Antibiotic treatment delay and outcome in acute bacterial meningitis

Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs

BACKGROUND

Antibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N.

PROCEDURE

We used Lean-Methodology and a Plan-Do-Study-Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub-process times, and clinical outcomes.

RESULTS

Our QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub-process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population.

CONCLUSION

Here we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N.

[Acute care of patients with bacterial meningitis]

BACKGROUND

Bacterial meningitis is a life-threatening emergency that is still associated with high mortality and poor outcome.

OBJECTIVE

The purpose of this article is to provide a review of clinical presentation, diagnostic procedure, therapy, and prognosis in bacterial meningitis. Prognostic factors which could be influenced positively are identified and a focused procedure in the emergency setting and for the treatment of complications are provided.

MATERIAL AND METHODS

This work is based on a literature search (PubMed, guidelines) and personal experience (standard operating procedures, SOP).

RESULTS

Despite improved health care, bacterial meningitis is still associated with high mortality and poor neurological outcome, which has remained largely unaltered during recent decades. Diagnosis and, more importantly, effective therapy of bacterial meningitis are often delayed, having an immediate negative influence on clinical outcome. Neurological and nonneurological complications often necessitate intensive care and may occur rapidly or in the further course of the disease.

CONCLUSION

Immediate initiation of effective therapy is crucial to positively influence mortality and neurological outcome. Antibiotics should be administered within 30 min after admission. To achieve this, a focused and well-organized procedure in the emergency setting is necessary. Because of intra- and extracranial complications, patients need to be treated on intensive care units including neurological expertise and interdisciplinary support.

Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture

BACKGROUND

In suspected acute bacterial meningitis (ABM), cerebral computerized tomography (CT) is recommended before lumbar puncture (LP) if mental impairment. Despite guideline emphasis on early treatment, performing CT prior to LP implies a risk of delayed treatment and unfavorable outcome. Therefore, Swedish guidelines were revised in 2009, deleting impaired mental status as a contraindication for LP without prior CT scan. The aim of the present study was to evaluate the guideline revision.

METHODS

The Swedish quality registry for community-acquired ABM was analyzed retrospectively. Door-to-antibiotic time and outcome were compared among patients treated 2005-2009 (n=394) and 2010-2012 (n=318). The effect of different LP-CT sequences was analyzed during 2008-2012.

RESULTS

Adequate treatment was started 1.2 hours earlier, and significantly more patients were treated <2 hours from admission 2010-2012 than 2005-2009. Compared with CT before LP, immediate LP resulted in 1.6 hours earlier treatment, significant increase in door-to-antibiotic times of <1 and <2 hours, and a favorable outcome. In 2010-2012, mortality was lower (6.9% vs 11.7%) and the risk of sequelae at follow-up decreased (38% vs 49%) in comparison with 2005-2009. Treatment delay resulted in a significantly increased risk for fatal outcome, with a relative increase in mortality of 12.6% per hour of delay.

CONCLUSIONS

The deletion of impaired mental status as contraindication for prompt LP and LP without prior CT scan are associated with significantly earlier treatment and a favorable outcome. A revision of current international guidelines should be considered.

Diagnosis of reversible causes of coma

Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.

In-hospital management of children with bacterial meningitis in Italy

Background

Over the years 2009–2013, we conducted a prospective study within a network established by the Italian Society of Pediatrics to describe the in-hospital management of children hospitalized for acute bacterial meningitis in 19 Italian hospitals with pediatric wards.

Methods

Hospital adherence to the study was voluntary; data were derived from clinical records. Information included demographic data, dates of onset of first symptoms, hospitalization and discharge; diagnostic evaluation; etiology; antimicrobial treatment; treatment with dexamethasone; in-hospital complications; neurological sequelae and status at hospital discharge. Characteristics of in-hospital management of patients were described by causative agent.

Results

Eighty-five patients were identified; 49.4% had received an antimicrobial treatment prior to admission. Forty percent of patients were transferred from other Centers; the indication to seek for hospital care was given by the primary care pediatrician in 80% of other children. Etiological agent was confirmed in 65.9% of cases; the most common infectious organism was Neisseria meningitidis (34.1%), followed by Streptococcus pneumoniae (20%). Patients with pneumococcal meningitis had a significant longer interval between onset of first symptoms and hospital admission. Median interval between the physician suspicion of meningitis and in-hospital first antimicrobial dose was 1 hour (interquartile range [IQR]: 1–2 hours). Corticosteroids were given to 63.5% of cases independently of etiology; 63.0% of treated patients received dexamethasone within 1 hour of antibiotic treatment, and 41.2% were treated for ≤4 days. Twenty-nine patients reported at least one in-hospital complication (34.1%). Six patients had neurological sequelae at discharge (7.1%). No deaths were observed.

Conclusions

We observed a rate of meningitis sequelae at discharge similar to that reported by other western countries. Timely assistance and early treatment could have contributed to the favorable outcome that was observed in the majority of cases. Adherence to recommendation for corticosteroid adjunctive therapy seems suboptimal, and should be investigated in further studies. Most meningitis cases were due to N. meningitidis and S. pneumoniae. Reaching and maintaining adequate vaccination coverage against pneumococcal and meningococcal invasive infections remains a priority to prevent bacterial meningitis cases.

Etiology and antimicrobial resistance patterns of acute bacterial meningitis in children: a 10-year referral hospital-based study in northwest iran

Background:

Bacterial meningitis is still considered as one of the most dangerous infectious diseases, which causes numerous complications and high mortality if not diagnosed and treated timely.

Objectives:

This study was performed to determine antimicrobial resistance patterns of bacterial pathogens isolated from acute bacterial meningitis at Tabriz Children Educational-Health Care Center in Iran.

Patients and Methods:

In a retrospective study (from 2003 through 2013), all patients with bacterial meningitis were identified by cerebrospinal fluids with positive results in culture (107 cases). Patients' necessary data was recorded in a questionnaire. Furthermore, the results of simultaneous blood culture were also examined. Ultimately, antimicrobial susceptibility of isolates was determined using the disc diffusion method.

Results:

One hundred and seven patients with bacterial meningitis were identified by cerebrospinal fluids with positive results in culture. All of patients (100%) had fever (male/female = 1.27/1). The most prevalent pathogens isolated from CSF culture were Streptococcus pneumoniae (34.5%), Haemophilus influenzae type b (23.36%), Neisseria meningitidis (6.54%), Serratia spp. (6.54%), and Klebsiella pneumoniae (5.6%), respectively. Moreover, the patients' blood culture had positive results in 36.44% of cases with H. influenzae type b (20.65%) and S. pneumoniae (6.54%) as the main bacteria isolated from blood. Meningitis occurred mostly in children under two years (P = 0.001). According to antimicrobial susceptibility test, a relatively high resistance was reported against some conventional cephalosporins and other antibiotics.

Conclusions:

S. pneumoniae and H. influenzae type b were the main pathogens of bacterial meningitis in children in the area under study. Most species had relatively high resistance to conventional antibiotics as compared to the past.

Neuro-intensive treatment targeting intracranial hypertension improves outcome in severe bacterial meningitis: an intervention-control study

OBJECTIVE

To evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness.

DESIGN

A prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012.

PATIENTS

Included patients were confirmed ABM-cases, aged 16-75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg.

MEASUREMENTS

The primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2-6 months.

OUTCOMES

The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05).

CONCLUSIONS

Early neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.

Intracranial malignant lesions correlate with the requirement for a long treatment course in postoperative central nervous system infection

AIM

Our aim was to study the clinical features of postoperative meningitis after neurosurgery and identify the factors affecting the duration of treatment.

METHODS

This retrospective study assessed 283 patients with postoperative bacterial meningitis in the Neurosurgery Department of Beijing Tiantan Hospital, Beijing, People's Republic of China, between January and December 2012. Patients' clinical data were reviewed, and multivariate logistic regression analysis was used to identify the factors associated with a prolonged treatment course.

RESULTS

The mortality rate was 0.4% in these patients, of whom 12.4% were found with pathogens in the cerebrospinal fluid. Among the three most common pathogens detected were methicillin-resistant Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa. The mean treatment course was 13.5±2.1 days. Interestingly, the treatment duration for postoperative meningitis was significantly longer in patients with intracranial malignant tumors than in those with benign lesions. Single-factor analysis showed that male sex (P=0.042) and malignant (rather than benign) lesions (P<0.001) were significantly associated with prolonged treatment duration. Multivariate analysis further confirmed that malignant intracranial lesions represented an independent risk factor for prolonged treatment duration (odds ratio: 2.5962; 95% confidence interval: 1.1092-6.6134).

CONCLUSION

The nature of the intracranial lesion is an independent risk factor for the duration of treatment in postoperative meningitis after neurosurgery.

Bacterial meningitis: new therapeutic approaches

Bacterial meningitis remains a disease with high mortality and long-term morbidity. Outcome critically depends on the rapid initiation of effective antibiotic therapy. Since a further increase of the incidence of pathogens resistant to antibacterials can be expected both in community-acquired and nosocomial bacterial meningitis, the choice of an optimum initial empirical antibiotic regimen will gain significance. In this context, the use of antibiotics which are bactericidal but do not lyse bacteria, may emerge as a therapeutic option. Conversely, the role of corticosteroids, which decrease the entry of hydrophilic antibacterials into the cerebrospinal fluid, as adjunctive therapy will probably decline as a consequence of the increasing antibiotic resistance of bacteria causing meningitis. Consequent vaccination of all children at present is the most efficient manner to reduce disease burden.

How Noninvasive Haemoglobin Measurement with Pulse CO-Oximetry Can Change Your Practice: An Expert Review

Trauma related haemorrhagic anaemia is rarely diagnosed by physical examination alone but typically includes measurement of blood haemoglobin, one of the most frequently ordered laboratory tests. Recently, noninvasive technologies have been developed that allow haemoglobin to be measured immediately without the need for intravenous access or having to take venous, arterial, or capillary blood. Moreover, with these technologies haemoglobin can be continuously measured in patients with active bleeding, to guide the start and stop of blood transfusions and to detect occult bleeding. Recent studies on the accuracy of the devices showed promising results in terms of accuracy of hemoglobin measurement compared to laboratory determination. The present review gives an overview on the technology itself and reviews the current literature on the subject.

Prompt administration of antibiotics is associated with improved outcomes in febrile neutropenia in children with cancer

BACKGROUND

Time-to-antibiotic (TTA) administration is a widely used quality-of-care measure for children with cancer and febrile neutropenia (FN). We sought to determine whether TTA is associated with outcomes of FN.

PROCEDURE

A single-center, retrospective cohort study was conducted of 1,628 FN admissions from 653 patients from 2001 to 2009. Outcome variables included (1) an adverse event (AE) composite of in-hospital mortality, pediatric intensive care unit (PICU) admission within 24 hours of presentation, and/or fluid resuscitation ≥ 40 ml/kg within 24 hours of presentation and (2) length of stay (LOS). TTA was measured as a continuous variable and in 60-minute intervals. Mixed regression models were constructed to evaluate associations of TTA with the outcome variables after adjusting for relevant covariates including cancer diagnosis, degree of myelosuppression, and presence of bacteremia.

RESULTS

The composite AE outcome occurred in 11.1% of admissions including 0.7% in-hospital mortality, 4.7% PICU admission, and 10.1% fluid resuscitation. In univariate analysis, TTA was associated with the composite AE outcome (Odds Ratio [OR] 1.29, 95% CI 1.02-1.64) but not LOS. In multivariate analysis, after adjustment for relevant covariates, 60-minute TTA intervals were associated with the composite AE outcome (61-120 minutes vs. ≤ 60 minutes, OR 1.81, 95% CI 1.01-3.26). Unexpectedly, admission from the emergency department (ED) was also independently associated with the composite AE outcome (ED vs. clinic, OR 3.15, 95% CI 1.95-5.09).

CONCLUSIONS

TTA and presentation to the ED are independently associated with poor outcomes of FN.

High mortality amongst adolescents and adults with bacterial meningitis in sub-Saharan Africa: an analysis of 715 cases from Malawi

Mortality from bacterial meningitis in African adults is significantly higher than those in better resourced settings and adjunctive therapeutic interventions such as dexamethasone and glycerol have been shown to be ineffective. We conducted a study analysing data from clinical trials of bacterial meningitis in Blantyre, Malawi to investigate the clinical parameters associated with this high mortality.

Methods

We searched for all clinical trials undertaken in Blantyre investigating bacterial meningitis from 1990 to the current time and combined the data from all included trial datasets into one database. We used logistic regression to relate individual clinical parameters to mortality. Adults with community acquired bacterial meningitis were included if the CSF culture isolate was consistent with meningitis or if the CSF white cell count was >100 cells/mm³ (>50% neutrophils) in HIV negative participants and >5 cells/mm³ in HIV positive participants. Outcome was measured by mortality at discharge from hospital (after 10 days of antibiotic therapy) and community follow up (day 40).

Results

Seven hundred and fifteen episodes of bacterial meningitis were evaluated. The mortality rate was 45% at day 10 and 54% at day 40. The most common pathogens were S.pneumoniae (84% of positive CSF isolates) and N.meningitidis (4%). 607/694 (87%) participants tested were HIV antibody positive. Treatment delays within the hospital system were marked. The median presenting GCS was 12/15, 17% had GCS<8 and 44.9% had a seizure during the illness. Coma, seizures, tachycardia and anaemia were all significantly associated with mortality on multivariate analysis. HIV status and pneumococcal culture positivity in the CSF were not associated with mortality. Adults with community acquired bacterial meningitis in Malawi present with a severe clinical phenotype. Predictors of high mortality are different to those seen in Western settings. Optimising in-hospital care and minimising treatment delays presents an opportunity to improve outcomes considerably.

Corticosteroids for acute bacterial meningitis

BACKGROUND

In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response.

OBJECTIVES

To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis.

SEARCH METHODS

We searched CENTRAL 2012, Issue 12, MEDLINE (1966 to January week 2, 2013), EMBASE (1974 to January 2013), Web of Science (2010 to January 2013), CINAHL (2010 to January 2013) and LILACS (2010 to January 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality.

MAIN RESULTS

Twenty-five studies involving 4121 participants were included. Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events.

AUTHORS' CONCLUSIONS

Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

Determinants of timely management of acute bacterial meningitis in the ED

PURPOSE

The purpose was to study the emergency management of patients with suspected meningitis to identify potential areas for improvement.

METHODS

All patients who underwent cerebrospinal fluid puncture at the emergency department of the University Hospital of Bern from January 31, 2004, to October 30, 2008, were included. A total of 396 patients were included in the study. For each patient, we analyzed the sequence and timing for the following management steps: first contact with medical staff, administration of the first antibiotic dose, lumbar puncture (LP), head imaging, and blood cultures. The results were analyzed in relation to clinical characteristics and the referral diagnosis on admission.

RESULTS

Of the 396 patient analyzed, 15 (3.7%) had a discharge diagnosis of bacterial meningitis, 119 (30%) had nonbacterial meningitis, and 262 (66.3%) had no evidence of meningitis. Suspicion of meningitis led to earlier antibiotic therapy than suspicion of an acute cerebral event or nonacute cerebral event (P < .0001). In patients with bacterial meningitis, the average time to antibiotics was 136 minutes, with a range of 0 to 340 minutes. Most patients (60.1%) had brain imaging studies performed before LP. On the other hand, half of the patients with a referral diagnosis of meningitis (50%) received antibiotics before performance of an LP.

CONCLUSIONS

Few patients with suspected meningitis received antimicrobial therapy within the first 30 minutes after arrival, but most patients with pneumococcal meningitis and typical symptoms were treated early; patients with bacterial meningitis who received treatment late had complex medical histories or atypical presentations.

Treatment of bacterial meningitis: an update

INTRODUCTION

The introduction of protein conjugate vaccines for Haemophilus influenzae type b (Hib), Streptococcus pneumoniae (S. pneumoniae) and Neisseria meningitidis (N. menigitidis) has changed the epidemiology of bacterial meningitis. Bacterial meningitis continues to be an important cause of mortality and morbidity, and our incomplete knowledge of its pathogenesis and emergence of antimicrobial resistant bacteria contribute to such mortality and morbidity. An early empiric antibiotic treatment is critical for the management of patients with bacterial meningitis.

AREAS COVERED

This article gives an overview on optimal treatment strategies of bacterial meningitis, along with considerations of new insights on epidemiology, clinical and laboratory findings supportive of bacterial meningitis, chemoprophylaxis, selection of initial antimicrobial agents for suspected bacterial meningitis, antimicrobial resistance and utility of new antibiotics, status on anti-inflammatory agents and adjunctive therapy, and pathogenesis of bacterial meningitis.

EXPERT OPINION

Prompt treatment of bacterial meningitis with an appropriate antibiotic is essential. Optimal antimicrobial treatment of bacterial meningitis requires bactericidal agents able to penetrate the blood-brain barrier (BBB), with efficacy in cerebrospinal fluid (CSF). Several new antibiotics have been introduced for the treatment of meningitis caused by resistant bacteria, but their use in human studies has been limited. More complete understanding of the microbial and host interactions that are involved in the pathogenesis of bacterial meningitis and associated neurologic sequelae is likely to help in developing new strategies for the prevention and therapy of bacterial meningitis.

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients

OBJECTIVE

To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients.

METHODS

We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated.

RESULTS

The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration.

DISCUSSION

The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.

Bacterial meningitis: current therapy and possible future treatment options

Despite targeted therapy, case-fatality rates and neurologic sequelae of bacterial meningitis remain unacceptably high. The poor outcome is mainly due to secondary systemic and intracranial complications. These complications seem to be both a consequence of the inflammatory response to the invading pathogen and release of bacterial components by the pathogen itself. Therefore, within the last decades, research has focused on the mechanism underlying immune regulation and the inhibition of bacterial lysis in order to identify new targets for adjuvant therapy. The scope of this article is to give an overview on current treatment strategies of bacterial meningitis, to summarize new insights on the pathophysiology of bacterial meningitis, and to give an outlook on new treatment strategies derived from experimental models.

Time-to-antibiotic administration as a quality of care measure in children with febrile neutropenia: a survey of pediatric oncology centers

Time-to-antibiotic administration (TTA) has been suggested as a quality-of-care (QOC) measure for pediatric oncology patients with febrile neutropenia (FN). Unknown, however, is to what extent pediatric oncology centers utilize TTA. Therefore, we designed and administered an electronic survey (68% response rate) of programs in the Children's Oncology Group to assess TTA utilization. Nearly half of respondents track TTA. Most reported using a benchmark of less than 60 min from arrival. TTA is a commonly used QOC measure for pediatric FN despite an absence of studies establishing its validity and a lack of data supporting its impact on outcomes of FN.

An audit of acute bacterial meningitis in a large teaching hospital 2005-10

BACKGROUND

Acute bacterial meningitis (ABM) is a rare disease associated with severe neurological sequelae and death. Clinical features on admission may be subtle and thus delay recognition. Previous studies have shown association between early administration of antibiotics and favourable outcomes.

AIM

To examine the presenting clinical features of patients aged >15 years with ABM admitted to a University teaching hospital. To audit investigations and treatment including lumbar puncture (LP), computed tomography (CT) and antibiotics against British Infection Association guidelines.

DESIGN

Retrospective observational audit.

METHODS

Hospital records were reviewed for presenting clinical features and timing of CT scan, LP and antibiotics.

RESULTS

Records of 39 patients with ABM were reviewed. The classical triad of fever, neck stiffness and altered mental state was present on admission in only 21% of cases. LP was contraindicated in 69% of cases. Immediate LP was carried out in only 17% of those who had no contraindication. Antibiotics were administered after a median of 79 min (interquartile range 24-213 min); 65% were given within 3 h after arrival. Eighty-five percent of patients had antibiotics in accordance with local guidelines.

CONCLUSION

In patients with ABM, the classical clinical features are uncommon on arrival to hospital and frequently evolve following admission. The majority of patients have contraindications to immediate LP. Efforts should be made to facilitate immediate LP performed in the Emergency Department when there are no contraindications. Earlier administration of antibiotics in cases of suspected ABM and close review following admission is recommended.

The adequacy of timely empiric antibiotic therapy for ventilator-associated pneumonia: an important determinant of outcome

OBJECTIVE

The individual impact of timeliness vs adequacy of empiric antibiotic therapy for a clinical suspicion of ventilator-associated pneumonia (CSVAP) is unknown. Accordingly, in patients with CSVAP and timely initiation of empiric antibiotic therapy, we determined the impact of inadequate therapy (IT).

METHODS

Analysis of a randomized trial of CSVAP treated empirically with meropenem or meropenem plus ciprofloxacin was done. Adequate therapy (AT) was considered present if all pathogens in the index culture were sensitive to the empiric antibiotics; IT was defined as the presence of pathogens resistant to the empiric antibiotics. A priori, for Pseudomonas sp, 2 antibiotics with activity against the organisms were required for AT to be considered present.

RESULTS

Of 739 patients with CSVAP, 350 had positive cultures: 313 (89.4%) had AT, and 37 (10.6%), IT. The IT group had higher intensive care unit (35.1% vs 11.8%, P = .0001) and hospital mortalities (48.7% vs 19.5%, P < .0001), increased mechanical ventilation (15.8 vs 6.8 days, P = .0005), intensive care unit stay (13.5 vs 8.4 days, P = .02), and hospital stay (42.2 vs 27.9 days, P = .04). In multivariate analysis and a separate case control analysis, the odds ratio of hospital mortality with IT was 3.05 (95% confidence interval, 1.25-7.45; P = .01) and 3.00 (95% confidence interval, 1.24-7.24; P = .01), respectively.

CONCLUSION

In the context of early administration of empiric broad spectrum antibiotics for CSVAP, IT is associated with higher morbidity and mortality.

Dexamethasone for adult community-acquired bacterial meningitis: 20 years of experience in daily practice

The aim of the study was to assess adjunctive intravenous dexamethasone in adult community-acquired bacterial meningitis (BM) in daily practice. Analysis of consecutive patients (1990-2009) with acute community-acquired bacterial meningitis in a single centre in Zagreb, Croatia, N = 304. Adjusted relative risks [RR, dexamethasone vs. no dexamethasone (control)] of Glasgow Outcome Scale (GOS) = 1 (death) and GOS = 5 (full recovery) at discharge/end of specific treatment were estimated considering demographics; co-morbidity; BM pathogenesis and on-admission characteristics, and cerebrospinal fluid (CSF) inflammation markers; causative agent and antibiotic use. Two hundred forty (79%) patients had proven BM (43.1% Streptococcus pneumoniae, any other agent ≤ 8.2%). No independent effects of dexamethasone on GOS = 1 or GOS = 5 were observed in the entire cohort (dexamethasone n = 119, control n = 185; RR = 1.06, 95% CI 0.77-1.45 and RR = 0.99, CI 0.83-1.20, respectively), microbiologically proven disease (dexamethasone n = 104, control n = 136; RR = 0.97, CI 0.69-1.38 and RR = 1.03, CI 0.82-1.28), pneumococcal disease (dexamethasone n = 71, control n = 60; RR = 0.95, CI 0.53-1.70 and RR = 0.82, CI 0.57-1.18), and also in other BM, subgroups based on consciousness disturbance, CSF markers, prior use of antibiotics and timing of appropriate antibiotic treatment. CSF markers did not predict the outcomes.

CONCLUSIONS

Our experience does not substantiate the reported benefits of adjunctive dexamethasone in adult BM. Socio-economic and methodological factors do not seem to explain this discrepancy. Empirical use of dexamethasone in this setting appears controversial.

Corticosteroids for acute bacterial meningitis

BACKGROUND

In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response.

OBJECTIVES

To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 1), MEDLINE (1966 to February 2010), EMBASE (1974 to February 2010) and Current Contents (2001 to February 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality.

MAIN RESULTS

Twenty-four studies involving 4041 participants were included. Similar numbers of participants died in the corticosteroid and placebo groups (18.0% versus 20.0%; risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.04, P = 0.18). There was a trend towards lower mortality in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.76, 95% CI 0.64 to 0.89) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced severe hearing loss in Haemophilus influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) and reduced mortality in Streptococcus pneumoniae meningitis (RR 0.84, 95% CI 0.72 to 0.98).In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events.

AUTHORS' CONCLUSIONS

Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.

Genetic variation in pro-inflammatory cytokines and meningococcal sepsis

PURPOSE OF REVIEW

Pro-inflammatory cytokines are an essential component of host defence in patients who are susceptible to meningococcal disease. This review summarizes what is currently known about genetic variations in genes encoding these defensive proteins and focuses on recent work investigating the potential role polymorphisms may play insusceptibility and severity of the disease.

RECENT FINDINGS

A recently developed porcine model revealed significant cytokine derangement early in severe meningococcal sepsis raising the suggestion of a causative role for maladaptive cytokine release in the disease course. In patients who survive septic shock caused by the meningococcus there is a low innate production capacity for interleukin-1beta. Several polymorphisms have been identified in genes encoding for pro-inflammatory cytokines, and recently studies have shown association with susceptibility to infection in polymorphism at both IL-1RA (+2018) and TNF (-308).

SUMMARY

Recent work is adding to the growing evidence that genetic variation in pro-inflammatory cytokines has a role in susceptibility and survival in meningococcal disease. However, data need to be interpreted with caution as there are many confounding factors, sample sizes are often small and there are challenges in identifying suitable control groups.

Adult community-acquired bacterial meningitis requiring ICU admission: epidemiological data, prognosis factors and adherence to IDSA guidelines

Numerous guidelines are available to guide empirical antimicrobial therapy (EAT) in acute bacterial meningitis (ABM) patients. We analysed prognosis factors and compliance to the Infectious Diseases Society of America (IDSA) guidelines in ABM patients requiring stay in an intensive care unit (ICU). A 10-year retrospective study, using prospectively collected data, in 82 ABM patients admitted to a 16-bed university-affiliated French ICU was undertaken. Seventeen patients (20.7%) died during ICU stay. Multivariate analysis isolated four factors associated with in-ICU death: alcoholism (P = 0.007), acute kidney injury (P = 0.006), age >60 years (P = 0.006) and ICU admission for neurological failure (P = 0.01). Causative pathogens were isolated for 62 (75.6%) patients, including 29 pneumococci, 14/28 of which were non-susceptible to penicillin. No characteristics, particularly recent hospitalisation and/or antibiotic delivery, was associated with penicillin susceptibility. Compliance to IDSA guidelines was 65%. Non-compliance concerned to be essentially the non-delivery or low dosage of vancomycin. Treatment compatible with IDSA guidelines was associated with a decreased ICU mortality in univariate (61.5% survival vs. 35.3%, P = 0.05) but not in multivariate analysis. In-ICU mortality associated with ABM remains high. Prognosis factors are related to the severity of disease or underlying conditions. Penicillin non-susceptible Streptococcus pneumoniae can occur without any of the usual predisposing factors.