Bacterial Meningitis in Patients using Immunosuppressive Medication: a Population-based Prospective Nationwide Study

Immunocompromised teenager with meningitis caused by Ureaplasma parvum

Infection in the immunocompromised patient is often challenging on multiple levels. It can be difficult to distinguish between manifestations of the underlying disease, infection or malignancy. Symptoms may be vague or even absent, deviations in the common inflammatory parameters discrete, imaging findings scarce and the causative microbe may be a true pathogen as well as opportunistic. Here, we report an immunosuppressed female in her late teens with a purulent meningitis due to Ureaplasma parvum-a very rare cause of infection in the central nervous system of adults. We wish to highlight the relevance of intracellular pathogens and the need to actively search for these microbes, especially when response to broad-spectrum antibiotic treatment is absent. Furthermore, we emphasise the need for adequate molecular microbial diagnostics in search of microbes that are difficult to identify by culture and where serology and antigen tests may be absent or unreliable due to immune suppression.

Clinical characteristics and prognosis of pediatric Listeria monocytogenes meningitis based on 10-year data from a large children's hospital in China

This study aims to summarize the clinical characteristics and prognosis of Listeria monocytogenes (LM) meningitis in children in Chongqing, China. A retrospective analysis of the clinical data and follow-up results of 20 LM meningitis patients admitted to the Children's Hospital of Chongqing Medical University (CHCMU) from January 2012 to December 2022 was performed. The LM meningitis incidence rate was between 0 and 14.3 per 100,000 persons. The median age at onset was 8.98 months. There were five neonate cases, which all had perinatal abnormalities. Seven non-neonatal cases (7/15, 46.7%) had a documented history of contaminated food intake. One case had primary immunodeficiency. The most common symptoms were fever (20/20), altered consciousness (19/20), and vomiting (15/20). Seven cases had seizures, eight cases had cranial nerve involvement, eight cases had positive Babinski sign, and 10 cases had positive meningeal signs. The most common complications were hyponatremia (6/20), hypokalemia (6/20), respiratory failure (5/20), subdural effusion (3/20), and hydrocephalus (2/20). Treatment primarily involved monotherapy or combination therapy with meropenem (15/20) and ampicillin (10/20). Fifteen cases were treated with monotherapy or combination therapy using vancomycin. Twelve cases were successfully followed up from 10 months to 9 years and 6 months, and all had favorable long-term outcomes. LM meningitis incidence in children is low and with nonspecific clinical manifestations. Strengthening food hygiene and safety education, and avoiding infections during pregnancy are important to prevent LM infection in neonates and high-risk individuals. Meropenem and ampicillin are the preferred treatments. Early diagnosis and treatment can improve prognosis.IMPORTANCEThe incidence of LM meningitis is extremely low, and there is currently no standardized treatment. We conducted a retrospective analysis of ten years of data from CHCMU regarding diagnosed LM meningitis cases, aiming to provide clinical evidence for the diagnosis and treatment.

Characterization and diagnosis spectrum of patients with cerebrospinal fluid pleocytosis

PURPOSE

There is an overlap in the cerebrospinal fluid (CSF) characteristics of patients presenting with different etiologies of CSF pleocytosis. Here, we characterized patients with CSF pleocytosis treated in a large hospital.

METHODS

A retrospective cohort study of 1150 patients with an elevated CSF leukocyte count > 5 cells/µl treated at a university hospital in Germany from January 2015 to December 2017 was performed. Information on clinical presentation, laboratory parameters, diagnosis and outcome was collected. Clinical and laboratory features were tested for their potential to differentiate between bacterial meningitis (BM) and other causes of CSF pleocytosis.

RESULTS

The most common etiologies of CSF pleocytosis were CNS infections (34%: 20% with detected pathogen, 14% without), autoimmune (21%) and neoplastic diseases (16%). CSF cell count was higher in CNS infections with detected pathogen (median 82 cells/µl) compared to autoimmune (11 cells/µl, p = 0.001), neoplastic diseases (19 cells/µl, p = 0.01) and other causes (11 cells/µl, p < 0.001). The CHANCE score was developed to differentiate BM from other causes of CSF pleocytosis: Multivariate regression revealed that CSF cell count > 100 cells/µl, CSF protein > 100 mg/dl, CRP > 5 mg/dl, elevated white blood cell count, abnormal mental status and nuchal rigidity are important indicators. The CHANCE score identified patients with BM with high sensitivity (92.1%) and specificity (90.9%) (derivation cohort: AUC: 0.955, validation cohort: AUC: 0.956).

CONCLUSION

Overall, the most common causes for CSF pleocytosis include infectious, neoplastic or autoimmune CNS diseases in ~ 70% of patients. The CHANCE score could be of help to identify patients with high likelihood of BM and support clinical decision making.

Adjunctive dexamethasone treatment in adults with listeria monocytogenes meningitis: a prospective nationwide cohort study

Background

A French cohort study described a detrimental effect of adjunctive dexamethasone treatment in listeria meningitis. Based on these results guidelines recommend not to use dexamethasone if L. monocytogenes is suspected or stop dexamethasone when the pathogen is detected. We studied clinical characteristics, treatment regimens and outcome of adults with Listeria monocytogenes meningitis in a nationwide cohort study on bacterial meningitis.

Methods

We prospectively assessed adults with community-acquired L. monocytogenes meningitis in the Netherlands between Jan 1, 2006, and July 1, 2022. We identified independent predictors for an unfavourable outcome (Glasgow Outcome Scale score 1 to 4) and mortality by logistic regression.

Findings

162 out of 2664 episodes (6%) of community-acquired bacterial meningitis episode were caused by L. monocytogenes in 162 patients. Adjunctive dexamethasone 10 mg QID was started with the first dose of antibiotics in 93 of 161 patients (58%) and continued for the full four days in 83 (52%) patients. Different doses, duration or timing of dexamethasone were recorded in 11 patients (7%) and 57 patients (35%) did not receive dexamethasone. The case fatality rate was 51 of 162 (31%) and an unfavourable outcome occurred in 91 of 162 patients (56%). Age and the standard regimen of adjunctive dexamethasone were independent predictors for an unfavourable outcome and mortality. The adjusted odds ratio of dexamethasone treatment for unfavourable outcome was 0.40 (95% confidence interval 0.19-0.81).

Interpretation

Adjunctive dexamethasone is associated with an improved outcome in patients with L. monocytogenes meningitis and should not be withheld if L. monocytogenes is suspected or detected as causative pathogen.

Funding

European Research Council and Netherlands Organisation for Health Research and Development.

Diagnostic accuracy of rapid antigen tests in cerebrospinal fluid for pneumococcal meningitis: a systematic review and meta-analysis

BACKGROUND

Streptococcus pneumoniae is a leading cause of bacterial meningitis worldwide. Conventional microbiological assays take several days and require the use of various drugs for empirical treatment. Rapid antigen tests in cerebrospinal fluid (CSF) may be useful to triage pneumococcal meningitis immediately.

OBJECTIVES

To elucidate whether rapid antigen tests in CSF are useful in the triage of pneumococcal meningitis.

METHODS

Data sourcesCochrane CENTRAL, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases were searched. Study eligibility criteriaAll types of cohort studies except multiple-group studies, where the sensitivity and specificity of rapid antigen tests in CSF compared with CSF culture can be extracted. ParticipantsPatients with suspected meningitis. TestsRapid antigen tests in CSF. Reference standardsOne or more of the following: blood culture, CSF culture, and polymerase chain reaction in CSF. Assessment of risk of biasThe methodological quality of the included studies was assessed using QUADAS-2. Methods of data synthesisWe used a random-effects bivariate model for the meta-analysis. We conducted a subgroup analysis by dividing studies into types of antigen tests, adults and children, low-income and high-income countries, and with or without exposure to antibiotics before lumbar puncture.

RESULTS

Forty-four studies involving 14 791 participants were included. Most studies had a moderate-to-low methodological quality. Summary sensitivity and specificity were 99.5% (95% confidence interval (CI), 92.4-100%) and 98.2% (95% CI, 96.9-98.9%), respectively. Positive predictive values and negative predictive values at the median prevalence (4.2%) in the included studies were 70.8% (95% CI, 56.6-79.9%) and 100% (95% CI, 99.7-100%), respectively. The diagnostic accuracy was consistent across the various subgroups, except for slightly reduced sensitivity in high-income countries.

CONCLUSIONS

Rapid antigen tests in CSF would be useful in triaging pneumococcal meningitis. Further studies are warranted to investigate the clinical benefit of ruling out pneumococcal meningitis based on the results of rapid antigen tests.

Burden of pneumococcal disease among adults in Southern Europe (Spain, Portugal, Italy, and Greece): a systematic review and meta-analysis

The aim was to summarize pneumococcal disease burden data among adults in Southern Europe and the potential impact of vaccines on epidemiology. Of 4779 identified studies, 272 were selected. Invasive pneumococcal disease (IPD) incidence was 15.08 (95% CI 11.01-20.65) in Spain versus 2.56 (95% CI 1.54-4.24) per 100,000 population in Italy. Pneumococcal pneumonia incidence was 19.59 (95% CI 10.74-35.74) in Spain versus 2.19 (95% CI 1.36-3.54) per 100,000 population in Italy. Analysis of IPD incidence in Spain comparing pre-and post- PCV7 and PCV13 periods unveiled a declining trend in vaccine-type IPD incidence (larger and statistically significant for the elderly), suggesting indirect effects of childhood vaccination programme. Data from Portugal, Greece and, to a lesser extent, Italy were sparse, thus improved surveillance is needed. Pneumococcal vaccination uptake, particularly among the elderly and adults with chronic and immunosuppressing conditions, should be improved, including shift to a higher-valency pneumococcal conjugate vaccine when available.

Listeria Monocytogenes Brain Abscesses in a Patient with Disseminated Non-Small Cellular Lung Cancer: MRI Findings

Brain abscesses caused by Listeria monocytogenes (LM) are very rare and carry a high mortality risk. We present a patient with disseminated non-small cellular lung cancer (NSCLC) and multiple unusual LM brain abscesses. These abscesses have multiple elongated peripherally enhancing lesions in a characteristic formation that is "worm or tramtrack-like" following the white matter fiber tracts.

SOP: emergency workup in patients with suspected acute bacterial meningitis

Introduction

Despite antibiotic therapy, adjunctive treatment with dexamethasone, and care on modern intensive care units, bacterial meningitis remains a life-threatening disease with a high mortality and morbidity. One of most critical factors that influences outcome is a targeted quick but profound workup and early initiation of therapy in the Emergency Department. This standardized operating procedure was designed to guide physicians through the workup of patients with suspected acute bacterial meningitis.

First steps

In patients with suspected community-acquired bacterial meningitis, the first steps aim at establishing a diagnosis and at starting empiric therapy without delay. Therefore, physicians need to seek for an early lumbar puncture that can be done safely without prior imaging if clinical signs that point at contraindications of a lumbar puncture are absent. Immediately after lumbar puncture, empiric therapy with ceftriaxone, ampicillin and dexamethasone should be started. In regions with a critical resistance rate of pneumococci against third generation cephalosporines, vancomycin or rifampicin need to be added.

Comments

Clinical signs that are associated with intracranial conditions that are a contraindication for a lumbar puncture are severely decreased consciousness, new onset focal neurological signs, and epileptic seizures. If any of these clinical signs are present, cerebral imaging is recommended before lumbar puncture. Whenever lumbar puncture is delayed, empiric therapy needs to be begun before cerebrospinal fluid is obtained.

Conclusion

Suspected acute bacterial meningitis is an emergency and requires attention with high priority in the emergency department to ensure a quick workup and early start of therapy.

Retrospective analysis of the etiology, clinical characteristics and outcomes of community-acquired bacterial meningitis in the University Infectious Diseases Centre in Lithuania

Background

The morbidity and mortality in community-acquired bacterial meningitis (CABM) remain substantial, and the etiology, clinical characteristics, treatment outcomes and predictors of poor prognosis must be assessed regularly. The aim of this study was to identify the distribution of etiological agents and their relationship with clinical characteristics, treatment and outcomes in this cohort of patients with CABM.

Methods

Our retrospective chart review analyzed the causative microorganisms, clinical characteristics, laboratory findings, treatment and outcomes of 159 adults with CABM hospitalized in the Infectious Diseases Centre of Vilnius University Hospital from January 1, 2009 to December 31, 2016. A Glasgow Outcome Scale (GOS) score ≤ 3 was defined as unfavorable outcome. Predictors of an unfavorable outcome were identified through logistic regression analysis.

Results

The median patient age was 36 (IQR 24–56), and 51.6% were male. Microbiologically confirmed causative agents were identified in 80 (50.3%) patients: N. meningitidis in 55 (34.6%) patients with serotype B accounting for 85% of cases, S. pneumoniae in 15 (9.4%), L. monocytogenes in 5 (3.1%) and other in 5 (3.1%). The clinical triad of fever, neck stiffness and a change in mental status was present in 59.1% of patients. Coexisting conditions and comorbidities were similar in all groups stratified by etiology. Initial antimicrobial treatment consisted of penicillin in 78 patients (49.1%) and ceftriaxone in 72 patients (45.3%). The median time in which antibiotic treatment was started was 40 min (IQR 30.0–90.0). The outcome was unfavorable in 15.7% of episodes and death occurred in 5.7% of cases and did not differ according to the causative agent. Risk factors for an unfavorable outcome were age > 65 years, coexisting pneumonia and a platelet count <150x10e9/l.

Conclusions

The most common causative agent of CABM was N. meningitidis, with serotype B clearly dominant. Causative agents did not influence the disease outcome. The strongest risk factors for an unfavorable outcome were older age, pneumonia and a low platelet count. Since the introduction of routine vaccination against meningococcus B for infants in Lithuania in 2018, the national vaccination policy may hopefully contribute to a decrease in the incidence of serogroup B meningococcal disease in the Lithuanian population.

Neuropsychiatric lupus: new mechanistic insights and future treatment directions

Patients with systemic lupus erythematosus (SLE) frequently show symptoms of central nervous system (CNS) involvement, termed neuropsychiatric SLE (NPSLE). The CNS manifestations of SLE are diverse and have a broad spectrum of severity and prognostic implications. Patients with NPSLE typically present with nonspecific symptoms, such as headache and cognitive impairment, but might also experience devastating features, such as memory loss, seizures and stroke. Some features of NPSLE, in particular those related to coagulopathy, have been characterized and an evidence-based treatment algorithm is available. The cognitive and affective manifestations of NPSLE, however, remain poorly understood. Various immune effectors have been evaluated as contributors to its pathogenesis, including brain-reactive autoantibodies, cytokines and cell-mediated inflammation. Additional brain-intrinsic elements (such as resident microglia, the blood-brain barrier and other neurovascular interfaces) are important facilitators of NPSLE. As yet, however, no unifying model has been found to underlie the pathogenesis of NPSLE, suggesting that this disease has multiple contributors and perhaps several distinct aetiologies. This heterogeneity presents a challenge for clinicians who have traditionally relied on empirical judgement in choosing treatment modalities for patients with NPSLE. Improved understanding of this manifestation of SLE might yield further options for managing this disease.

Etiology, clinical presentation, outcome and the effect of initial management in immunocompromised patients with community acquired bacterial meningitis

OBJECTIVES

The aim was to analyze differences in clinical presentation, etiology, management, and outcome between immunocompromised and immunocompetent patients with acute bacterial meningitis (ABM).

METHODS

Data were extracted from 1056 adult ABM patients prospectively registered in the national Swedish quality register for ABM during 2008-2017. Primary endpoint was 30-day mortality and secondary endpoints 90-day mortality and unfavorable outcome.

RESULTS

An immunocompromised state was observed in 352 (33%) of the 1056 patients. Streptococcus pneumoniae dominated in both immunocompromised and immunocompetent patients (53% in both groups), whereas L monocytogenes occurred in 11% and 2%, respectively. The unadjusted odds ratio (OR) for 30-day mortality in immunocompromised compared to immunocompetent patients was 1.68 (95% confidence interval (CI): 1.07-2.63). Adjusted for age, sex, and mental status on admission the OR was 1.34 (CI: 0.82-2.21). Adjusted also for time to antibiotic treatment and corticosteroids the OR was 1.10 (CI: 0.59-2.05), and in patients without Listeria meningitis 0.98 (CI: 0.50-1.90). Although, the ORs were higher for 90-day mortality and unfavorable outcome the effects of adjustments were similar.

CONCLUSION

Mortality in immunocompromised patients with ABM is only moderately increased unless caused by Listeria. This difference is further reduced in patients given early antibiotic treatment and adjunctive corticosteroids.

FUNDING

This work was supported by Stockholm County Council.

Histopathology of Listeria Meningitis

Listeria monocytogenes meningitis is the third most common cause of bacterial meningitis in adults and has high mortality and morbidity rates. We describe the clinical course and score brain pathology of 5 patients who died of listeria meningitis. All patients were immunocompromised and ages ranged between 48 and 76 years. Three cases were confirmed by cerebrospinal fluid culture; one was confirmed by brain culture; and one diagnosis was based on a positive blood culture and neuropathological findings. Mild inflammation of meningeal arteries was found in 3 of 5 cases (60%). Moderate/severe ventriculitis was seen in 4 of 4 cases (100%), abscesses in 3 of 4 cases (75%), mild vascular inflammation in 4 of 5 cases (80%), mild/moderate hemorrhage in 2 of 4 cases (50%), mild/moderate thrombosis of meningeal artery in 3 of 5 cases (60%), and 1 case (25%) showed a moderate infarct. The inflammatory cells present in the meninges were characterized by a mix of monocytes, macrophages, and neutrophils and removal of apoptotic inflammatory cells by macrophages (efferocytosis). Gram stain showed intra- and extracellular presence of rod-shaped bacteria in 3 cases. Pathological examination was characterized by moderate to severe ventriculitis, abscesses and abundant efferocytosis which has been suggested to be exploited by L. monocytogenes for cell-to-cell spread.

Community-acquired Escherichia coli meningitis and spondylodiscitis in an adult patient with discoid lupus erythematosus

Acute bacterial meningitis has a high impact on adult mortality worldwide. Community-acquired Escherichia coli meningitis (CA-ECM) is a rare and poorly described condition and the available knowledge is based on low evidence research, mainly from case reports. We describe a case of CA-ECM in Portugal in an adult patient with discoid lupus erythematosus under immunomodulatory therapy. A 73-year-old woman was admitted to the emergency department with fever and altered mental status over 48 h. Cerebrospinal fluid analysis showed 185 leukocytes/μL, including 85% neutrophils, hypoglycorrhachia (less than 5 mg/dL) and elevated protein of 423 mg/dL with positive culture for Escherichia coli. She was treated with ceftriaxone. Imaging studies also demonstrated spondylodiscitis and arthritis. She responded well to antimicrobial therapy and completed the treatment as an outpatient.

Epidemiology of community-acquired bacterial meningitis

PURPOSE OF REVIEW

The epidemiology of bacterial meningitis has been dynamic in the past 30 years following introduction of conjugated vaccines against Haemophilus influenzae type B, Streptococcus pneumoniae and Neisseria meningitidis. The purpose of this review is to describe recent developments in bacterial meningitis epidemiology.

RECENT FINDINGS

The incidence of bacterial meningitis in Western countries (Finland, Netherlands, and the United States) gradually declined by 3-4% per year to 0.7-0.9 per 100 000 per year in the past 10-20 years. In African countries (Burkina Faso and Malawi), incidence rates are still substantially higher at 10-40 per 100 000 persons per year. Introduction of pneumococcal conjugate vaccines have not consistently decreased overall pneumococcal meningitis incidence because of serotype replacement. Following the introduction of serogroup A and C meningococcal vaccines, the incidence of meningococcal meningitis because of these serogroups strongly decreased. Novel outbreaks in the African meningitis belt by serogroup C and increased incidence of serogroup W in the United Kingdom and the Netherlands were observed recently.

SUMMARY

Bacterial meningitis remains an important infectious disease, despite a gradual decline in incidence after large-scale vaccination campaigns. Further development of vaccines with broader coverage is important, as is continuous surveillance of bacterial meningitis cases.

Prophylactic Palmitoylethanolamide Prolongs Survival and Decreases Detrimental Inflammation in Aged Mice With Bacterial Meningitis

Easy-to-achieve interventions to promote healthy longevity are desired to diminish the incidence and severity of infections, as well as associated disability upon recovery. The dietary supplement palmitoylethanolamide (PEA) exerts anti-inflammatory and neuroprotective properties. Here, we investigated the effect of prophylactic PEA on the early immune response, clinical course, and survival of old mice after intracerebral E. coli K1 infection. Nineteen-month-old wild type mice were treated intraperitoneally with two doses of either 0.1 mg PEA/kg in 250 μl vehicle solution (n = 19) or with 250 μl vehicle solution only as controls (n = 19), 12 h and 30 min prior to intracerebral E. coli K1 infection. The intraperitoneal route was chosen to reduce distress in mice and to ensure exact dosing. Survival time, bacterial loads in cerebellum, blood, spleen, liver, and microglia counts and activation scores in the brain were evaluated. We measured the levels of IL-1β, IL-6, MIP-1α, and CXCL1 in cerebellum and spleen, as well as of bioactive lipids in serum in PEA- and vehicle-treated animals 24 h after infection. In the absence of antibiotic therapy, the median survival time of PEA-pre-treated infected mice was prolonged by 18 h compared to mice of the vehicle-pre-treated infected group (P = 0.031). PEA prophylaxis delayed the onset of clinical symptoms (P = 0.037). This protective effect was associated with lower bacterial loads in the spleen, liver, and blood compared to those of vehicle-injected animals (P ≤ 0.037). PEA-pre-treated animals showed diminished levels of pro-inflammatory cytokines and chemokines in spleen 24 h after infection, as well as reduced serum concentrations of arachidonic acid and of one of its metabolites, 20-hydroxyeicosatetraenoic acid. In the brain, prophylactic PEA tended to reduce bacterial titers and attenuated microglial activation in aged infected animals (P = 0.042). Our findings suggest that prophylactic PEA can counteract infection associated detrimental responses in old animals. Accordingly, PEA treatment slowed the onset of infection symptoms and prolonged the survival of old infected mice. In a clinical setting, prophylactic administration of PEA might extend the potential therapeutic window where antibiotic therapy can be initiated to rescue elderly patients.

Characterization of a Listeria monocytogenes meningitis mouse model

BACKGROUND

Listeria monocytogenes is a common cause of bacterial meningitis. We developed an animal model of listerial meningitis.

METHODS

In survival studies, C57BL/6 mice received intracisternal injections with different L. monocytogenes sequence type 1 (ST1) colony forming units per milliliter (CFU; n = 48, 105, 106, 107, 108, and 109 CFU/ml). Second, mice were inoculated with 108 CFU/ml ST1 and sacrificed at 6 h and 24 h (n = 12/group). Outcome parameters were clinical score, CFUs, cyto- and chemokine levels, and brain histopathology. Third, 84 mice were inoculated (109 CFU/ml ST1) to determine optimal antibiotic treatment with different doses of amoxicillin and gentamicin. Fourth, mice were inoculated with 109 CFU/ml ST1, treated with amoxicillin, and sacrificed at 16 h and 24 h (n = 12/group) for outcome assessment. Finally, time point experiments were repeated with ST6 (n = 24/group).

RESULTS

Median survival time for inoculation with 108 and 109 CFU/ml ST1 was 46 h and 40 h; lower doses of bacteria led to minimal clinical signs of disease. Brain levels of IL-6, IL-17A, and IFN-γ were elevated at 24 h, and IL-1β, IL-6, IL-10, IFN-γ, and TNF-α were elevated in blood at 6 h and 24 h. Histopathology showed increased meningeal infiltration, vascular inflammation of meningeal vessels, hemorrhages, and ventriculitis. In the treatment model, brain levels of IL-6 and IL-17A and blood levels of IL-6 and IFN-γ were elevated. Compared to ST6, infection with ST1 led initially to higher levels of IL-1β and TNF-α in blood and more profound neuropathological damage. At 16 h post inoculation, IL-1β, IL-10, and TNF-α in blood and IL-6, IL17A, TNF-α, and IFN-γ levels in brain were higher in ST1 compared to ST6 without differences in CFUs between STs. At 24 h, neuropathology score was higher in ST1 compared to ST6 (p = 0.002) infected mice.

CONCLUSIONS

We developed and validated a murine model of listerial meningitis. ST1-infected mice had a more severe inflammatory response and brain damage as compared to ST6-infected mice.

Update on community-acquired bacterial meningitis: guidance and challenges

BACKGROUND

The existing heterogeneity in diagnostic work-up and treatment strategies in bacterial meningitis was the incentive to develop a European evidence-based guideline, which was published in 2016 by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Infections of the Brain (ESGIB).

AIMS

To summarize salient features of the guideline, identify recent developments and challenges currently faced.

SOURCES

The ESCMID guideline, ongoing trial registries.

CONTENT

Epidemiology, clinical symptoms, diagnostic work-up and therapy strategies of acute bacterial meningitis.

IMPLICATIONS

The incidence of bacterial meningitis has decreased following pneumococcal and meningococcal conjugate vaccine introduction. In the diagnosis of bacterial meningitis the clinical characteristics and laboratory parameters are of limited diagnostic accuracy and therefore cerebrospinal fluid analysis remains the principal contributor to the final diagnosis. The ESCMID guideline advises to start empiric treatment within one hour of arrival in all suspected meningitis cases, and choice of antibiotics needs to be differentiated according to the patient's age, risk factors, and local resistance rates of pneumococci. Dexamethasone is the only proven adjunctive treatment and should be started together with the antibiotics. The follow-up of surviving patients should include evaluation for hearing loss and pneumococcal vaccination to prevent recurrences. Future perspectives include further development and implementation of vaccines, and new treatments aimed at further reducing the inflammatory response. Studies on implementation of the new guideline should determine adherence and evaluate whether improved prognosis can be achieved by following protocolled management strategies.