRP3 in the CSF, which were correlated with several blood indicators, including NLR, PLR, and lymphocyte and monocyte counts.ConclusionsOur results suggested that the level of CSF NLRP3 could represent the severity of CABM in adults. CSF NLRP3 may be a good biomarker for the diagnosis of CABM and for the discrimination between CABM and VM. It may also be a better biomarker for predicting the prognosis of adult patients with CABM when compared to the NLR or the lymphocyte and monocyte counts.

Longer than 2 hours to antibiotics is associated with doubling of mortality in a multinational community-acquired bacterial meningitis cohort

To optimally define the association between time to effective antibiotic therapy and clinical outcomes in adult community-acquired bacterial meningitis. A systematic review of the literature describing the association between time to antibiotics and death or neurological impairment due to adult community-acquired bacterial meningitis was performed. A retrospective cohort, multivariable and propensity-score based analyses were performed using individual patient clinical data from Australian, Danish and United Kingdom studies. Heterogeneity of published observational study designs precluded meta-analysis of aggregate data (I2 = 90.1%, 95% CI 71.9–98.3%). Individual patient data on 659 subjects were made available for analysis. Multivariable analysis was performed on 180–362 propensity-score matched data. The risk of death (adjusted odds ratio, aOR) associated with treatment after two hours was 2.29 (95% CI 1.28–4.09) and increased substantially thereafter. Similarly, time to antibiotics of greater than three hours was associated with an increase in the occurrence of neurological impairment (aOR 1.79, 95% CI 1.03–3.14). Among patients with community-acquired bacterial meningitis, odds of mortality increase markedly when antibiotics are given later than two hours after presentation to the hospital.

Recurrent Community-Acquired Bacterial Meningitis in Adults.

BackgroundRecurrent bacterial meningitis has been found to occur in about 5% of meningitis cases.MethodsWe analyzed adults with recurrent episodes in a prospective nationwide cohort study of community-acquired bacterial meningitis.ResultsOf 2264 episodes of community-acquired bacterial meningitis between 2006 and 2018, 143 (6%) were identified as recurrent episodes in 123 patients. The median age was 57 years (interquartile range [IQR], 43–66), and 57 episodes (46%) occurred in men. The median duration between the first and the current episode was 5 years (IQR, 1–15). For 82 of 123 patients (67%), it was the first recurrent episode, 31 patients had 2–5 previous episodes (25%), 2 had 6–10 episodes (2%), and 2 had >10 episodes (2%). Predisposing factors were identified in 87 of 118 patients (74%) and most commonly consisted of ear or sinus infections (43 of 120, 36%) and cerebrospinal fluid leakage (37 of 116, 32%). The most common pathogens were Streptococcus pneumoniae (93 of 143, 65%) and Haemophilus influenzae (19 of 143, 13%). The outcome was unfavorable (Glasgow outcome scale score, <5) in 24 episodes with recurrent meningitis (17%) vs 810 for nonrecurrent meningitis patients (39%, P < .001). Six of 143 died (4%) vs 362 of 2095 patients (17%, P < .001).ConclusionsRecurrent meningitis occurs mainly in patients with ear or sinus infections and cerebrospinal fluid leakage. Predominant causative pathogens are S. pneumoniae and H. influenzae. The disease course is less severe, resulting in lower case fatality compared with nonrecurrent meningitis patients.

Spontaneous community-acquired bacterial meningitis in adults admitted to the intensive care units in the Caribbean French West Indies: Unusual prevalence of Klebsiella pneumonia

An unusual prevalence of Klebsiella pneumoniae (24%) was observed in 25 adults admitted to the intensive care units of two University Hospitals in the French West Indies, for spontaneous community-acquired bacterial meningitis. All tested isolates had several prominent features of hypervirulent isolates, including rmpa and iuc genes, K1 or K2 capsular serotypes.

Normocellular Community-Acquired Bacterial Meningitis in Adults: A Nationwide Population-Based Case Series

This study sought to describe the clinical presentation of normocellular community-acquired bacterial meningitis in adults. Using the prospective, nationwide, population-based database of the Danish Study Group of Infections of the Brain, the study identified all adults with normocellular community-acquired bacterial meningitis who were treated at departments of infectious diseases in Denmark from 2015 through 2018. Normocellular community-acquired bacterial meningitis was defined as a cerebrospinal fluid leukocyte count of up to 10×106/L combined with detection of bacteria in the cerebrospinal fluid. Outcome was categorized according to the Glasgow Outcome Scale at discharge. Normocellular cerebrospinal fluid was observed in 12 of 696 (2%) patients with community-acquired bacterial meningitis. The median age was 70 years (range 17 to 92 years), and 8 of 12 (67%) patients were male. All patients had symptoms suggestive of community-acquired bacterial meningitis and pathogens identified by culture (Streptococcus pneumoniae, n=10; Staphylococcus aureus, n=1) or polymerase chain reaction (Neisseria meningitidis; n=1) of the cerebrospinal fluid. Bacteremia was found in 9 of 12 (75%) patients, and 1 of 12 (8%) presented with septic shock. None of the patients had serious underlying immunocompromising conditions. The median times from admission to lumbar puncture and meningitis treatment were 2.5 hours (interquartile range 1.1 to 3.9 hours) and 2.6 hours (interquartile range 0.9 to 22.8 hours). In 3 of 11 (27%) patients, empiric treatment for community-acquired bacterial meningitis was interrupted by a normal cerebrospinal fluid cell count. The overall case-fatality rate was 3 of 12 (25%); meningitis treatment was interrupted in 1 of these patients, and 8 of 12 (67%) had a Glasgow Outcome Scale score of 1 to 4 at discharge. Normocellular community-acquired bacterial meningitis is not very common, but it is important to consider and may be associated with a pneumococcal cause.

Community-acquired bacterial meningitis in adults: emergency department management protocol.

Acute bacterial meningitis (ABM) is a rare but disabling infectious condition that requires a performant multidisciplinary management approach. Between 70 and 90 adult patients are diagnosed with community-acquired ABM in Belgium annually, and reported case fatality rates range from 17 to 40%. The currently available guidelines provide evidence-based guidance on how to manage this disease. However, these guidelines do not translate the evidence to the daily practice at the emergency department in a Belgian healthcare context. We created a taskforce in University Hospitals Leuven consisting of experts with complementary expertise in managing this disease: neurology, neurosurgery, intensive care medicine, microbiology and infectious diseases. The taskforce agreed upon a flowchart containing seven management steps encompassing all relevant phases in emergency ABM management. In addition to the focus on timely and adequate initiation of antimicrobial treatment, the flowchart and protocol also provide guidance on practical hurdles such as how to assess the safety of performing a lumbar puncture and when to refer patients to the intensive care department. This protocol was implemented in University Hospitals Leuven and fosters inter-disciplinary coordination of ABM care.

Community-acquired bacterial meningitis in adults: in-hospital prognosis, long-term disability and determinants of outcome in a multicentre prospective cohort

ObjectivesTo identify factors associated with unfavourable in-hospital outcome (death or disability) in adults with community-acquired bacterial meningitis (CABM). MethodsIn a prospective multicentre cohort study (COMBAT; February 2013 to July 2015), all consecutive cases of CABM in the 69 participating centres in France were enrolled and followed up for 12 months. Factors associated with unfavourable outcome were identified by logistic regression and long-term disability was analysed. ResultsAmong the 533 individuals enrolled, (Streptococcus pneumoniae 53.8% (280/520 isolates identified), Neisseria meningitidis 21.3% (111/520), others 24.9% (129/520)), case fatality rate was 16.9% (90/533) and unfavourable outcome occurred in 45.0% (225/500). Factors independently associated with unfavourable outcome were: age >70 years (adjusted odds ratio (aOR) 4.64; 95% CI 1.93–11.15), male gender (aOR 2.11; 95% CI 1.25–3.57), chronic renal failure (aOR 6.65; 95% CI 1.57–28.12), purpura fulminans (aOR 4.37; 95% CI 1.38–13.81), localized neurological signs (aOR 3.72; 95% CI 2.29–6.05), disseminated intravascular coagulation (aOR 3.19; 95% CI 1.16–8.79), cerebrospinal fluid (CSF) white-cell count <1500 cells/μL (aOR 2.40; 95% CI 1.42–4.03), CSF glucose concentration (0.1–2.5 g/L: aOR 1.92; 95% CI 1.01–3.67; <0.1 g/L: aOR 2.24; 95% CI 1.01–4.97), elevated CSF protein concentration (aOR 1.09; 95% CI 1.03–1.17), time interval between hospitalization and lumbar puncture >1 day (aOR 2.94; 95% CI 1.32–6.54), and S. pneumoniae meningitis (aOR 4.99; 95% CI 1.98–12.56), or meningitis other than N. meningitidis (aOR 4.54; 95% CI 1.68–12.27). At 12 months, 26.7% (74/277) had hearing loss, 32.8% (87/265) depressive symptoms, 31.0% (86/277) persistent headache, and 53.4% had a physical health-related quality of life (142/266) <25th centile of the distribution of the score in the general French population (p < 0.0001). ConclusionsThe burden of CABM (death, disability, depression, impaired quality of life and hearing loss) is high. Identification of cases from the first symptoms may improve prognosis. ClinicalTrialGov identification number: NCT01730690.

Community-acquired Bacterial Meningitis in Adults With Cerebrospinal Fluid Leakage

BackgroundCerebrospinal fluid (CSF) leakage is a risk factor for developing bacterial meningitis.MethodsWe analyzed episodes of community-acquired bacterial meningitis associated with CSF leakage from a prospective nationwide cohort study.ResultsCSF leakage was identified in 65 episodes of 2022 episodes (3%) in 53 patients. The cause of CSF leakage was identified in 49 of 65 episodes (75%), which most commonly consisted of ear-nose-throat surgery (19 of 49 episodes [29%]) and remote head trauma (15 of 49 episodes [23%]). The episode was a recurrent meningitis episode in 38 patients (59%). Of the recurrent episodes, 27 had known CSF leakage (71%) of whom 20 (53%) had previous surgery aiming to close the leak. Nine patients (38%) with known CSF leakage had been vaccinated (23-valent pneumococcal vaccine in 9 patients, meningococcal serogroup C vaccine in 2, meningococcal serogroup A and Haemophilus influenzae type b vaccine each in 1 patient). Streptococcus pneumoniae was cultured in 33 episodes (51%) and H. influenzae in 11 episodes (17%). The most common pneumococcal serotypes were 3 (4 episodes), 35B, 9N, 38, and 15C (each 2 episodes). Haemophilus influenzae was unencapsulated in all 10 episodes with known capsule type. The outcome was unfavorable in 8 episodes (12%) and no patient died.ConclusionsBacterial meningitis in patients with CSF leakage has a high recurrence rate, despite surgical repair or vaccination, and outcome is generally favorable. CSF leakage should be suspected in patients with bacterial meningitis presenting with liquorrhea, recurrent meningitis, or with disease caused by H. influenzae.

Community-acquired meningitis in adults caused by Escherichia coli in Denmark and The Netherlands

ObjectivesWe aimed to examine risk factors, presenting characteristics and complications of Escherichia coli community-acquired bacterial meningitis in adults. MethodsObservational cohort study of adults > 16 years of age with cerebrospinal fluid culture-positive E. coli meningitis in Denmark and the Netherlands. Exclusion criteria were primary brain abscess, previous neurosurgery and nosocomial infections. We analysed baseline characteristics, concomitant infections and neurological complications. Outcome was assessed using the Glasgow Outcome Scale score (GOS) at discharge with GOS 1–4 categorised as unfavourable outcome. ResultsWe identified 36 patients with a median age of 69 years (interquartile range 61–83) of whom 15 (42%) were females. Immuno-compromise was present in 11 (31%) patients. Nineteen (53%) patients had concomitant infections consisting of urinary tract infections in 13 (36%), pneumonia in three (9%) and septic arthritis in two (6%). Bacteraemia with E. coli was found in 26 of 34 (76%) patients. Thirteen patients died (36%) and unfavourable outcome at discharge occurred in 23 (64%). Deaths were attributed to systemic complications in 12 (92%) patients. ConclusionCommunity-acquired E. coli meningitis in adults is a severe disease that primarily occurs in elderly patients with concomitant infections and an immunocompromised state. Outcome is often poor and mainly caused by systemic complications.

Variation in coagulation and fibrinolysis genes evaluated for their contribution to cerebrovascular complications in adults with bacterial meningitis in the Netherlands

To study whether genetic variation in coagulation and fibrinolysis genes contributes to cerebrovascular complications in bacterial meningitis. We performed a nationwide prospective genetic association study in adult community-acquired bacterial meningitis patients. The exons and flanking regions of 16 candidate genes involved in coagulation and fibrinolysis pathways were sequenced. We analyzed whether genetic variation in these genes resulted in a higher risk of cerebrovascular complications, unfavorable outcome and differences in thrombocyte count on admission. From 2006 to 2011, a total of 1101 bacterial meningitis patients were identified of whom 622 supplied DNA for genotyping and passed genetic quality control steps. In 139 patients (22%) the episode of bacterial meningitis was complicated by cerebral infarction, and 188 (30%) had an unfavorable outcome. We identified the functional variant rs494860 in the protein Z (PROZ) gene as our strongest association with occurrence of cerebral infarction (odds ratio (OR) 0.49 (95% confidence interval 0.33-0.73), p = 5.2 × 10-4). After Bonferroni correction for multiple testing no genetic variant was significantly associated (p-value threshold 2.7 × 10-4). Our study suggests a functional genetic variation in the PROZ gene, rs494860, may be of importance in bacterial meningitis pathogenesis and cerebral infarction risk. Replication of this finding in other cohort studies populations is needed.

Risk scores for outcome in bacterial meningitis: Systematic review and external validation study

To perform an external validation study of risk scores, identified through a systematic review, predicting outcome in community-acquired bacterial meningitis. MEDLINE and EMBASE were searched for articles published between January 1960 and August 2014. Performance was evaluated in 2108 episodes of adult community-acquired bacterial meningitis from two nationwide prospective cohort studies by the area under the receiver operating characteristic curve (AUC), the calibration curve, calibration slope or Hosmer-Lemeshow test, and the distribution of calculated risks. Nine risk scores were identified predicting death, neurological deficit or death, or unfavorable outcome at discharge in bacterial meningitis, pneumococcal meningitis and invasive meningococcal disease. Most studies had shortcomings in design, analyses, and reporting. Evaluation showed AUCs of 0.59 (0.57-0.61) and 0.74 (0.71-0.76) in bacterial meningitis, 0.67 (0.64-0.70) in pneumococcal meningitis, and 0.81 (0.73-0.90), 0.82 (0.74-0.91), 0.84 (0.75-0.93), 0.84 (0.76-0.93), 0.85 (0.75-0.95), and 0.90 (0.83-0.98) in meningococcal meningitis. Calibration curves showed adequate agreement between predicted and observed outcomes for four scores, but statistical tests indicated poor calibration of all risk scores. One score could be recommended for the interpretation and design of bacterial meningitis studies. None of the existing scores performed well enough to recommend routine use in individual patient management.

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.

Community-Acquired Bacterial Meningitis in Adults

Community-acquired bacterial meningitis (CABM) is a life-threatening infection that can be complicated by neurological deficits among survivors. These outcomes have prompted interventions in prevention and treatment. These include an ever-expanding list of vaccines and adjunctive therapy, including early corticosteroid administration. Researchers conducted a prospective cohort study in the Netherlands to provide a contemporary evaluation of the disease's incidence, clinical aspects, and management. Adult (aged …

Community-acquired bacterial meningitis in adults with cancer or a history of cancer.

To study the incidence, clinical presentation, causative bacteria, and outcome of community-acquired bacterial meningitis in adults with cancer. We evaluated incidence and characteristics of patients with cancer included in a nationwide prospective cohort study of adults with community-acquired meningitis performed in the Netherlands from March 1, 2006, to September 31, 2014. All patients underwent a neurologic examination at hospital discharge, and outcome was graded using the Glasgow Outcome Scale. Active cancer was identified in 68 of 1,351 episodes (5%) and a history of cancer in 87 (6%). The annual incidence of community-acquired bacterial meningitis was 2.71-fold (95% confidence interval [CI] 1.68-4.36, p < 0.001) increased for patients with cancer compared to patients without cancer in 2010, and 3.52-fold (95% CI 2.16-5.73, p < 0.001) in 2013. The clinical presentation of bacterial meningitis in patients with cancer compared to patients without cancer was similar. Patients with active cancer presented with lower leukocyte count in blood (12.1 × 10(9) cells/L vs 17.3 × 10(9) cells/L, p < 0.001) and CSF (670 cells/mm(3) vs 2,567 cells/mm(3), p < 0.001) and were more likely to be infected with Listeria monocytogenes (21% vs 5%, p < 0.001) than patients without cancer. Active cancer was identified as an independent risk factor for unfavorable outcome in bacterial meningitis (odds ratio 1.85, 95% CI 1.09-3.13). One of 8 patients with community-bacterial meningitis was identified to have a history of cancer and cancer was considered active in half of these patients. Patients with active cancer present with lower CSF leukocyte counts, are more likely to be infected with L monocytogenes, and are at high risk of unfavorable outcome.

Community-acquired bacterial meningitis in adults in the Netherlands, 2006–14: a prospective cohort study

We studied causative pathogens, clinical characteristics, and outcome of adult community-acquired bacterial meningitis after the introduction of adjunctive dexamethasone treatment and nationwide implementation of paediatric conjugate vaccines. In this cohort study, we prospectively assessed adults (age >16 years) with community-acquired bacterial meningitis in the Netherlands, identified through the National Reference Laboratory for Bacterial Meningitis or individual physicians between Jan 1, 2006, and July 1, 2014. We identified independent predictors of an unfavourable outcome (Glasgow Outcome Scale score 1-4) by logistic regression. We assessed 1412 episodes of community-acquired bacterial meningitis. Incidence declined from 1·72 cases per 100,000 adults per year in 2007-08, to 0·94 per 100,000 per year in 2013-14. Streptococcus pneumoniae caused 1017 (72%) of 1412 episodes. Rates of adult bacterial meningitis decreased most sharply among pneumococcal serotypes included in paediatric conjugate vaccine, and in meningococcal meningitis. We found no evidence of serotype or serogroup replacement. The overall case fatality rate was 244 (17%) of 1412 episodes and unfavourable outcome occurred in 531 (38%) of 1412 episodes. Predictors of unfavourable outcome were advanced age, absence of otitis or sinusitis, alcoholism, tachycardia, lower score on the Glasgow Coma Scale, cranial nerve palsy, a cerebrospinal fluid white-cell count lower than 1000 cells per μL, a positive blood culture, and a high serum C-reactive protein concentration. Adjunctive dexamethasone was administered for 1234 (89%) of 1384 assessed episodes. The multivariable adjusted odds ratio of dexamethasone treatment for unfavourable outcome was 0·54 (95% CI 0·39-0·73). The incidence of adult bacterial meningitis has decreased substantially, which is partly explained by herd protection by paediatric conjugate vaccines. Adjunctive dexamethasone treatment was associated with substantially improved outcome. European Research Council, National Institute of Public Health and the Environment, European Union, Academic Medical Center, and Netherlands Organization for Health Research and Development.

Therapeutic hypothermia for adult community-acquired bacterial meningitis—Historical control study

ObjectiveDespite advances in antibiotic therapy and critical care, community-acquired bacterial meningitis (CABM) continues to have poor outcome in a significant portion of patients. This study was designed to assess the efficacy of therapeutic hypothermia (TH) in the treatment of CABM. Material and methodsIn a period from January 2009 to January 2013, 41 enrolled patients with CABM were treated with TH. Their outcome was compared to 90 patients in the historical control group that were recruited from the existing database and included patients in a period between 1994 and 2008 with Glasgow coma scale score (GCS) ≤9 and respiratory failure. TH was indicated in patients with GCS ≤9, respiratory failure, and breath holding index ≤0.835 (measured with transcranial Doppler). If the acoustic window was absent, GCS ≤9 plus optic nerve sheath diameter of ≥6mm plus respiratory failure were indications for TH. ResultsOutcome variables were mortality and neurologic recovery measured with the Glasgow outcome scale (GOS). The incidence of hospital mortality (19.5% vs 48.9%, p=0.002) and adverse neurological outcome (GOS 1–3) (43.9% vs 65.6%, p=0.023) were significantly lower in patients treated with TH. Multivariate analysis confirmed the positive effect of TH on hospital mortality (OR=0.059, 95% CI 0.017–0.211) and risk of adverse neurological outcome (OR=0.209, 95% CI 0.082–0.534) after an adjustment for other risk factors of unfavorable patients' outcome. ConclusionsThe new therapeutic concept based on hypothermia significantly improves the outcome in adult patients with severe CABM.