[Childhood bacterial meningitis. Bacterial epidemiology and antibiotic resistance].
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Anti-Bacterial Agents↗
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[Concentration of proinflammatory cytokines (TNF-alpha, IL-8) in the cerebrospinal fluid and the course of bacterial meningitis].
Bacterial meningitis is still associated with high mortality rate and severe neurological sequels. The aim of the study was to assess correlation between concentration of proinflammatory cytokines (TNF-alpha, IL-1 beta, IL-8) in the cerebrospinal fluid (CSF) and patient condition described on the basis of Glasgow Coma Scale (GCS), changes in the CSF (pleocytosis, protein and glucose level), mortality rate and occurrence of neurological complications. 42 patients with bacterial meningitis have been analysed. Control group consisted of 25 patients with viral meningitis and 23 patients without meningitis. In analysed group with bacterial meningitis the correlation between number of scores aggregated by patients in GCS and outcome has been observed. Concentration of TNF-alpha, IL-1 beta, IL-8 in CSF of patient with bacterial meningitis was significantly higher (mean value; 705.2 pg/ml, 401.1 pg/ml and 1696.0 pg/ml) than in control group (viral meningitis: 7.93 pg/ml, 31.89 pg/ml, 405.28 pg/ml, without meningitis: 0.38 pg/ml, 2.55 pg/ml, 32.56 pg/ml). Negative correlation between concentration of investigated cytokines in the CSF of patient with bacterial meningitis and GCS has been observed. Furthermore TNF-alpha and IL-8 levels correlated with pleocytosis, and protein and glucose levels, whereas IL-1 beta correlated with pleocytosis and protein level in CSF. Connection between TNF-alpha and IL-1 beta but not IL-8 level and outcome of bacterial meningitis has been observed. High TNF-alpha in the CSF (median value 953 pg/ml) was associated with significant risk of patient death. IL-1 beta has been better prognostic indicator. Patients who developed neurological sequels had median value of IL-1 beta level 401.3 pg/ml, and those who died had 585.9 pg/ml vs 244.7 pg/ml in the group who survived without any complications. Analysis of the ROC curve-revealed, that concentration of IL-1 beta > or = 289.9 pg/ml with 88.9% sensitivity and 67.7% specifity differentiate cases who at risk for death. For TNF-alpha the cut-off was > or = 538.9 pg/ml. The sensitivity for determined critical point was 77%, and specificity was 68.7%. Our investigation confirm that TNF alpha, IL-1 beta, IL-8 are useful in differential diagnosis of neuroinfections. Assessment of patients with bacterial meningitis on the basis of GCS is helpful to establish prognosis, and CGS seems to correlate with the intensity of inflammation in the CSF. High concentration of TNF-alpha, and IL-1 beta in the CSF are associated with the risk of patient death during the course of bacterial meningitis, but IL-1 beta has been the better prognostic marker.
Adolescent↗
[Normocellular bacterial meningitis].
Bacterial meningitis is usually associated with pleocytosis of the cerebrospinal fluid due to the presence of polymorphonuclear leucocytes. However, 75 cases of bacterial meningitis without pleocytosis have been published. Normocellular bacterial meningitis accounts for 3.5% (1-42%) of all patients suffering from bacterial meningitis and is seen in all age groups: The finding can be explained by three different mechanisms including 1) lumbar puncture performed early in the course of meningitis, 2) immune deficiency, and 3) relative leucopenia due to severe sepsis. Normocellular bacterial meningitis is in general associated with a good prognosis except for cases with severe underlying diseases. A high concentration of bacteria in a normocellular cerebrospinal fluid might also indicate a poor prognosis.
Humans↗
Dexamethasone in adults with community-acquired bacterial meningitis.
Bacterial meningitis in adults is a severe disease with high fatality and morbidity rates. Experimental studies have shown that the inflammatory response in the subarachnoid space is associated with an unfavourable outcome. In these experiments, corticosteroids, and in particular dexamethasone, were able to reduce the inflammatory cascades in the subarachnoid space. The use of corticosteroids as adjunctive therapy in adults with bacterial meningitis has been evaluated in six studies, performed over a time period of 40 years. Most studies on adjunctive dexamethasone therapy in adults with bacterial meningitis were limited by methodological flaws. In 2002, a study with sufficient statistical power to show significant differences was published. This European Dexamethasone Study showed that adjunctive dexamethasone therapy reduced the rate of unfavourable outcomes in adults with bacterial meningitis from 25% to 15%. In this study, adjunctive treatment with dexamethasone was given before or with the first dose of antibacterials, without serious adverse effects. A quantitative review showed a consistent beneficial effect of dexamethasone on mortality and a borderline statistical beneficial effect on neurological sequelae. On the basis of the available evidence, adjunctive dexamethasone therapy should be initiated before or with the first dose of antibacterials and continued for 4 days in all adults with suspected or proven bacterial meningitis, regardless of bacterial aetiology. In patients with both meningitis and septic shock, dexamethasone therapy cannot be unequivocally recommended, but the use of lower doses seems reasonable at present. Since prompt use of dexamethasone and appropriate antibacterials improves the prognosis of adults with bacterial meningitis, hospitals will require protocols to include dexamethasone with the initial antibacterial therapy.
Adult↗
Timing of Administration of Antimicrobial Therapy in Bacterial Meningitis.
Bacterial meningitis is an important cause of morbidity and mortality in the United States and throughout the world. The diagnosis of bacterial meningitis is often delayed in patients as a result of numerous factors such as length of illness, use of radiologic imaging studies, and/or prior use of antimicrobial agents. Many textbooks emphasize the need for prompt initiation of antimicrobial therapy in a patient with suspected acute bacterial meningitis to prevent many of the long-term sequelae associated with this disorder. We have reviewed the literature to determine if there is a standard of care for timing of administration of antimicrobial therapy in patients with a diagnosis of acute bacterial meningitis. Although the clinical data are inconclusive, it makes intuitive sense to initiate antimicrobial therapy as soon as possible in any patient with suspected or proven bacterial meningitis before the patient's illness advances to a high level of clinical severity, beyond which antimicrobial therapy is less likely to be of benefit. However, clinical experiences suggest that patient outcome in bacterial meningitis is a result of multiple factors, since some patients treated within a few hours of symptoms develop an adverse outcome whereas others who are symptomatic for days prior to presentation suffer no adverse sequelae.
Journal Article↗
Children who are seen but not referred: hearing assessment after bacterial meningitis.
Bacterial meningitis is an important cause of hearing loss in children. Previous studies have shown that a proportion of survivors of childhood bacterial meningitis do not have a formal hearing assessment. To confirm this finding amongst children treated for bacterial meningitis in our hospital, a retrospective audit was performed. The hospital case notes and community audiological records were examined to see how many children were referred for hearing assessment after their illness, and how many actually attended. Between 1984 and 1991, 194 children were directly admitted to our hospital with bacterial meningitis. Thirteen children died, and hearing assessment was carried out on 135 of the 181 survivors (75%), 15 of whom had evidence of sensorineural hearing loss. The major reason for hearing not being assessed was non-referral (31 out of 46 cases), 12 children did not attend for assessment despite referral, and three moved shortly after discharge. Thirty of the children remaining in the area who had no assessment (69.7%) were however seen in hospital out-patients. Routine referral for hearing testing at discharge, with re-referral at out-patient attendance, could help increase the number of children assessed after bacterial meningitis.
Aftercare↗
Pathogenesis and pathophysiology of bacterial meningitis.
Bacterial meningitis remains a disease with associated unacceptable morbidity and mortality rates despite the availability of effective bactericidal antimicrobial therapy. Through the use of experimental animal models of infection, a great deal of information has been gleaned concerning the pathogenic and pathophysiologic mechanisms operable in bacterial meningitis. Most cases of bacterial meningitis begin with host acquisition of a new organism by nasopharyngeal colonization followed by systemic invasion and development of a high-grade bacteremia. Bacterial encapsulation contributes to this bacteremia by inhibiting neutrophil phagocytosis and resisting classic complement-mediated bactericidal activity. Central nervous system invasion then occurs, although the exact site of bacterial traversal into the central nervous system is unknown. By production and/or release of virulence factors into and stimulation of formation of inflammatory cytokines within the central nervous system, meningeal pathogens increase permeability of the blood-brain barrier, thus allowing protein and neutrophils to move into the subarachnoid space. There is then an intense subarachnoid space inflammatory response, which leads to many of the pathophysiologic consequences of bacterial meningitis, including cerebral edema and increased intracranial pressure. Attenuation of this inflammatory response with adjunctive dexamethasone therapy is associated with reduced concentrations of tumor necrosis factor in the cerebrospinal fluid, with diminished cerebrospinal fluid leukocytosis, and perhaps with improvement of morbidity, as demonstrated in recent clinical trials. Further information on the pathogenesis and pathophysiology of bacterial meningitis should lead to the development of more innovative treatment and/or preventive strategies for this disorder.
Animals↗
Laboratory aids in the diagnosis of bacterial meningitis.
Bacterial meningitis is a uncommon but serious infectious disease. Critical care personnel have a great deal of difficulty in differentiating aseptic meningitis from partially treated meningitis from bacterial meningitis. Such a differentiation has obvious implications for therapy and prognosis. This article provides guidelines in using clinical criteria as well as cerebrospinal fluid parameters to diagnosis the commonly encountered infectious causes of meningitis. The current interpretation of laboratory tests such as countercurrent immunoelectrophoresis, latex agglutination, enzyme-linked immunosorbent assays, limulus assays, and lactic acid levels are discussed.
Bacterial Infections↗
Laboratory diagnosis of bacterial meningitis.
Bacterial meningitis is relatively common, can progress rapidly, and can result in death or permanent debilitation. This infection justifiably elicits strong emotional reactions and, hopefully, immediate medical intervention. This review is a brief presentation of the pathogenesis of bacterial meningitis and a review of current knowledge, literature, and recommendations on the subject of laboratory diagnosis of bacterial meningitis. Those who work in clinical microbiology laboratories should be familiar with the tests used in detecting bacteria and bacterial antigens in cerebrospinal fluid (CSF) and should always have the utmost appreciation for the fact that results of such tests must always be reported immediately. Academic and practical aspects of the laboratory diagnosis of bacterial meningitis presented in this review include the following: anatomy of the meninges; pathogenesis; changes in the composition of CSF; etiological agents; processing CSF; microscopic examination of CSF; culturing CSF; methods of detecting bacterial antigens and bacterial components in CSF (counter-immunoelectrophoresis, coagglutination, latex agglutination, enzyme-linked immunosorbent assay, Limulus amebocyte lysate assay, and gas-liquid chromatography); use of the polymerase chain reaction; and practical considerations for testing CSF for bacterial antigens.
Animals↗
Cephalosporins in childhood bacterial meningitis.
Bacterial meningitis remains one of the most common life threatening infections of childhood. There exists a conventional therapy for this disease. However, with the increasing incidence of Haemophilus strains resistant to ampicillin and chloramphenicol and Streptococcus pneumonia strains relatively resistant to penicillin, alteration of current therapeutic regimens for meningitis may become necessary. Cephalosporins were considered as alternatives to the conventional therapy for the treatment of bacterial meningitis during the past decade. However, there are still some discrepancies on the use of these against some organisms despite the advent of the cephalosporins. Thus, a review article analyzing quite a number of reliable clinical trials related to cephalosporins for the treatment of bacterial meningitis during the past decade to date is introduced.
Ampicillin↗
Effectiveness of adjunctive treatment with steroids in reducing short-term mortality in a high-risk population of children with bacterial meningitis.
Bacterial meningitis is still an important cause of death and/or persistent nervous system damage in children living in developing countries. The aim of the study was to evaluate the effectiveness of steroids in reducing mortality and neurologic sequelae in children affected by bacterial meningitis within the context of a developing country (Mozambique), where the case-fatality rate of this disease is over 30 per cent. Seventy children with bacterial meningitis were randomized to receive either conventional antibiotic therapy or antibiotic therapy plus dexamethasone. On hospital admission there were no statistically significant differences between the two groups with regard to clinical and laboratoristic features. When dexamethasone was used early mortality, within 24 h, was significantly reduced (1/34 v. 8/36, P < 0.05). Total mortality among steroid treated patients, including those who were comatose on admission, was also reduced even if the difference did not reach statistical significance. A favourable trend in terms of fewer serious neurologic abnormalities was also observed among survivors in the steroid treated patients (5/26 v. 7/24). Fever and CSF abnormalities also disappeared more rapidly in patients receiving dexamethasone (P < 0.05). This study showed that the beneficial effect of adjunctive steroid therapy in children with bacterial meningitis can be even more important in areas where the case-fatality rate of this disease is still very high.
Anti-Bacterial Agents↗
Adjunctive Corticosteroids in Adults with Bacterial Meningitis.
Bacterial meningitis is a complex disorder in which neurologic injury is caused, in part, by the causative organism and, in part, by the host's own inflammatory response. In studies of experimental bacterial meningitis, adjuvant treatment with corticosteroids, specifically dexamethasone, has beneficial effects. On the basis of these experimental studies, several clinical trials were undertaken to determine the effects of adjunctive corticosteroids in patients with bacterial meningitis. On the basis of overall benefit without detrimental effects by subgroup analysis, dexamethasone therapy should be initiated before or with the first dose of antibiotic and should be continued in most patients with community-acquired acute bacterial meningitis. For patients with a low suspicion of meningitis but an urgent need for antibiotics before cerebrospinal fluid can be obtained, we recommend initiation of treatment with dexamethasone, with discontinuation of dexamethasone therapy as soon as the diagnosis has been excluded.
Journal Article↗
The role of corticosteroids in infants and children with bacterial meningitis.
Bacterial meningitis continues to be a cause of substantial morbidity in infants and children. Hearing impairment is the most common sequela of this disease. Corticosteroids have been used in an attempt to reduce the incidence of meningitis-induced hearing loss. Some studies have demonstrated a decrease in the incidence of hearing impairment in patients treated with cefuroxime plus dexamethasone compared with cefuroxime alone. Similar data are lacking for other frequently used antibiotics. Based on these studies, the use of dexamethasone should be considered in infants and children greater than two months of age with suspected bacterial meningitis. Critical issues including the timing of steroid initiation in relation to antibiotic therapy and the appropriate antibiotic-corticosteroid regimen must be addressed. Studies should be performed to define the exact role of corticosteroids in the treatment of bacterial meningitis. Until additional data are available, we recommend the use of dexamethasone in pediatric patients older than two months of age with bacterial meningitis.
Cefotaxime↗
Conjugates and reverse vaccinology to eliminate bacterial meningitis.
Bacterial meningitis is caused mainly by Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis. Haemophilus influenzae type b vaccines have been extremely successful in eradicating the disease from those countries where the vaccine has been introduced. The recent licensure of the conjugated pneumococcal vaccine suggests that this pathogen also will be soon controlled. Consequently, if we succeed in developing effective vaccines against meningococcus, this will enable us to eliminate bacterial meningitis. The global elimination of bacterial meningitis is a goal which, if appropriate resources are applied, can be reached within the first fifteen years of the 21st century.
Adult↗
Epidemiology of bacterial meningitis.
Bacterial meningitis caused by Haemophilus influenzae type B (Hib) has almost disappeared from the United States, Canada, and other countries that have implemented routine vaccination with Hib conjugate vaccines. The overall incidence of meningitis in these countries has declined by more than 50%, and the age distribution of susceptibility has shifted, so that the disease is now more common in adults than in children. Another new feature of the epidemiology of bacterial meningitis has been the occurrence of clusters of meningococcal disease. Such clusters have been school related, mainly in adolescents, and most clusters have been associated with a clone of group C, serotype 2a. The role of cigarette smoking as a risk factor for bacterial meningitis has been confirmed and adds urgency to the efforts to control smoking in adolescents and young adults.
Adolescent↗
[The role of cytokines in bacterial meningitis].
Bacterial meningitis is the serious infection of the central nervous system (CNS), and stimulated by bacteria inflammatory host response has crucial role in its pathogenesis. The most important elements of this response are cytokines, especially tumor necrosis factor (TNF-alpha), interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and interleukin-10 (IL-10), which have antiinflammatory activity. Production of cytokines in the CNS triggers a cascade of inflammatory mediators. Better understanding of mechanisms which take place during the course of the bacterial meningitis can be useful in differential diagnosis, prognosis and treatment of this disease. Investigations on the role of cytokines in the bacterial meningitis, have great therapeutic implications, and can result in introduction to the treatment antiinflammatory drugs, which can help to reduce mortality rate and number of complications.
Anti-Inflammatory Agents↗
[A rare and serious complication of spinal anesthesia: bacterial meningitis].
Bacterial meningitis following spinal anaesthesia is a rare but serious complication. We describe a case in which an old woman received spinal anaesthesia for hip replacement. Diagnosing the aetiologic agent is a major medical challenge. The possible aetiological causes of this complication are discussed and the difficulty in differentiation between aseptic and bacterial meningitis noted.
Aged↗
Pathogenesis of bacterial meningitis.
Bacterial meningitis is fatal in 5% to 40% of patients and causes neurologic sequelae in up to 30% of survivors. Much has been learned recently about the mechanisms that lead to brain injury during meningitis. Once bacteria have gained access to the central nervous system, their multiplication triggers a complex host response consisting of humoral and cellular immune mediators, reactive oxygen intermediates, matrix-metalloproteinases, and other host-derived factors. Alterations of the cerebral vasculature, with disruption of the blood brain barrier and global and focal ischemia, ultimately lead to functional and structural brain damage. This article reviews current concepts of the pathophysiology of bacterial meningitis and emphasizes possible therapeutic strategies to prevent its harmful consequences.
Animals↗