Culture-proven Bacterial Meningitis Research Articles

Diagnostic Utility of Cerebrospinal Fluid White Blood Cell Components for the Identification of Bacterial Meningitis in Infants.

To evaluate the diagnostic and predictive utility of cerebrospinal fluid (CSF) white blood cell (WBC) components in the diagnosis of bacterial meningitis in infants discharged from the neonatal intensive care unit (NICU). We identified a cohort of infants discharged from a Pediatrix NICU between 1997 and 2020 who did not have an immunodeficiency, had at least 1 CSF culture collected within the first 120 days of life, and at least 1 CSF laboratory specimen obtained on the day of culture collection. We only included an infant's first CSF culture and excluded cultures from CSF reservoirs and those growing contaminants or nonbacterial organisms. We examined the utility of CSF WBC components to diagnose or predict bacterial meningitis by calculating sensitivity, specificity, positive and negative predictive values, likelihood ratios, and area under the receiver operating curve (AUC) at different cutoff values for each parameter. We performed subgroup analysis excluding infants treated with antibiotics the day before CSF culture collection. Of the 20 756 infants that met the study inclusion criteria, 320 (2%) were diagnosed with bacterial meningitis. We found (AUC [95% CI]) CSF WBC count (0.76 [0.73-0.79]), CSF neutrophil count (0.74 [0.70-0.78]), and CSF neutrophil percent (0.71 [0.67-0.75]) had the highest predictive values for bacterial meningitis, even when excluding infants with early antibiotic administration. No single clinical prediction rule had the optimal discriminatory power for predicting culture-proven bacterial meningitis, and clinicians should be cautious when interpreting CSF WBC parameters in infants with suspected meningitis.

Clinical characteristics and outcomes in febrile infants aged 29-90 days with urinary tract infections and cerebrospinal fluid pleocytosis.

Fever without a focus is a common reason for medical evaluations, hospitalizations, and the antimicrobial treatment of infants younger than 90 days. The presence of cerebrospinal fluid (CSF) pleocytosis could be challenge for clinicians who treat febrile young infants with urinary tract infection (UTI). We evaluated the factors associated with sterile CSF pleocytosis and the clinical outcomes of the patients. A retrospective review of patients aged 29-90 days with febrile UTIs who underwent a non-traumatic lumbar puncture (LP) at Pusan National University Hospital from January 2010 to December 2020 was conducted. CSF pleocytosis was defined as white blood cell (WBC) counts ≥9/mm3. A total of 156 patients with UTI were eligible for this study. Four (2.6%) had concomitant bacteremia. However, no patients had culture-proven bacterial meningitis. In correlation analysis, although weak strength, CSF WBC counts were positively correlated with C-reactive protein (CRP) level (Spearman r = 0.234; P = 0.003). Thirty-three patients had CSF pleocytosis [21.2%; 95% confidential interval (CI), 15.5-28.2]. The time from fever onset to the hospital visit, peripheral blood platelet counts, and CRP level at admission were statistically significant in patients with sterile CSF pleocytosis compared to those without CSF pleocytosis. In the multiple logistic regression, only CRP was independently associated with sterile CSF pleocytosis (cutoff, 3.425 mg/dl; adjusted odds ratio, 2.77; 95% CI, 1.19-6.88). The proportion of fever defervescence by hospital day 2 was 87.9% in patients with CSF pleocytosis and 89.4% in those without CSF pleocytosis (P = 0.759). There was no statistical difference in the fever defervescence curves between the two patient groups (P = 0.567). No patients had neurological manifestations or complications. Coexisting sterile CSF pleocytosis among febrile infants with UTIs suggest a systemic inflammatory response. However, the clinical outcomes between the two groups were similar. A selective LP should be considered in young infants with evidence of UTI, and inappropriate antibiotic therapy for sterile CSF pleocytosis should be avoided.

Acinetobacter Meningitis: A Retrospective Study on its Incidence and Mortality Rates in Postoperative Patients at a Tertiary Care Centre in Northern India

Introduction: Acinetobacter species is a non fermenting, Gram negative bacillus, a causative pathogen of hospital-acquired infections due to its inherent Multidrug-Resistant (MDR) property. It is held responsible for the majority of nosocomial meningitis in patients undergoing neurosurgical procedures. Aim: To identify the clinical characteristics, drug-resistance and mortality rate among the patients suffering from meningitis caused by Acinetobacter baumannii. Materials and Methods: This retrospective study was carried out in the Bacteriology section of the Department of Microbiology at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, from February 2019 to February 2022. A total of 150 Cerebrospinal Fluid (CSF) samples from routine bacterial culture-confirmed patients were included in the study. All clinical data were extracted from the Hospital Information System (HIS). All the isolates were identified by Matrix Assisted Laser Desorption/Ionisation-Time of FlightMass Spectrometry (MALDI-TOF-MS) assay and antibiotic sensitivity testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: The study included 150 (7.55%) cases of culture-proven bacterial meningitis among 1,986 CSF samples collected from February 2019 to February 2022. There were 45 (30.0%) cases of Acinetobacter meningitis. Thirty-five (77.8%) patients had undergone neurosurgical procedures for the removal of spaceoccupying lesions from the brain parenchyma. Forty-two (93.3%) isolates were resistant to amikacin and a cumulative resistance of almost 93.3% to 95.6% was observed among cephalosporins. Fluoroquinolone resistance was observed in 43 (95.6%) patients and carbapenem resistance was observed in 42 (93.33%) isolates. Overall, 12 (26.7%) succumbed to their infections. Conclusion: Acinetobacter meningitis causes delay in the recovery of the patient undergoing intracranial surgery, amounting to a delay in brain parenchyma healing in the case of neurosurgical patients.

Accuracy of Clinical and Cerebrospinal Fluid Indicators in the Diagnosis of Bacterial Meningitis in Infants

The diagnosis of bacterial meningitis (BM) is problematic in young infants, as clinical features may be nonspecific or even absent. Cerebrospinal fluid (CSF) analysis usually confirms the diagnosis, but the CSF parameters can be normal also in culture-proven BM. Our objective was to identify the clinical and CSF indices, that quickly and without laboratory likely lead to the diagnosis of confirmed of probable BM in young infants in Angola. We conducted a prospective, observational, single-site study from February 2016 to October 2017 in the Pediatric Hospital of Luanda. All assessed infants showed symptoms and signs compatible of BM or neonatal sepsis and were <90 days of age. Of the 1088 infants, 212 (19%) showed bacteria in CSF, while 88 (8%) had probable BM. Independent clinical indicators of BM were not-clear CSF, seizures, weight <2500 g and illness >7 days. In infants with BM, CSF leukocytes were >10 × 106/L in 46%, CSF glucose <25 mg/dL in 43% and CSF protein >120 mg/dL in 58%. All measured parameters were in normal range in 25% of patients. In 515 infants with normal CSF parameters, bacteria were found in 74 (14%). In these infants, illness >7 days, weight <2500 g and malnutrition increased the probability of BM. Our study confirms and underlines the problems in diagnosing BM in young infants. While the CSF parameters were normal in 25% of infants, the easily recognizable unclear appearance of CSF was the single strongest predictor of BM.

Prevalence of Bacterial Meningitis Among Febrile Infants Aged 29-60 Days With Positive Urinalysis Results

Fever in the first months of life remains one of the most common pediatric problems. Urinary tract infections are the most frequent serious bacterial infections in this population. All published guidelines and quality initiatives for febrile young infants recommend lumbar puncture (LP) and cerebrospinal fluid (CSF) testing on the basis of a positive urinalysis result to exclude bacterial meningitis as a cause. For well infants older than 28 days with an abnormal urinalysis result, LP remains controversial. To assess the prevalence of bacterial meningitis among febrile infants 29 to 60 days of age with a positive urinalysis result to evaluate whether LP is routinely required. MEDLINE and Embase were searched for articles published from January 1, 2000, to July 25, 2018, with deliberate limitation to recent studies. Before analysis, the search was repeated (October 6, 2019) to ensure that new studies were included. Studies that reported on healthy, full-term, well-appearing febrile infants 29 to 60 days of age for whom patient-level data could be ascertained for urinalysis results and meningitis status were included. Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and used the Newcastle-Ottawa Scale to assess bias. Pooled prevalences and odds ratios (ORs) were estimated using random-effect models. The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with positive urinalysis results. The secondary outcome was the prevalence of bacterial meningitis, defined by CSF testing or suggestive history at clinical follow-up. The parent search yielded 3227 records; 48 studies were included (17 distinct data sets of 25 374 infants). The prevalence of culture-proven meningitis was 0.44% (95% CI, 0.25%-0.78%) among 2703 infants with positive urinalysis results compared with 0.50% (95% CI, 0.33%-0.76%) among 10 032 infants with negative urinalysis results (OR, 0.74; 95% CI, 0.39-1.38). The prevalence of bacterial meningitis was 0.25% (95% CI, 0.14%-0.45%) among 4737 infants with meningitis status ascertained by CSF testing or clinical follow-up and 0.28% (95% CI, 0.21%-0.36%) among 20 637 infants with positive and negative urinalysis results (OR, 0.89; 95% CI, 0.48-1.68). In this systematic review and meta-analysis, the prevalence of bacterial meningitis in well-appearing febrile infants 29 to 60 days of age with positive urinalysis results ranged from 0.25% to 0.44% and was not higher than that in infants with negative urinalysis results. These results suggest that for these infants, the decision to use LP should not be guided by urinalysis results alone.

Neonatal Bacterial Meningitis: Single Reference Center Experience and Review of Current Literature: A Retrospective Cohort Study

OBJECTIVE: Despite improvements in neonatal care, neonatal bacterial meningitis is still an emerging problem worldwide with high rates of mortality. The present study evaluates data on suspected- and culture-proven neonatal bacterial meningitis in the light of a single tertiary reference center experience in Turkey in comparison with the globe. STUDY DESIGN: In this retrospective cohort study newborns admitted to Hacettepe University Ihsan Dogramaci Children’s Hospital Neonatal Intensive Care Unit during a 5-year-period between April 2014-May 2019 and who underwent atraumatic lumbar puncture were included. RESULTS: Two hundred sixty-four patients fulfilled the inclusion criteria. Most common symptoms in all patients raised suspicion in favor of NBM and resulted in lumbar puncture were fever (34.5%, n=91), respiratory distress (31.1%, n=82), lethargy (31.1%, n=82), and apnea (26.1%, n=69). The incidence of culture-proven NBM among suspected patients was 5.7% (n=15/264); while the incidence is 3.1 per 1000 (15/4574) at all Neonatal Intensive Care Unit admissions. Respiratory distress (60.0%, n=9/15) and apnea (40.0%, n=6/15) were the most common symptoms in patients with NBM; which may be due to the predominance of premature newborns in the NBM group. The most common microorganisms in CSF cultures were coagulase-negative Staphylococci with Methicillin-resistant Staphylococcus epidermidis being most common among all. CONCLUSIONS: The present study underlines high rates of culture-proven neonatal bacterial meningitis among suspected newborns despite improvements in modern health care, which raises attention to careful evaluation of these patients and early administration of properly-selected antibiotics. Our incidence rates are in keeping with studies from the developed world.

78 CONCOMITANT MENINGITIS AMONG FEBRILE YOUNG INFANTS 29-60 DAYS OLD WITH A POSITIVE URINALYSIS AND THE NEED FOR LUMBAR PUNCTURE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Fever among infants in the first months of life remains among the most common pediatric problems in the Emergency Department (ED) setting. These infants are at increased risk of potentially life-threatening serious bacterial infection (SBI), specifically urinary tract infections (UTIs), bacteremia and bacterial meningitis. Infants with UTIs have historically been considered at increased risk of bacterial meningitis. A presumptive diagnosis of UTI relies entirely upon abnormal urinalysis results in the ED, prompting further invasive testing by lumbar puncture, broad-spectrum antibiotic exposure and hospitalization. However, the necessity of lumbar puncture for infants older than 28 days on the basis of an abnormal urinalysis has been questioned for over a decade and remains controversial. Objectives The objective of this study was to estimate the prevalence of meningitis among well-appearing, febrile infants aged 29-60 days with a positive urinalysis, to inform whether routine CSF testing is required in these patients. Design/Methods We searched MEDLINE and Embase for articles published from January 1, 2000 to July 25, 2018, deliberately limiting the search to recent studies to account for: 1) changing SBI epidemiology; 2) evolving clinical definitions of UTI; and, 3) improvements in urinalysis diagnostic accuracy for febrile young infants. Studies were eligible for inclusion if they reported urinalysis results and SBI prevalence. In the case of studies reporting UTI prevalence but not UA results, or aggregate data only, the corresponding authors were contacted for details. The primary outcome was the prevalence of culture-proven bacterial meningitis among infants with a positive urinalysis. The secondary outcome was the prevalence of bacterial meningitis among infants with a positive urinalysis, defined by either a positive CSF culture or a suggestive history at 1-month post-discharge if CSF testing was not undertaken in the ED. Studies were assessed for bias using the Critical Appraisal Skills Programme (CASP) tool, and prevalence estimates for bacterial meningitis were pooled in a random effects meta-analysis. Results The parent search yielded 2334 unique citations, of which screening by title and abstract identified 106 for full text review. Eleven studies met inclusion and were ultimately included in the final meta-analysis. Seven studies did not have significant risk of bias for the primary outcome of interest. Among 1430 febrile infants with a positive urinalysis and CSF testing performed, 5 infants had culture-proven bacterial meningitis (primary outcome; prevalence 0.33%, 95% CI: 0.1% to 0.79%). Only these same 5 infants were considered to have bacterial meningitis among 2311 infants with a positive urinalysis and meningitis status ascertained by either CSF testing or clinical follow-up (secondary outcome; prevalence 0.24%, 95% CI: 0.08 to 0.54%). Conclusion The prevalence of bacterial meningitis in well appearing febrile infants aged 29-60 days with a positive urinalysis is low. The practice of lumbar puncture in this subgroup of infants should not be guided by urinalysis results alone, but rather on the basis of other clinical criteria. Results should inform decisions regarding invasive testing and aid in shared decision-making.

74 MULTICENTER VALIDATION OF CORRECTION FACTORS FOR CEREBROSPINAL FLUID LABORATORY VALUES IN YOUNG INFANTS WITH A TRAUMATIC LUMBAR PUNCTURE

Abstract Background The evaluation of fever among infants in the first months of life remains one of the most common problems in pediatric healthcare. Approximately 10% harbor potentially life-threatening infections including bacterial meningitis, frequently necessitating invasive cerebrospinal fluid (CSF) testing by lumbar puncture (LP). LPs are often traumatic leading to uninterpretable results and consequently, broad-spectrum antibiotic exposure and prolonged hospitalization. Several strategies have been proposed to identify low-risk infants with traumatic LPs, including recently-derived correction factors, however studies validating the safety and diagnostic utility of such approaches are lacking. Objectives To evaluate the test characteristics and misclassification rates of recently described ratio-based correction methods for the interpretation of CSF results among young infants with traumatic LPs. Design/Methods We undertook a multicenter cohort study of infants aged ≤60 days with a traumatic LP performed at two urban tertiary Pediatric hospitals from 2006 to 2018. Traumatic LPs were defined as CSF specimens with ≥10,000 RBCs/mm3, and for infants aged ≤28 days and 29-60 days, pleocytosis was defined as ≥20 and ≥10 WBC/mm3, respectively, and abnormal protein ≥1.15 and ≥0.89 g/L, respectively. CSF WBCs and protein were adjusted downward for traumatic LPs using RBC ratio-based correction methods (newly derived 877:1, commonly used 500 and 1000:1, peripheral RBC:WBC ratio, and newly derived 1000 RBCs:0.011g/L protein). Descriptive statistics are presented with sensitivity, specificity, and negative predictive values of unadjusted and adjusted CSF for predicting culture-proven bacterial meningitis. Results Of 4,912 LPs meeting inclusion criteria, 437 (8.9%) were traumatic, among which 4 (0.9%) were positive for bacterial meningitis. Compared to uncorrected CSF WBC counts, both 877 and 1000 correction factors classified fewer infants with pleocytosis (38.0% and 42.6% vs 81.7%). These correction factors both maintained 100% sensitivity and 100% negative predictive value, and performed with greater specificity for bacterial meningitis than the uncorrected WBC count (62.6% and 58.0% vs 18.5%). No infants with bacterial meningitis were misclassified using either 877 or 1000:1 correction factors. CSF 500:1 and peripheral RBC:WBC correction ratios performed with the lowest sensitivity and negative predictive values and both misclassified 1 infant with bacterial meningitis. Corrected CSF protein outperformed uncorrected protein in specificity (66.8% vs 33.9%), but did not add diagnostic value when used in combination with WBC correction ratios. Conclusion Correction of the CSF WBC count substantially reduced the number of infants classified with CSF pleocytosis. The newly-derived 877:1 correction factor performed with the best test characteristics, safely reclassifying nearly half of all infants with a traumatic LP. It may be appropriate to use a correction factor in the evaluation of CSF cell counts in traumatic LPs in order to more effectively risk-stratify febrile young infants, reduce antibiotic exposure and admission duration.

2587. Etiology and Outcome of Acute Neonatal Infectious Encephalitis

BackgroundThere are very few studies on acute encephalitis with onset during the neonatal period. The objectives of this study were to investigate the etiology and salient clinical features of neonatal encephalitis.MethodsNeonates with possible infectious encephalitis (IE) were prospectively enrolled. Inclusion criteria included encephalopathy (altered/fluctuating level of consciousness ≥24 hours) plus ≥2 of: fever/temperature instability; seizure(s); focal neurologic findings; CSF pleocytosis; EEG abnormalities consistent with encephalitis; neuroimaging abnormalities consistent with encephalitis. Neonates with a clear diagnosis of post-perinatal asphyxial encephalopathy or culture proven bacterial meningitis were excluded. Results shown as absolute numbers, proportions or medians [interquartile range] as appropriate.ResultsFifty-nine neonates fulfilled the inclusion/exclusion criteria (June 2013–November 2018). Empiric acyclovir was initiated in 49 (83.1%) cases. An infectious etiology was identified in 25 (42.4%): enteroviruses (n = 15), HSV (n = 5), HHV6 (n = 2), parainfluenza 3 (n = 1), influenza A (n = 1), CMV (n = 1). A noninfectious cause was confirmed in 20 (33.9%): missed hypoxic-ischemic encephalopathy (n = 10), genetic/metabolic disorders (n = 7), ischemic/hemorrhagic stroke (n = 3). No specific etiology was identified in 14 (23.7%). Thirteen (52%) neonates with IE either died (n = 7) or suffered neurologic sequelae (n = 6). Deaths were attributable to HSV (n = 4), enteroviruses (n = 2) and HHV6 (n = 1). Neurocognitive sequelae were documented in one case each of enterovirus, HSV2, HHV6, CMV, parainfluenza 3 and influenza A. Differences between neonates with and without IE, respectively, included age in days of symptom onset (7 [6, 10] vs. 1 [0, 3]; P < 0.001), gestational age (37.0 [36.0, 39.0] vs. 38.6 [37.6, 40.0]; P = 0.045), peripheral leukocyte count (10.5 [IQR 5.9, 14.6] vs. 14.3 [IQR 10.7, 21.7]; P = 0.008) and CSF glucose (2.80 [IQR 2.3, 3.2] vs. 3.10 [2.8, 3.8]; P = 0.003).ConclusionEnteroviruses and HSV are the predominant causes of neonatal IE. Outcome of neonatal IE is poor with approximately half dying or suffering neurologic sequelae.Disclosures All authors: No reported disclosures.

Anaerobic bacterial meningitis in adults

Anaerobic infection is a very uncommon condition in adult bacterial meningitis (ABM), and its clinical characteristics have yet to be clarified. We enrolled 540 patients with culture-proven bacterial meningitis during a study period of 30 years (1986–2015), of whom 13 (2.4%) had anaerobic infections. These 13 patients were eight men and five women, aged 22–77 years. Among them, 53.8% (7/13) had a postneurosurgical state as the preceding event, and 79.6% (10/13) had underlying medical conditions including diabetes mellitus, malignancy, liver cirrhosis, cerebral infarct and alcoholism. Nosocomial and mixed infections were found in 15.5% (2/13) and 46.1% (6/13) of the patients, respectively. A total of 14 anaerobic strains were isolated from cerebrospinal fluid specimens, including nine Gram-negative (G(−)) strains: Fusobacterium nucleatum (3), Prevotella species (3) and Bacteroides fragilis (3), and five Gram-positive (G(+)) strains: Propionibacterium acnes (3) and Peptostreptococcus micros (also known as Parvimonas micra) (2). All of the implicated G(+) anaerobic bacteria were susceptible to penicillin, and no multiple drug-resistant strains were found among the implicated G(−) anaerobic bacteria. Despite treatment, 30.8% (4/13) of the patients died. Of the nine survivors, 22.2% (2/9) had a full recovery, while the other 77.8% (7/9) had varying degrees of neurological deficits. Compared with the good outcome group (n = 6, modified Rankin scale (mRS) scores: 0–2), the poor outcome group (n = 7, mRS scores ≧3) had higher incidence of seizure. These results may offer a preliminary view of the clinical characteristics of anaerobic ABM.

Response of Vancomycin according to Steroid Dosage in Pediatric Patients with Culture-Proven Bacterial Meningitis.

BackgroundThis study aimed to evaluate the efficacy of combined vancomycin and steroid therapy for the treatment of culture-proven bacterial meningitis in pediatric patients.Materials and MethodsWe identified a total of 86 pediatric patients with culture-positive cerebrospinal fluid who were treated at our facility between 2005 and 2015. Ten of these patients (5 boys and 5 girls) received first-line treatment with vancomycin as the initial form of therapy. All cultured bacteria were sensitive to vancomycin. We retrospectively analyzed these cases to examine the relationship between concomitant steroid dosage and antibiotic treatment effectiveness.ResultsNine of the 10 patients included in our analysis received steroid treatment. Of these, 3 received high-dose steroid therapy and 6 received low-dose steroid therapy. Five patients did not respond to vancomycin, including all 3 patients in the high-dose steroid group and 2 patients in the low-dose steroid group. Our analysis confirmed that the response rate to vancomycin treatment was significantly reduced in accordance with steroid dosage (P = 0.035). Patients who did not to respond to vancomycin with concomitant high-dose steroid administration improved clinically after the substitution of vancomycin with teicoplanin.ConclusionThe use of steroids, especially in high doses, may impair the effectiveness of vancomycin for treating bacterial meningitis in pediatric patients. Physicians should be cautious when administering concomitant steroid therapy and should carefully monitor the steroid dosage.

Cerebrospinal fluid cytokines in the diagnosis of bacterial meningitis in infants.

Bacterial meningitis poses diagnostic challenges in infants. Antibiotic pretreatment and low bacterial density diminish cerebrospinal fluid (CSF) culture yield, while laboratory parameters do not reliably identify bacterial meningitis. Pro and anti-inflammatory cytokines are elevated in bacterial meningitis and may be useful diagnostic adjuncts when CSF cultures are negative. In a prospective cohort study of infants, we used cytometric bead arrays to measure tumor necrosis factor alpha (TNF-α), interleukin 1 (IL-1), IL-6, IL-8, IL-10, and IL-12 in CSF. Receiver operating characteristic (ROC) analyses and Principal component analysis (PCA) were used to determine cytokine combinations that identified bacterial meningitis. Six hundred and eighty four infants < 6 mo were included; 11 had culture-proven bacterial meningitis. IL-6 and IL-10 were the individual cytokines possessing greatest accuracy in diagnosis of culture proven bacterial meningitis (ROC analyses; area under the concentration-time curve (AUC) 0.91; 0.9103 respectively), and performed as well as, or better than combinations identified using ROC and PCA. CSF cytokines were highly correlated with each other and with CSF white blood cell count (WBC) counts in infants with meningitis. A subset of antibiotic pretreated culture-negative subjects demonstrated cytokine patterns similar to culture positive subjects. CSF cytokine levels may aid diagnosis of bacterial meningitis, and facilitate decision-making regarding treatment for culture negative meningitis.

Analysis of clinical outcomes in pediatric bacterial meningitis focusing on patients without cerebrospinal fluid pleocytosis.

Cerebrospinal fluid (CSF) cell count and biochemical examinations and cultures form the basis for the diagnosis of bacterial meningitis. However, some patients do not have typical findings and are at a higher risk of being missed or having delayed treatment. To better understand the correlation between CSF results and outcomes, we evaluated CSF data focusing on the patients with atypical findings. This study enrolled CSF culture-proven bacterial meningitis patients aged from 1 month to 18 years in a medical center. The patients were divided into "normal" and "abnormal" groups for each laboratory result and in combination. The correlations between the laboratory results and the outcomes were analyzed. A total of 175 children with confirmed bacterial meningitis were enrolled. In CSF examinations, 16.2% of patients had normal white blood cell counts, 29.5% had normal glucose levels, 24.5% had normal protein levels, 10.2% had normal results in two items, and 8.6% had normal results in all three items. In logistic regression analysis, a normal CSF leukocyte count and increased CSF protein level were related to poor outcomes. Patients with meningitis caused by Streptococcus pneumoniae and hyponatremia were at a higher risk of mortality and the development of sequelae. In children with bacterial meningitis, nontypical CSF findings and, in particular, normal CSF leukocyte count and increased protein level may indicate a worse prognosis.

Abstract W P252: Bleeding and Infection Risk with External Ventricular Drainage and Thrombolysis for Intraventricular Hemorrhage

Introduction: Retrospective series report varying rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions or independent adjudication. Hypothesis: Risks of bleeding and infection in the ongoing CLEAR Phase III trial are not higher than those previously reported in EVD case series or earlier dose finding trials. Methods: Cases were prospectively enrolled after placement of EVD for obstructive IVH and randomized to receive thrice daily injections of 1mg/1ml of recombinant tissue plasminogen activator or placebo until clearance of the IVH or maximum 12 doses. All cases received daily CT scans and sampling of cerebrospinal fluid (CSF) for the first week. We counted any detected new hemorrhage or expansion of prior bleed on CT scan by &gt;5ml in volume or &gt; 5mm in diameter, after placement of the EVD until 30 days after its removal. Symptomatic bleeds and infections were adjudicated by an independent committee, based on previously articulated criteria. Meta-analysis of published series of EVD placement was compiled using STATA software. Results: Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 42 of 3,794 cases (1.1%) screened for CLEAR III. The first 175 cases enrolled in CLEAR III have completed adjudication of adverse events. Twenty-five subjects (14.3%) experienced one or more new bleeds or expansions, including 2 symptomatic hemorrhages (1.1%). Four cases (2.3%) had culture proven bacterial meningitis or ventriculitis, although many manifested varying sterile CSF pleocytosis in reaction to IVH. These rates were at the lower respective ranges of confidence intervals presently defined in meta-analysis of published series of EVD. Conclusion: The rates of new bleeds and bacterial meningitis/ventriculitis are very low with EVD for IVH, despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases and generalization to &gt; 60 trial sites. Any independent risk related to thrombolysis awaits unblinding of results at trial completion.

Occurrence of Pneumococcal Meningitis in Iraq

This study focuses on the relative frequency of Streptococcus pneumoniae in children with culture-proven bacterial meningitis. The epidemiology has been investigated with clinical and laboratory findings in The Central Public Health Laboratory, Iraq from April to September, 2010. From (138) samples , (55) cases (39.85 %) were diagnosed by physician as bacterial meningitis, (23) cases (16.66 %) as viral menginitis , (18) cases (13.04 %) as different medical cases (e.g febrile convulsion , meningoencephalitis , epilepsy …etc) and (42) cases (30.43 %) as unidentified medical cases. For bacterial meningitis S.pneumoniae was isolated from (10) cases (18.18 %) only. The median age for bacterial meningitis was (130.75) month and the predominance was in the age group (1-20) months which appear as (42) cases (76.36 %) . Fever was the frequent presenting symptoms in (49) cases (89.09 %) , followed vomiting in (34) cases (61.81 %) , then irritability and seizures in (29 ,25) cases (52.72 , 45.45) % respectively . In bacterial meningitis , the mean for glucose and protein levels was (44 and 65) (mg/dl) respectively.

Occurrence of Pneumococcal Meningitis in Iraq

This study focuses on the relative frequency of Streptococcus pneumoniae in children with culture-proven bacterial meningitis. The epidemiology has been investigated with clinical and laboratory findings in The Central Public Health Laboratory, Iraq from April to September, 2010. From (138) samples , (55) cases (39.85 %) were diagnosed by physician as bacterial meningitis, (23) cases (16.66 %) as viral menginitis , (18) cases (13.04 %) as different medical cases (e.g febrile convulsion , meningoencephalitis , epilepsy …etc) and (42) cases (30.43 %) as unidentified medical cases. For bacterial meningitis S.pneumoniae was isolated from (10) cases (18.18 %) only. The median age for bacterial meningitis was (130.75) month and the predominance was in the age group (1-20) months which appear as (42) cases (76.36 %) . Fever was the frequent presenting symptoms in (49) cases (89.09 %) , followed vomiting in (34) cases (61.81 %) , then irritability and seizures in (29 ,25) cases (52.72 , 45.45) % respectively . In bacterial meningitis , the mean for glucose and protein levels was (44 and 65) (mg/dl) respectively.

Can Broad-Range 16S Ribosomal Ribonucleic Acid Gene Polymerase Chain Reactions Improve the Diagnosis of Bacterial Meningitis? A Systematic Review and Meta-analysis

We aim to evaluate the accuracy of the broad-range 16S polymerase chain reaction test in the diagnosis of bacterial meningitis through a systematic review and meta-analysis. We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Registry, using the Medical Subject Headings terms "polymerase chain reaction," "RNA, ribosomal, 16S," and "bacterial meningitis." For our primary analysis, we examined the 16S polymerase chain reaction in culture-proven bacterial meningitis. In ancillary observations, we included studies of culture-negative presumed bacterial meningitis, in which there was high clinical suspicion for bacterial meningitis despite negative cerebrospinal fluid culture results. We extracted information necessary to calculate sensitivity and specificity and used bivariate hierarchic modeling meta-analysis methods to obtain pooled statistics. We also estimated potential sources of error and bias such as between-study heterogeneity and publication bias. Fourteen of 299 studies met inclusion criteria for culture-proven bacterial meningitis; 448 (16.1%) of 2,780 subjects had positive cerebrospinal fluid culture results. Pooled analysis demonstrated a sensitivity of 92% (95% confidence interval [CI] 75% to 98%), specificity of 94% (95% CI 90% to 97%), positive likelihood ratio of 16.26 (95% CI 9.07 to 29.14), and negative likelihood ratio of 0.09 (95% CI 0.03 to 0.28) for culture-proven bacterial meningitis. The polymerase chain reaction test result was also positive in 30% of cases of culture-negative presumed bacterial meningitis. There was significant heterogeneity between studies. This meta-analysis supports the role of 16S ribosomal ribonucleic acid polymerase chain reaction as a diagnostic tool in bacterial meningitis. With further refinements in technology, the polymerase chain reaction test has the potential to become a useful adjunct in the diagnosis of bacterial meningitis in the emergency department.

Factors for poor prognosis of neonatal bacterial meningitis in a medical center in Northern Taiwan

Bacterial meningitis has long been a severe infectious disease in neonates, as well as a leading cause of adverse outcomes. We designed this study to know the factors for poor prognosis in neonatal bacterial meningitis. We enrolled children aged less than 1 month who were admitted to Mackay Memorial Hospital from 1984 to 2008 and had culture-proven bacterial meningitis. The laboratory data and children's clinical features were recorded. The patients' outcomes were divided into four groups: death, having sequelae, complete recovery, and loss to follow-up. Patients with the outcomes of death and having sequelae were regarded as having a poor prognosis. Those who were lost to follow-up were excluded from the analysis of outcome. Multivariate analyses were performed to find the risk factors for poor prognosis. One hundred fifty-six neonates fulfilled the inclusion criteria. Among these, 96 were boys (61.5%) and 102 (65.4%) had concomitant bacteremia. Group B streptococci (39.1%) and Escherichia coli (20.1%) were the two leading pathogens. Excluding those who were lost to follow-up (4.5%), 22 of 149 patients (14.8%) died, 36 (24.2%) had sequelae, and 91 (61.1%) recovered completely. Cerebrospinal fluid (CSF) protein more than 500 mg/dL at admission {odds ratio (OR): 171.18 [95% confidence interval (CI): 25.6-1000]}, predisposition to congenital heart disease [OR: 48.96 (95% CI: 6.06-395.64)], hearing impairment found during hospitalization [OR: 23.40 (95% CI: 3.62-151.25)], and seizure at admission or during hospitalization [OR: 10.10 (95% CI: 2.11-48.32)] were the factors predicting poor prognosis. In this 25-year study of newborns with bacterial meningitis, approximately one-seventh of the patients died, while two-fifths had sequelae. Nearly two-thirds of these had concomitant bacteremia. Group B streptococci and E. coli remained the two leading pathogens throughout the study period. Several factors for poor prognosis in newborns with culture-proven bacterial meningitis were found: high CSF protein concentration, congenital heart disease, hearing impairment, and seizure.

The Causative Organisms of Bacterial Meningitis in Korean Children in 1996-2005

Bacterial meningitis remains a serious cause of morbidity and mortality in childhood, despite the availability of effective vaccines against Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae. The purpose of this study was to analyze data on bacterial meningitis cases in Korea from 1996 through 2005. The information of all hospitalized bacteria-proven meningitis cases was obtained from 17 university hospitals nationwide. A total of 402 cases were identified. Of these, 125 (29.9%) cases were neonates. Streptococcus agalactiae was the most common bacteria responsible for 99 (24.6%) of all cases regardless of age, followed by S. pneumoniae for 91 (22.6%) and H. influenzae for 67 (16.7%) patients. The common etiology beyond the neonatal period was S. pneumoniae for 91 (33.0%) followed by H. influenzae for 63 (22.8%) patients. The overall case fatality rate was 9.4%, which was similar with that in 1986-1995. In conclusion, S. agalactiae, S. pneumoniae and H. influenzae were important etiologic agents of bacterial meningitis in children in the last 10 yrs. It is required to establish the preventive strategy of the three bacteria. The nationwide epidemiologic study should be continued to evaluate immunization strategy and efficacy.

Burden of group A streptococcal meningitis in Salvador, Brazil: report of 11 years of population-based surveillance

Over recent decades, a resurgence of invasive group A streptococcal (GAS) infections has been observed; GAS remains a rare cause of pyogenic meningitis. We report herein population-based findings of long-term surveillance for GAS meningitis in Salvador, Brazil, and estimate the overall burden of invasive GAS infections. From February 1996 to February 2007 we conducted active surveillance for GAS meningitis in the state reference hospital for infectious diseases in Salvador, Brazil. Data on clinical presentation, laboratory records, and outcome were collected through interviews and chart review. GAS isolates were evaluated for antimicrobial susceptibility and emm type. We identified 20 cases of GAS meningitis, which accounted for 0.9% of all culture-proven bacterial meningitis in the study period. The mean annual incidence of GAS meningitis was 0.03 cases per 100,000 population in metropolitan Salvador and peaked in children <1 year of age (0.67 cases per 100,000 population). Among 17 cases with clinical information available, 41% required intensive care unit support and 25% died. Tested isolates were susceptible to penicillin and exhibited large emm type diversity. Based on the incidence of GAS meningitis, we estimate that the annual incidence of GAS infection is 3 cases per 100,000 population in metropolitan Salvador. Although rare, GAS is a life-threatening cause of bacterial meningitis. Knowledge of the incidence and emm type variability of the disease is necessary for planning immunization strategies.