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PubMed1950

The diagnosis and treatment of meningitis.

Treatment of meningitis is no longer a question of the administration of antimeningococcal serum and awaiting results. Today there is at hand an ever expanding armamentarium of drugs effective on various bacteria, rickettsia and some of the larger viruses. The skillful use of these singly or in combination offers an excellent prognosis in most forms of bacterial meningitis. Tuberculous meningitis continues to present a poor outlook, but this has been improved with more intensive therapy. More effective agents are needed in the treatment of this disease."Shotgun" therapy may be indicated in critically ill patients prior to accurate bacteriological diagnosis; it is more important that therapy should include an effective agent or combination of agents than to attempt to determine in advance the most potent form of specific therapy. Partially treated purulent meningitis may be confused with aseptic meningitis. There is at present no effective therapeutic agent for the viral meningitides, but the prognosis is favorable in most of these diseases without specific therapy.

Bacteria↗
PubMed1986

Arthritis in children with bacterial meningitis.

Forty-eight patients with arthritis and meningitis were identified by hospital chart review among 2,089 cases of bacterial meningitis treated between 1969 and 1984. The etiologic agents were Haemophilus influenzae in 38 cases (79%), Neisseria meningitidis in nine cases (19%), and Staphylococcus aureus in one case (2%). Thirteen patients had more than one joint affected: two affected joints, ten patients; three affected joints, two patients; and four affected joints, one patient. The elbow (34%) and knee (29%) were most frequently affected. Joint-fluid aspirations were done in 44 patients; 22 cases (50%) had bacteria or bacterial antigen identified in joint fluid by culture, Gram's stain, or counter-immunoelectrophoresis: H influenzae (20 cases), N meningitidis (one case), and S aureus (one case). Of the 48 patients, 14 patients were noted to have arthritis at the time of diagnosis of meningitis, 16 patients on the first to sixth day, and 17 patients on the seventh day of treatment or later; one patient developed arthritis 12 days after treatment of H influenzae meningitis had been stopped. Fourteen cases with a culture-proved bacterial etiology of the arthritis developed arthritis within four days of treatment; the exception was a patient who developed arthritis after treatment of meningitis was stopped. Of the 21 patients with culture-negative joint fluid and who developed arthritis later in the course of treatment, 19 patients were considered to have possible immune complex arthritis. Management consisted of antibiotic therapy in all patients, open incision and drainage in 17 patients (36%), and multiple aspirations in 12 patients (25%). Of the remaining 19 patients, 15 patients had a single arthrocentesis performed and four patients had no aspiration. Early-onset arthritis appeared to be related to bacteremia whereas late-onset arthritis may be immune complex mediated.

Adolescent↗
PubMed1986

Quantitative levels of C-reactive protein in cerebrospinal fluid in patients with bacterial meningitis and other conditions.

We measured levels of C-reactive protein (CRP) in the cerebrospinal fluid in 145 children, using a solid-phase radioimmunoassay. The CRP levels in 49 patients with culture-proved bacterial meningitis ranged from 0 to 51,000 ng/ml (median 1460 ng/ml). In 33 patients with aseptic meningitis, values were much lower range 0 to 438 ng/ml; (median 17 ng/ml). In patients with CSF pleocytosis (greater than 10 WBC/microliter), CRP greater than 100 ng/ml was 95% accurate in identifying those with bacterial meningitis. However, a few patients with bacterial meningitis and little or no CSF pleocytosis had low levels of CRP at admission. Among the 63 patients with nonmeningitic conditions, those with bacterial infections frequently (10 of 13 had CRP greater than 100 ng/ml, whereas CRP elevations were infrequent (seven (18%) of 40) in patients with viral infections and other conditions. CRP diffuses into the CSF as readily as other proteins, but in bacterial meningitis the CSF/serum ratio of CRP was lower than that of albumin and IgG. The measurement of CRP in CSF is potentially a very useful diagnostic tool, but certain inherent limitations must be recognized, because some patients may fail to mount a prompt inflammatory response.

Adolescent↗
PubMed1976

Acute bacterial meningitis in childhood. Incidence and mortality in a defined population.

Cases of acute bacterial (excluding tuberculous) meningitis and meningococcal infection, occurring in children under 10 years of age in the North-West Metropolitan region between 1969 and 1973 have been studied retrospectively by case-note review. The risk of having an acute meningococcal infection was estimated to be 1 in 1090, and that of having an attack of haemophilus meningitis to be 1 in 1500, but the age of 10 years. The case-fatality rates for meningococcal infection, haemophilus meningitis, and pneumococcal meningitis were 10.9%, 5.7%, and 16.4% respectively. Meningitis was not diagnosed in life in 26 of 94 fatal cases (28%).

Child↗
PubMed2002

[Non-tubercular bacterial meningitis in children in Antananarivo, Madagascar].

OBJECTIVE: To determine the bacterial causal agents of meningitis and their pattern of resistance, in children more than one month to 14 years of age. METHODS: A 2 years, prospective study (June 1998 to June 2000) on bacterial meningitis in children was carried out in the main hospitals in Antananarivo. The enrollment criteria upon admission were fever with symptoms of meningitis and/or convulsions and/or coma. A lumbar puncture was systematically performed in each child. The aspect of the cerebrospinal fluid was described, the level of protein and glucose estimated, soluble antigens measured. Following the examination of a Gram straining, an aliquot of the fluid was cultured on specific medium. Antimicrobial sensitivity testing of isolated pathogens was performed. RESULTS: Bacterial meningitis was confirmed in 119 children: 95 (80%) and 111 (93%) were less than 12 and 24 months of age, respectively. The sex distribution was 1:1. Three predominant microorganisms were identified: Streptococcus pneumoniae (45%), Haemophilus influenzae b (43%) and Neisseria meningitidis (10%) of which ten of 12 cases were belonging to serogroup B. The other microorganisms isolated were E. coli (2%). S. pneumoniae were found to be sensitive to penicillin G and H. influenzae were found to be sensitive to the third generation cephalosporins. Seven percent of the S. pneumoniae strains were mildly resistant (R + I) to chloramphenicol and between 29 and 50% to aminoglucosides. A moderate resistance against gentamicin and amoxicillin was found in 22-29% of the H. influenzae strains. The mortality rate was high (31%) and among the surviving children 30% presented with neurosensitive disorders. CONCLUSION: According to these data we may recommend the inclusion of vaccination against H. influenzae in the children immunization program in Madagascar. The early diagnosis and treatment with appropriate antibiotics, such as third generation of cephalosporins, are other critical measures to be taken in order to reduce the risk of developing severe complications associated to bacterial meningitis.

Adolescent↗
PubMed1997

Pattern of bacterial meningitis in Italy, 1994.

During 1994, 603 cases of bacterial meningitis were reported in Italy. Seventy-five percent of cases with determined etiology was due to three agents: Neisseria meningitidis (33.4%), Streptococcus pneumoniae (23.4%) and Haemophilus influenzae (18.6%). The majority of cases due to N. meningitidis and H. influenzae occurred in subjects below five years of age (35.7% and 84.8%, respectively) while S. pneumoniae accounted for 52.8% of meningitis cases in subjects older than 44 year of age. The estimated incidence of N. meningitidis on the national population in 1994 was 0.27 per 100,000. Serogroup B accounted for 62.5% of the serotyped isolates, group C for 23.1%, group A for 7.2%, group W135 for 3.6%, group Y for 1.8%. All tested meningococcal strains were susceptible to penicillin as well as to rifampin. Incidence of meningococcal meningitis in 1994 has been low suggesting that its relative importance compared to other bacteria causing meningitis is likely to change in the future. Therefore, extended surveillance on bacterial meningitis by other etiological agents has to be maintained and implemented in order to undertake the appropriate control measures and evaluate their effect.

Adolescent↗
PubMed2006

[Acute meningitis in Córdoba, Colombia (2002-2004)].

OBJECTIVE: Establishing characteristic epidemiologic and microbiologic features of acute meningitis in the Córdoba department. METHODOLOGY: A descriptive epidemiological study was carried out between June 2002 and June 2004 at the Hospital San Jerónimo in Montería. All suspicious cases of meningitis were included; laboratory tests included cytological smear, biochemistry, latex, Gram stain and culture. RESULTS: 57 (11.3%) and 85 (16.8%) of the 503 samples of cerebrum spinal fluid (CSF) were confirmed by culture as being probable cases. There were 6 cases of polymicrobial infection, making a total of 63 isolates: 17 non-fermenting Gram-negative bacilli (26.9%), 16 Streptococcus pneumoniae (25.4%), 7 Enterobacteriaceae (11%), 5 Criptococcus neoformans (8%) 4 Neisseria meningitidis serotype B (6.3%), 3 S. viridans (4.8%), 2 Streptococcus group B (3.2%), 2 Haemophilus influenzae type B (3.2%), 2 Staphylococcus negative coagulase (3.2%), 2 S. aureus (3.2%), 2 Enterococcus (3.2%) and 1 Candida albicans (1.6%). The S. Pneumoniae serotypes found were: 5 (n=4), 23F (n=3), 14 (n=2), 18C (n=2), 18A (n=l1, 17F (n=l1, 1 (n=1). CONCLUSIONS: The study led to determining epidemiological and microbiological aspects of acute meningitis in the Códoba department which had been unknown up to now. Streptococcus pneumoniae (25.4% was the main aetiological agent of meningitis; the epidemiologic aspects so established confirmed the need for strengthening and implementing measures for controlling meningitis in C6ódoba and its surveillance there.

Acute Disease↗
PubMed2001

Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment.

OBJECTIVE: Despite the lack of evidence defining a time interval during which cerebrospinal fluid (CSF) culture yield will not be affected by previous antibiotic therapy, recent publications cite a "minimum window" of 2 to 3 hours for recovery of bacterial pathogens after parenteral antibiotic administration. We conducted a retrospective review of children with bacterial meningitis to describe the rate at which parenteral antibiotic pretreatment sterilizes CSF cultures. METHODS: The medical records of pediatric patients who were discharged from a tertiary children's hospital during a 5-year period with the final diagnosis of bacterial meningitis or suspected bacterial meningitis were reviewed. The decay in yield of CSF cultures over time was evaluated in patients with lumbar punctures (LP) delayed until after initiation of parenteral antibiotics and in patients with serial LPs before and after initiation of parenteral antibiotics. RESULTS: The pathogens that infected the 128 study patients were Streptococcus pneumoniae (49), Neisseria meningitidis (37), group B Streptococcus (21), Haemophilus influenzae (8), other organisms (11), and undetermined (3). Thirty-nine patients (30%) had first LPs after initiation of parenteral antibiotics, and 55 (43%) had serial LPs before and after initiation of parenteral antibiotics. After >/=50 mg/kg of a third-generation cephalosporin, 3 of 9 LPs in meningococcal meningitis were sterile within 1 hour, occurring as early as 15 minutes, and all were sterile by 2 hours. With pneumococcal disease, the first negative CSF culture occurred at 4.3 hours, with 5 of 7 cultures negative from 4 to 10 hours after initiation of parenteral antibiotics. Reduced susceptibility to beta-lactam antibiotics occurred in 11 of 46 pneumococcal isolates. Group B streptococcal cultures were positive through the first 8 hours after parenteral antibiotics. Blood cultures were positive in 74% of cases without pretreatment and in 57% to 68% of cases with negative CSF cultures. CONCLUSIONS: The temptation to initiate antimicrobial therapy may override the principle of obtaining adequate pretreatment culture material. The present study demonstrates that CSF sterilization may occur more rapidly after initiation of parenteral antibiotics than previously suggested, with complete sterilization of meningococcus within 2 hours and the beginning of sterilization of pneumococcus by 4 hours into therapy. Lack of adequate culture material may result in inability to tailor therapy to antimicrobial susceptibility or in unnecessarily prolonged treatment if the clinical presentation and laboratory data cannot exclude the possibility of bacterial meningitis.

Adolescent↗
PubMed2003

[Etiology and clinical course of meningitis in children].

The aim of the paper was to pinpoint the etiological factors which caused meningitis, and to describe the course of the illness in the patients hospitalized in the years 1991-2000 at the observation ward of the Paediatrics Propaedeutics Clinic of the Paediatrics Institute. Etiological factors were determined in 42 of 80 cases included in the study: in 32 out of 62 purulent meningitis cases and 10 out of 18 aseptic meningitis cases. In purulent meningitis the most commonly isolated pathogens were N. meningitidis (16%), S. pneumoniae (8.1%), K. pneumoniae (4.9%) and H. influenzae type B (4.9%), where as in aseptic meningitis--mumps and herpes viruses. Despite appropriate treatment in 47% of cases there were observed complications such as hydrocephalus, brain oedema, ependymitis as well as hearing or vision impairment and failure to thrive.

Adolescent↗
PubMed1992

Childhood bacterial meningitis in Al-Baha province, Saudi Arabia.

A retrospective review of 71 paediatric patients admitted with bacterial meningitis to the King Fahad Hospital at Al-Baha, Saudi Arabia, during an 8-year period revealed a preponderance of males (67.6%) and young subjects with 88.7% being below 24 months of age. The commonest cerebrospinal fluid pathogens in the series were Haemophilus influenzae type B (HIB), Streptococcus pneumoniae and Group B-beta haemolytic streptococcus, which were responsible for 47.3, 34.5 and 9.1% of cases respectively. Neisseria meningitidis which is a major cause of meningitis in most other reports was uncommon in the present series, and was isolated from only two patients. All the children with Group B-beta haemolytic streptococcal meningitis were below 3 months of age while 96.2% of the children with HIB meningitis were younger than 2 years. Mortality was highest (40%) among the infants with Group B-beta haemolytic streptococcal meningitis. Six (23.1%) of the HIB isolated were resistant to ampicillin and two (7.7%) were resistant to both ampicillin and chloramphenicol. There is a need for greater emphasis on prevention through the use of available vaccines including the newly introduced conjugate vaccines against HIB which are capable of eliciting immune responses in infants as young as 2 months.

Bacteremia↗
PubMed2006

[Bacterial meningitis in adults: a retrospective multicentric study in Tuscany (Italy)].

The Infectious Diseases Unit of Lucca Hospital conducted a multicentric retrospective study to evaluate the epidemiological and clinical features of adult patients affected by bacterial meningitis attending all the Infectious Diseases Units of Tuscany (Italy) from July 1999 to June 2004. A specific questionnaire was sent to all the units to collect information about each case of bacterial meningitis occurring in patients older than sixteen. Patients with meningitis by Mycobacterium tuberculosis were excluded from the analysis. Nine out of 12 Infectious Diseases Units of Tuscany took part in the study and 197 cases were identified. Most cases of meningitis occurred during 2002 with a slight reduction in cases in subsequent years. Streptococcus pneumoniae and Neisseria meningitidis were the most frequently isolated pathogens with an increase in diagnosis from 1999 to 2004; in 23.8% of patients no pathogens were isolated, with a reduction in meningitis from unknown aetiology from 1999 to 2004. Most patients were treated with a combination of two antibiotics, and corticosteroid drugs were added to the therapy; in the group of patients treated with corticosteroid drugs invalidating complications occurred in 23% of cases and 5% of patients died. In all, 27 out of 197 subjects (13.7%) developed invalidating complications and 20 out of 197 patients (10.2%) died.

Adolescent↗
PubMedDate not supplied

[Clinical-epidemiological assessment of bacterial meningitis in the province of Cordoba (1983-1989)].

533 cases of bacterial meningitis diagnosed in the province of Cordoba over a period of seven years are analyzed. 53.7% of the cases are in males, with 71.2% of the cases being detected in children under 14 (p less than 0.001). Greater incidence has been observed in Cordoba city than in the province, with a direct relationship being between morbidity and population density. The months with lower average temperature account for 45.6 por 100 of all the diagnosed cases of meningitis. By etiology, 51.9% were meningococcal meningitis, followed by meningitis produced by unknown germs (35.3%) and by H. influenzae. The illness developed in 91.3% of cases to a cure, with sequelae in 4.1% and death in 4.4%. Meningitis produced by H: influenzae was what caused most sequelae and that produced by S. pneumoniae was the most lethal. Isolated N. meningitidis presented 100% sensitivity to penicillin and cephalosporins, H. influenzae 91.7% chloramphenicol and only 28.3% to penicillin.

Adolescent↗
PubMedDate not supplied

[Evaluation of the criteria used for the interruption of treatment in bacterial meningitis (persistent pleocytosis and hyper-cervicospinal fluid proteins (author's transl)].

Among 809 patients with bacterial meningitis persistent pleocytosis greater than 60 white blood, cells/mm3, after 10 days or more of therapy, was found in 25 patients and persistent hypercervicospinal fluid proteins greater than 70 mg/dl in 24. In 14 patients there was an association of these disturbances. All cases, except one, were adequately treated. Persistent pleocytosis and hyper-cervicospinal fluid proteins, uncommon inmeningococcal meningitis, were frequent in pneumococcal and more frequent in Haemophilus influenzae meningitis. In pneumococcal and Haemophilus influenzae meningitis the incidence of neurologic sequelae was greater in patients with persistent pleocytosis and hyper-cervicospinal fluid proteins than without them. In adequately treated patients, persistent pleocytosis or hyper-cervicospinal fluid proteins alone cannot be used as an indication of prolonging or changing therapy of bacterial meningitis.

Albumins↗
PubMed1984

Meningitis in Cape Town children.

A prospective clinical and microbiological survey of 213 children who presented to the teaching hospitals of the Cape Peninsula with meningitis was performed during a winter month. The predominant bacterium isolated was Neisseria meningitidis and this survey uncovered an outbreak of viral meningitis due to echovirus 4 of the Du Toit strain. In comparison with previous studies, the absence of fever in 20% of the cases of meningococcal disease and the isolation of N. meningitidis group B organisms which were resistant to sulphonamides are noted. Cases of N. meningitidis meningitis with initial clinical and cerebrospinal fluid findings indistinguishable from those in echovirus 4 meningitis are presented to emphasize the difficulties encountered in making a differential diagnosis. We recommend that in endemic areas all children with meningitis should be observed in hospital for at least 48 hours until the diagnosis of N. meningitidis has been excluded bacteriologically.

Adolescent↗
PubMed1983

Diagnostic use of cerebrospinal fluid lactic acid levels in meningitis.

Analysis of cerebrospinal fluid lactic acid levels in 62 patients suspected of having meningitis was performed. Lactic acid was measured enzymatically using lactic acid dehydrogenase with the liberation of NADH. In a control (no meningitis) group, 46 children had a mean cerebrospinal fluid lactic acid level of 14.7 +/- 2.2 mg/dl; 3 with febrile seizure had a mean lactic acid level of 33.5 +/- 0.98 mg/dl. In 9 cases of bacterial meningitis, the mean lactic acid level was 54.8 +/- 16.8 mg/dl. In 3 patients of aseptic meningitis, the mean lactic acid level was 34.5 +/- 1.0 mg/dl. Serial lactate determination was done in three patients and they were well correlated with the clinical response and other cerebrospinal fluid findings. These data suggest that the determination of cerebrospinal fluid lactic acid may be of diagnostic value in differentiating between bacterial and aseptic meningitis.

Adolescent↗
PubMed1997

Epidemiology of post-neonatal bacterial meningitis in Cape Town children.

Bacterial meningitis is a major cause of childhood morbidity and mortality in South Africa. However, comprehensive regional or national epidemiological data, essential for rational public health interventions, are lacking. The purpose of this 1-year prospective study, from 1 August 1991 to 31 July 1992, was to define the magnitude of the problem of childhood bacterial meningitis in Cape Town. The study group consisted of all children, aged > 1 month to < 14 years, who presented with proven bacterial meningitis at all the hospitals in the Cape Town metropolitan area. During the year 201 cases were identified: 101 (50.2%) were due to Neisseria meningitidis, 74 (36.8%) were due to Haemophilus influenzae and 26 (12.9%) were due to Streptococcus pneumoniae. The overall incidence rate (95% confidence interval) for children less than 14 years, 5 years and 1 year was 34 (30-40), 76 (65-88) and 257 (213-309) per 100,000 children, respectively. The rate was highest in black infants, 416 (316-545)/100,000. This was 2 times greater than the rate in coloured infants and about 4.5 times greater than the rate in white infants. The median age of all the children was 10 months. The ages of children with haemophilus and pneumococcal meningitis were similar, 9 and 7.5 months respectively (P = 0.43), while children with meningococcal meningitis were significantly older (22 months) than the others (P < 0.01). The overall case fatality rate was 5%, and 12.9% of survivors had significant neurological sequelae (disability) on discharge.

Adolescent↗
PubMed1993

Staphylococcus aureus meningitis. A review of 104 nationwide, consecutive cases.

METHODS: Based on a nationwide registration, the clinical and bacteriologic data from 61 postoperative and 43 hematogenous cases of Staphylococcus aureus meningitis in Denmark from 1986 through 1989 were reviewed. RESULTS: Postoperative meningitis was a foreign body infection in 89% of the cases and had a lower mortality (18% [11/61]) compared with hematogenous meningitis (56% [24/43]). Hematogenous S aureus meningitis seems to be part of an overwhelming, disseminated infection as indicated by the following: 81% of the patients had bacteremia, 21% had endocarditis, and 12% had osteomyelitis. Most patients were older, often with underlying diseases, community-acquired infections, and a clinical picture of severe meningitis. The major findings were mental status changes and a high rate (34%) of focal neurological changes. The initial leukocyte count in the cerebrospinal fluid sample was low, and the bacteria were seen in Gram's stain smears in 40% of cases only. The prognosis was related to the age of the patients and the initial antibiotic treatment. Patients treated with penicillinase-stable penicillins in combination with fusidic acid may have a better prognosis. Three (12%) of 25 surviving patients had severe sequelae. CONCLUSIONS: Hematogenous S aureus meningitis is a severe disease with a high mortality related to age, presence of shock, and infection with strains of phage type 95.

Adolescent↗
PubMed1999

The challenge of drug-induced aseptic meningitis.

Several drugs can induce the development of aseptic meningitis. Drug-induced aseptic meningitis (DIAM) can mimic an infectious process as well as meningitides that are secondary to systemic disorders for which these drugs are used. Thus, DIAM constitutes a diagnostic and patient management challenge. Cases of DIAM were reviewed through a MEDLINE literature search (up to June 1998) to identify possible clinical and laboratory characteristics that would be helpful in distinguishing DIAM from other forms of meningitis or in identifying a specific drug as the culprit of DIAM. Our review showed that nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, intravenous immunoglobulins, and OKT3 antibodies (monoclonal antibodies against the T3 receptor) are the most frequent cause of DIAM. Resolution occurs several days after drug discontinuation and the clinical and cerebrospinal fluid profile (neutrophilic pleocytosis) do not allow DIAM to be distinguished from infectious meningitis. Nor are there any specific characteristics associated with a specific drug. Systemic lupus erythematosus seems to predispose to NSAID-related meningitis. We conclude that a thorough history on prior drug intake must be conducted in every case of meningitis, with special focus on those aforementioned drugs. If there is a suspicion of DIAM, a third-generation cephalosporin seems a reasonable treatment option until cerebrospinal fluid cultures are available.

Anti-Bacterial Agents↗