Severity of childhood bacterial meningitis and duration of illness before diagnosis

Emergency Department Volume and Delayed Diagnosis of Serious Pediatric Conditions

Importance

Diagnostic delays are common in the emergency department (ED) and may predispose to worse outcomes.

Objective

To evaluate the association of annual pediatric volume in the ED with delayed diagnosis.

Design, Setting, and Participants

This retrospective cohort study included all children younger than 18 years treated at 954 EDs in 8 states with a first-time diagnosis of any of 23 acute, serious conditions: bacterial meningitis, compartment syndrome, complicated pneumonia, craniospinal abscess, deep neck infection, ectopic pregnancy, encephalitis, intussusception, Kawasaki disease, mastoiditis, myocarditis, necrotizing fasciitis, nontraumatic intracranial hemorrhage, orbital cellulitis, osteomyelitis, ovarian torsion, pulmonary embolism, pyloric stenosis, septic arthritis, sinus venous thrombosis, slipped capital femoral epiphysis, stroke, or testicular torsion. Patients were identified using the Healthcare Cost and Utilization Project State ED and Inpatient Databases. Data were collected from January 2015 to December 2019, and data were analyzed from July to December 2023.

Exposure

Annual volume of children at the first ED visited.

Main Outcomes and Measures

Possible delayed diagnosis, defined as a patient with an ED discharge within 7 days prior to diagnosis. A secondary outcome was condition-specific complications. Rates of possible delayed diagnosis and complications were determined. The association of volume with delayed diagnosis across conditions was evaluated using conditional logistic regression matching on condition, age, and medical complexity. Condition-specific volume-delay associations were tested using hierarchical logistic models with log volume as the exposure, adjusting for age, sex, payer, medical complexity, and hospital urbanicity. The association of delayed diagnosis with complications by condition was then examined using logistic regressions.

Results

Of 58 998 included children, 37 211 (63.1%) were male, and the mean (SD) age was 7.1 (5.8) years. A total of 6709 (11.4%) had a complex chronic condition. Delayed diagnosis occurred in 9296 (15.8%; 95% CI, 15.5-16.1). Each 2-fold increase in annual pediatric volume was associated with a 26.7% (95% CI, 22.5-30.7) decrease in possible delayed diagnosis. For 21 of 23 conditions (all except ectopic pregnancy and sinus venous thrombosis), there were decreased rates of possible delayed diagnosis with increasing ED volume. Condition-specific complications were 11.2% (95% CI, 3.1-20.0) more likely among patients with a possible delayed diagnosis compared with those without.

Conclusions and Relevance

EDs with fewer pediatric encounters had more possible delayed diagnoses across 23 serious conditions. Tools to support timely diagnosis in low-volume EDs are needed.

The Impact and Burden of Neurological Sequelae Following Bacterial Meningitis: A Narrative Review

The burden, impact, and social and economic costs of neurological sequelae following meningitis can be devastating to patients, families and communities. An acute inflammation of the brain and spinal cord, meningitis results in high mortality rates, with over 2.5 million new cases of bacterial meningitis and over 236,000 deaths worldwide in 2019 alone. Up to 30% of survivors have some type of neurological or neuro-behavioural sequelae. These include seizures, hearing and vision loss, cognitive impairment, neuromotor disability and memory or behaviour changes. Few studies have documented the long-term (greater than five years) consequences or have parsed out whether the age at time of meningitis contributes to poor outcome. Knowledge of the socioeconomic impact and demand for medical follow-up services among these patients and their caregivers is also lacking, especially in low- and middle-income countries (LMICs). Within resource-limited settings, the costs incurred by patients and their families can be very high. This review summarises the available evidence to better understand the impact and burden of the neurological sequelae and disabling consequences of bacterial meningitis, with particular focus on identifying existing gaps in LMICs.

A systematic review of the organizational, environmental, professional and child and family factors influencing the timing of admission to hospital for children with serious infectious illness

Background

Infection, particularly in the first 5 years of life, is a major cause of childhood deaths globally, many deaths from infections such as pneumonia and meningococcal disease are avoidable, if treated in time. Some factors that contribute to morbidity and mortality can be modified. These include organisational and environmental factors as well as those related to the child, family or professional.

Objective

Examine what organizational and environmental factors and individual child, family and professional factors affect timing of admission to hospital for children with a serious infectious illness.

Design

Systematic review.

Data sources

Key search terms were identified and used to search CINAHL Plus, Medline, ASSIA, Web of Science, The Cochrane Library, Joanna Briggs Institute Database of Systematic Review.

Study appraisal methods

Primary research (e.g. quantitative, qualitative and mixed methods studies) and literature reviews (e.g., systematic, scoping and narrative) were included if participants included or were restricted to children under 5 years of age with serious infectious illnesses, included parents and/or first contact health care professionals in primary care, urgent and emergency care and where the research had been conducted in OECD high income countries. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies.

Main findings

Thirty-six papers were selected for full text review; 12 studies fitted the inclusion criteria. Factors influencing the timing of admission to hospital included the variability in children’s illness trajectories and pathways to hospital, parental recognition of symptoms and clinicians non-recognition of illness severity, parental help-seeking behaviour and clinician responses, access to services, use and non-use of ‘gut feeling’ by clinicians, and sub-optimal management within primary, secondary and tertiary services.

Conclusions

The pathways taken by children with a serious infectious illness to hospital are complex and influenced by a variety of potentially modifiable individual, organisational, environmental and contextual factors. Supportive, accessible, respectful services that provide continuity, clear communication, advice and safety-netting are important as is improved training for clinicians and a mandate to attend to ‘gut feeling’.

Implications

Relatively simple interventions such as improved communication have the potential to improve the quality of care and reduce morbidity and mortality in children with a serious infectious illness.

Prevalence of Inconsistencies in the Recorded Outcomes of Clinical Evaluations

OBJECTIVES

The aims of the study were to determine the prevalence of variations in the recorded outcomes of clinical evaluations by 2 different physicians during a single patient visit and to comment on observations of physician practices regarding history taking and physical examination.

METHODS

Structured interviews were conducted with both junior and supervising physicians after they had evaluated patients in a pediatric emergency department who presented with complaints of fever (temperature, >100.4°F) in infants younger than 3 months, fever (temperature, >102.2°F) in infants aged 3 to 12 months, headache in patients older than 5 years, abdominal pain in patients older than 5 years, and head injury in patients younger than 18 years. Data were analyzed with descriptive statistics.

RESULTS

Most of the data reported by both junior and supervising physicians showed response disagreement. The questions on fever (temperature, >102.2°F) in infants aged 3 to 12 months showed 29% (10/34) disagreement on fever duration and 45% (5/11) on fever height. Questions on abdominal pain in children older than 5 years showed 24% (24/100) disagreement on reporting right lower quadrant pain and 10% (11/106) on right lower quadrant tenderness on examination; however, the discrepancy rates were 56% (56/100) when considering less than complete agreement on all painful sites and 53% (56/106) on all tender sites. Supervising physicians questioned and examined patients presenting with abdominal pain more often than those presenting with other complaints.

CONCLUSIONS

There are significant variations in the recorded outcome of clinical evaluations by 2 different physicians during a single patient visit. Supervising physicians are more cautious to question and examine patients presenting with abdominal pain compared with other chief complaints.

The clinical presentation of acute bacterial meningitis varies with age, sex and duration of illness

AIM

This Swedish study reviewed differences in clinical presentation and laboratory findings of acute bacterial meningitis in children aged one month to 17 years in Västerbotten County, Sweden.

METHODS

A register-based study was performed for the period 1986 to 2013 using the Västerbotten County Council's patient registration and laboratory records at the Department of Laboratory Medicine at Umeå University Hospital. The medical records were reviewed to extract data and confirm the diagnosis.

RESULTS

We found 103 cases of acute bacterial meningitis, and Haemophilus influenzae was the most common pathogen, causing 40.8% of all cases, followed by Streptococcus pneumoniae at 30.1% and Neisseria meningitidis at 9.7%. Significant differences in clinical presentation and laboratory findings were found. Younger children were more unwell than older ones and had more diffuse symptoms on admission. In addition, important sex-related differences were found that might explain the higher case fatality rates for boys than girls. For example, boys tended to have a higher disturbance in the blood-brain barrier, which is known to be a negative prognostic factor.

CONCLUSION

This study showed that clinical presentation for acute bacterial meningitis varied with age and sex and, to a lesser extent, on the duration of the illness.

Clinical characteristics and prognostic factors in childhood bacterial meningitis: a multicenter study

OBJECTIVE

To evaluate clinical features and sequela in children with acute bacterial meningitis (ABM).

STUDY DESIGN

Multicenter retrospective study.

MATERIAL AND METHODS

Study includes retrospective chart review of children hospitalised with ABM at 11 hospitals in İstanbul during 2005. Follow up visits were conducted for neurologic examination, hearing evaluation and neurodevelopmental tests.

RESULTS

Two hundred and eighty three children were included in the study. Median age was 12 months and 68.6% of patients were male. Almost all patients had fever at presentation (97%). Patients younger than 6 months tended to present with feeding difficulties (84%), while patients older than 24 months were more likely to present with vomitting (93%) and meningeal signs (84%). Seizures were present in 65 (23%) patients. 26% of patients were determined to have at least one major sequela. The most common sequelae were speech or language problems (14.5%). 6 patients were severely disabled because of meningitis. Presence of focal neurologic signs at presentation and turbid cerebrospinal fluid appearance increased sequelae significantly. Childen under 24 months of age developed neurologic sequelae more commonly than older children.

CONCLUSION

Symptoms and signs were largely depending on the age of the patient. Speech or language problems were the most common sequelae following meningitis.

Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis

Few data sources are available to assess the global and regional risk of sequelae from bacterial meningitis. We aimed to estimate the risks of major and minor sequelae caused by bacterial meningitis, estimate the distribution of the different types of sequelae, and compare risk by region and income. We systematically reviewed published papers from 1980 to 2008. Standard global burden of disease categories (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) were labelled as major sequelae. Less severe, minor sequelae (behavioural problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia), and multiple impairments were also included. 132 papers were selected for inclusion. The median (IQR) risk of at least one major or minor sequela after hospital discharge was 19.9% (12.3-35.3%). The risk of at least one major sequela was 12.8% (7.2-21.1%) and of at least one minor sequela was 8.6% (4.4-15.3%). The median (IQR) risk of at least one major sequela was 24.7% (16.2-35.3%) in pneumococcal meningitis; 9.5% (7.1-15.3%) in Haemophilus influenzae type b (Hib), and 7.2% (4.3-11.2%) in meningococcal meningitis. The most common major sequela was hearing loss (33.9%), and 19.7% had multiple impairments. In the random-effects meta-analysis, all-cause risk of a major sequela was twice as high in the African (pooled risk estimate 25.1% [95% CI 18.9-32.0%]) and southeast Asian regions (21.6% [95% CI 13.1-31.5%]) as in the European region (9.4% [95% CI 7.0-12.3%]; overall I(2)=89.5%, p<0.0001). Risks of long-term disabling sequelae were highest in low-income countries, where the burden of bacterial meningitis is greatest. Most reported sequelae could have been averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.

Cerebrospinal fluid levels of interleukin-6 and interleukin-12 in children with meningitis

PURPOSE

Certain cytokines play important roles in the pathophysiology of meningitis. The main purpose of this study was to investigate if the levels of interleukin-6 (IL-6) and interleukin-12 (IL-12) in cerebrospinal fluid (CSF) could be diagnostic predictors of bacterial meningitis in children.

METHODS

CSF was obtained from 95 patients suspected with meningitis. These cases were classified to the bacterial meningitis (n = 12), aseptic meningitis (n = 41), and nonmeningitis (n = 42) groups. The levels of IL-6 and IL-12 in CSF were measured using the enzyme-linked immmunosorbent assays test.

RESULTS

The CSF IL-6 levels in the bacterial meningitis group (45.2 +/- 50.0 pg/ml) were significantly higher than those in the aseptic meningitis group (12.9 +/- 10.2 pg/ml) and the nonmeningitis group (6.5 +/- 7.8 pg/ml; p < 0.05). The CSF IL-12 levels in the bacterial meningitis group (69.8 +/- 67.1 pg/ml) were significantly higher than those in the aseptic meningitis group (22.9 +/- 10.8 pg/ml) and the nonmeningitis group (15.3 +/- 11.2 pg/ml; p < 0.05). With regard to diagnosis, the measurement of CSF IL-6 and IL-12 levels showed sensitivities of 96% and 96%, respectively, and specificities of 51% and 75%, respectively.

CONCLUSION

It is suggested that the CSF IL-6 and IL-12 levels are useful markers for distinguishing bacterial meningitis from aseptic meningitis.

Test characteristics and interpretation of cerebrospinal fluid gram stain in children

BACKGROUND

Few data exist regarding the test characteristics of cerebrospinal fluid (CSF) Gram stain among children at risk for bacterial meningitis, especially the rate of false positive Gram stain.

METHODS

We conducted a retrospective cohort study of children seen in the emergency department of Children's Hospital Boston who had CSF obtained between December 1992 and September 2005. Patients who had ventricular shunts, as well as those who received antibiotics before CSF was obtained were excluded. Test characteristics of CSF Gram stain were assessed using CSF culture as the criterion standard. Patients were considered to have bacterial meningitis if there was either: (1) growth of a pathogen, or (2) growth of a possible pathogen noted on the final CSF culture report and the patient was treated with a course of parenteral antibiotics for 7 days or more without other indication.

RESULTS

A total of 17,569 eligible CSF specimens were collected among 16,036 patients during the 13-year study period. The median age of study subjects was 74 days. Seventy CSF specimens (0.4%) had organisms detected on Gram stain. The overall sensitivity of Gram stain to detect bacterial meningitis was 67% [42 of 63; 95% confidence interval (CI): 54-78] with a positive predictive value of 60% (42 of 70; 95% CI: 48-71). Most patients without bacterial meningitis have negative Gram stain [specificity 99.9% (17,478 of 17,506; 95% CI: 99.8-99.9)] with a negative predictive value of 99.9 (17,478 of 17,499; 95% CI: 99.8-99.9).

CONCLUSIONS

CSF Gram stain is appropriately used by physicians in risk stratification for the diagnosis and empiric treatment of bacterial meningitis in children. Although a positive Gram stain result greatly increases the likelihood of bacterial meningitis; the result may be because of contamination or misinterpretation in 40% of cases and should not, by itself, result in a full treatment course for bacterial meningitis.

Recognising serious illness in feverish young children in primary care

Increasing the opportunity for prompt clinical assessment is the priority

Prognostic factors and determinants of fatal outcome due to bacterial meningitis in the Lazio region of Italy, 1996–2000

OBJECTIVES

To estimate case fatality rates (CFR) of bacterial meningitis and analyze factors associated with mortality due to bacterial meningitis in the Italian region of Lazio.

METHODS

Patients reported with bacterial meningitis during the period 1996-2000, who died within 30 days from hospitalization (cases), were compared with survivors (controls) for factors related to healthcare. Age, gender, residence, bacterial agent, co-morbidities, and signs of disease severity were also analyzed in the final model. Healthcare factors were analyzed using current surveillance databases.

RESULTS

Disease severity (OR=8.84; 95% CI=3.35-23.34) and age >44 years (OR=4.59; 95% CI=2.01-10.48) were the risk factors most strongly associated with death, while treatment in an infectious diseases ward was a protective factor, although modified by patient residence and by co-morbidities.

CONCLUSIONS

This protective effect was possibly due to differences in treatment protocols between the infectious diseases ward and other wards. The protective effect was found to be stronger for residents of Rome, suggesting delayed access to infectious diseases wards for non-residents. The difference in risk of dying from meningitis at younger ages than that found in other studies should be further evaluated, using information on bacteria serogroups and antibiotic susceptibility.

Clinical data and factors associated with poor outcome in pneumococcal meningitis

We carried out a 4-year study of 159 children (ages 1 month-14 years) with pneumococcal meningitis. The study was divided into two periods: the retrospective period (1998-2000: 107 patients), and the prospective period (2001-2002: 52 patients). About 2/3 of the children were under 2 years of age: 72 (45%) were under 1 year of age and 38 (24%) had meningitis during the second year of life. One-third of the patients had signs of otitis media; convulsions were more frequent in patients under 1 year compared with older patients (34.7 vs. 14.9%; P=0.004); 13/159 children (8.2%) died; 93/159 (58.5%) recovered completely, 12.6% had motor sequelae, 6.9% hydrocephalus, 29.8% sensorineural hearing loss; 140/159 (88%) were treated with third generation cephalosporins, yet only 8.7% of the pneumococci identified were completely penicillin-resistant (> or =1 microg/ml); 119/159 were treated with dexamethasone. Four patients had received an injection of heptavalent vaccine. Antibiotics for 1 week prior to admission, shock, abnormal pupils, leukocytes count <6,000 mm(3), and CSF glucose < or =8.5 mg/dl were significantly associated with poor outcome and/or death in the univariate analysis. No patient with leukocytosis >16,000/mm(3) died. Conclusion. Sequelae are very common in pneumococcal meningitis. Poor outcome was associated with pupillary abnormality and a leukocyte count <6,000/mm(3) on admission. Leukocytosis was protective against poor outcome.

Nonsevere acute otitis media: a clinical trial comparing outcomes of watchful waiting versus immediate antibiotic treatment

OBJECTIVE

The widespread use of antibiotics for treatment of acute otitis media (AOM) has resulted in the emergence of multidrug-resistant pathogens that are difficult to treat. However, it has been shown that most children with nonsevere AOM recover without ABX. The objective of this study was to evaluate the safety, efficacy, acceptability, and costs of a non-ABX intervention for children with nonsevere AOM.

METHODOLOGY

Children 6 months to 12 years old with AOM were screened by using a novel AOM-severity screening index. Parents of children with nonsevere AOM received an educational intervention, and their children were randomized to receive either immediate antibiotics (ABX; amoxicillin plus symptom medication) or watchful waiting (WW; symptom medication only). The investigators, but not the parents, were blinded to enrollment status. Primary outcomes included parent satisfaction with AOM care, resolution of symptoms, AOM failure/recurrence, and nasopharyngeal carriage of Streptococcus pneumoniae strains resistant to ABX. Secondary outcomes included medication-related adverse events, serious adverse events, unanticipated AOM-related office and emergency department visits and telephone calls, the child's absence from day care or school resulting from AOM, the parent's absence from school or work because of their child's AOM, and costs of treatment. Subjects were defined as failing (days 0-12) or recurring (days 13-30) if they experienced a higher AOM-severity score on reexamination.

RESULTS

A total of 223 subjects were recruited: 73% were nonwhite, 57% were <2 years old, 47% attended day care, 82% had experienced prior AOM, and 83% had not been fully immunized with heptavalent pneumococcal vaccine. One hundred twelve were randomized to ABX, and 111 were randomized to WW. Ninety-four percent of the subjects were followed to the 30-day end point. Parent satisfaction with AOM care was not different between the 2 treatment groups at either day 12 or 30. Compared with WW, symptom scores on days 1 to 10 resolved faster in subjects treated with immediate ABX. At day 12, among the immediate-ABX group, 69% of tympanic membranes and 25% of tympanograms were normal, compared with 51% of normal tympanic membranes and 10% of normal tympanograms in the WW group. Parents of children in the ABX group gave their children fewer doses of pain medication than did parents of children in the WW group. Subjects in the ABX group experienced 16% fewer failures than subjects in the WW group. Of the children in the WW group, 66% completed the study without needing ABX. Immediate ABX resulted in eradication of S pneumoniae carriage in the majority of children, but S pneumoniae strains cultured from children in the ABX group at day 12 were more likely to be multidrug-resistant than strains from children in the WW group. More ABX-related adverse events were noted in the ABX group, compared with the WW group. No serious AOM-related adverse events were observed in either group. Office and emergency department visits, phone calls, and days of work/school missed were not different between groups. Prescriptions for ABX were reduced by 73% in the WW group compared with the ABX group. Costs of ABX averaged $47.41 per subject in the ABX group and $11.43 in the WW group.

CONCLUSIONS

Sixty-six percent of subjects in the WW group completed the study without ABX. Parent satisfaction was the same between groups regardless of treatment. Compared with WW, immediate ABX treatment was associated with decreased numbers of treatment failures and improved symptom control but increased ABX-related adverse events and a higher percent carriage of multidrug-resistant S pneumoniae strains in the nasopharynx at the day-12 visit. Key factors in implementing a WW strategy were (a) a method to classify AOM severity; (b) parent education; (c) management of AOM symptoms; (d) access to follow-up care; and (e) use of an effective ABX regimen, when needed. When these caveats are observed, WW may be an acceptable alternative to immediate ABX for some children with nonsevere AOM.

A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis

BACKGROUND

Despite an extensive literature, the impact of both adjunctive steroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis is controversial.

AIM

To determine the independent contribution of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis in a representative population with good access to medical services.

METHODS

Data were obtained from laboratories and hospital records to assemble a population register in Sydney, Australia, 1994-99. Follow up questionnaires were completed by attending physicians.

RESULTS

A total of 122 cases of pneumococcal meningitis aged 0-14 years were identified. Almost 50% of 120 children with available records either died (n = 15) or had permanent neurological impairment (n = 39). Early use (before or with parenteral antibiotics) of corticosteroids protected against death or severe morbidity (adjusted OR 0.21, 95% CI 0.05 to 0.77). Delayed diagnosis was associated with increased morbidity in survivors (OR 3.4, 95% CI 1.03 to 11.4) but not with increased mortality.

CONCLUSION

In a population with good access to health care and after adjusting for other known prognostic variables, early recognition of pneumococcal meningitis and treatment with adjunctive dexamethasone significantly improves outcomes. These data add to those from randomised controlled trials. Implementation requires development of protocols and guidelines for use in emergency departments.

Referral and previous care of children with meningitis in Nigeria: implications for the presentation and outcome of meningitis in developing countries

There is a paucity of data on the referral of children with meningitis in developing countries, and on the relationship of presentation and outcome to previous care. Referral and previous care were investigated in 281 post-neonatal children treated in two tertiary centres. Data were obtained through the review of referral notes from orthodox health facilities, interview of parents/guardians and review of admission notes. Forty-four (16%) children were facility-referred and 81 (29%) self-referred from orthodox facilities while 156 (55%) were self-referred without previous care in these facilities. The facility-referrals (n=44) included 19 (43%) with meningitis on treatment, 13 (30%) with suspected meningitis and 12 (27%) with unsuspected meningitis. Twenty-two (50%) were referred because of deterioration, partial response or non-response to treatment, 5 (11%) on request by the parents, 9 (21%) on the suspicion of meningitis or other neurological disorder and 7 (16%) for mixed reasons. No reason was given in 1 case of meningitis on treatment. Among the 19 children referred with meningitis on treatment, only 1 was referred within 24 h of diagnosis, a confirmatory lumbar puncture was done only in 7, and only 10 of 18 (no data in 1 case) were on reasonably appropriate antibiotic regimens. Previous care in orthodox facilities was significantly associated with delayed presentation (>3 days of illness, p<0.001), partial treatment (p<0.001), lack of typical signs (p<0.05), severe illness (p<0.01), and adverse outcome (death or recovery with neurological sequelae, p<0.05). Limited recognition of the possibility of meningitis in acutely ill children and an inadequate referral practice may account for these effects. A clear delineation of referral needs might reduce the magnitude of these problems.

Diagnosis and management of acute otitis media

This evidence-based clinical practice guideline provides recommendations to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM). The American Academy of Pediatrics and American Academy of Family Physicians convened a committee composed of primary care physicians and experts in the fields of otolaryngology, epidemiology, and infectious disease. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to AOM. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific definition of AOM. It addresses pain management, initial observation versus antibacterial treatment, appropriate choices of antibacterials, and preventive measures. Decisions were made based on a systematic grading of the quality of evidence and strength of recommendations, as well as expert consensus when definitive data were not available. The practice guideline underwent comprehensive peer review before formal approval by the partnering organizations. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Invasive Haemophilus influenzae type b infections in children in Paraguay

BACKGROUND

In Paraguay, as in most Latin American countries, data on the epidemiology and clinical characteristics of Haemophilus influenzae type b (Hib) diseases are scarce and incomplete.

METHODS

To address this issue, we performed a retrospective analysis of 102 patients admitted to the Instituto de Medicina Tropical, a referral hospital in Asunción, Paraguay, between January 1991 and September 1995 with diagnosis of invasive Hib infection. This study included patients 15 years of age and under-identified with positive cultures for Hib in blood, cerebrospinal fluid, or other sterile body fluids.

RESULTS

Eighty three (81%) patients presented with meningitis as principal focus of infection with median age of 9 months. Forty five (54%) patients with Hib meningitis were <12 months of age and 20 (24% of total cases) were <6 months of age. Overall mortality rate of meningitis was 13%. Of 11 patients who died, 10 (91%) were <12 months of age (p <0.02). Risk for mortality was correlated with presence of coma during admission (p <0.007) and CSF glucose level of <10 mg/dL (p <0.05). Severe sequelae such as bilateral hearing loss, hydrocephalus, and mental retardation were observed in 39% (28/72) of surviving patients, of whom 18 (51%) patients were <12 months of age (p <0.02). Thirty percent of isolated strains of Hib were resistant to ampicillin, 20% were resistant to chloramphenicol, and 10% to both drugs.

CONCLUSIONS

This information provides evidence concerning the importance of continued support for Hib vaccine supplies in immunization programs in countries with limited resources such as Paraguay.

Educational intervention for parents and healthcare providers leads to reduced antibiotic use in acute otitis media

We used a controlled before-and-after design with the aims of reducing both the total consumption of antibiotics and the use of broad-spectrum antibiotics against acute otitis media (AOM), and to study to what extent prescriptions for antibiotics against AOM were dispensed. Information on evidence-based treatment of uncomplicated AOM was provided to doctors and nurses, and written guidelines were implemented. Pamphlets and oral information concerning symptomatic treatment and the limited effect of antibiotic use in AOM were given to parents. Eligible patients were 819 children aged 1-15 y. The proportion of patients receiving a prescription for antibiotics was reduced from 90% at baseline to 74% during the study period. The proportion of prescriptions for penicillin V increased from 72% at baseline to 85% during the study period. There were no significant changes at the control site. The proportion of dispensed prescriptions was 70% both at baseline and during the study period. Educational efforts reduced the total consumption of antibiotics and the use of broad-spectrum antibiotics for AOM in children aged 1-15 y at an emergency call service. Data on antibiotic use in AOM based only on prescribing overestimates the use of antibiotics.

Sensorineural hearing loss following acute bacterial meningitis in non-neonates

OBJECTIVE

Sensorineural hearing loss (SNHL) is an important sequelae of acute bacterial meningitis (ABM) in children. This study was undertaken to determine the incidence of SNHL following meningitis in non-neonates and its correlation with various factors.

METHODS

Children between the ages of 1 month and 12 years with ABM admitted in a teaching hospital over a period of 18 months were enrolled. Detailed history was taken, clinical examination performed and cerebrospinal fluid analyzed at commencement of therapy, 48 hours later and at the end of treatment. On discharge brainstem evoked response audiometry (BERA) was recorded. Data were analyzed using appropriate statistical tests.

RESULTS

Out of 32 children enrolled, 9 (28.1%) developed SNHL, bilateral in 21.9% and unilateral in 6.2%. Among hearing impaired subjects, 11.2% had mild while 44.4% each had moderate and profound hearing loss. Age, presence of vomiting, altered sensorium seizures and aminoglycoside usage were not significantly different in those with and without SNHL, but the total duration of fever was (p<0.05). There was significantly higher protein content and neutrophils in the second CSF sample of those with SNHL.

CONCLUSION

There is a greater than 50% probability of the child developing SNHL if neutrophil percentage in the second CSF is 80% or more. Since the overall risk of SNHL is significant in children with meningitis, it is recommended that BERA be recorded in all, so that early intervention may be possible.

Acute bacterial meningitis in children admitted to a rural Kenyan hospital: increasing antibiotic resistance and outcome

BACKGROUND

Acute bacterial meningitis (ABM) is an important cause of mortality in Africa, but most studies are based in urban referral hospitals. Poor laboratory facilities make diagnosis difficult, and treatment is limited to inexpensive antibiotics.

METHODS

We retrospectively reviewed data from children admitted with ABM to a Kenyan district hospital from 1994 through 2000. We calculated the minimum incidence in children admitted from a defined area. We also examined the antibiotic susceptibility patterns.

RESULTS

We identified 390 cases (1.3% of all admissions) of whom 88% were <5 years old. The apparent minimum annual incidence in children younger than 5 years of age increased from 120 to 202 per 100,000 between 1995 and 2000 (P < 0.001). Increasing the lumbar punctures performed by including prostrated or convulsing children significantly increased the number of cases detected (P < 0.005). The most common organisms in infants <3 months were streptococci and Enterobacteriaceae. Streptococcus pneumoniae (43.1%) and Haemophilus influenzae (41.9%) were predominant in the postneonatal period. The overall mortality was 30.1%, and 23.5% of survivors developed neurologic sequelae. Chloramphenicol resistance of H. influenzae rose from 8% in 1994 to 80% in 2000 (P < 0.0001) accompanied by an apparent increase in mortality. A short history, impaired consciousness and hypoglycemia were associated with death. Prolonged coma and low cerebrospinal fluid glucose were associated with neurologic sequelae.

CONCLUSION

ABM in rural Kenya is a severe illness with substantial mortality and morbidity. Prognosis could be improved by broadening the criteria for lumbar puncture and use of appropriate antibiotics.

A revised clinical method for assessment of severity of acute bacterial meningitis

The aim of this study was to simplify a previously described clinical method of assessing severity of meningitis. An 8.5-point, six-item model for the risk of an abnormal course (seizures during treatment) or adverse outcome (death or recovery with neurological sequelae) was developed using a set of six bedside features: age < or = 2 yrs, 2 points; duration of illness > 7 days, 1.5 points; seizures, 2.5 points; hypovolaemic shock, 1 point; coma, 0.5 point; and abnormal muscle tone, 1 point. A high-risk score (< or = 2.5 points) was associated with a relative risk (95% CI) of 7.4 (2.4, 22.7) of seizures during treatment, and 6.3 (2.6, 17.2) for an adverse outcome (death or major or minor sequelae). The revised model should be suitable for use where laboratory facilities are not readily available, as in many developing countries, or when contra-indications to lumbar puncture are an important consideration on admission, as in severely ill patients, as well as when there are not such limitations.

Impact of human immunodeficiency virus type 1 infection on the epidemiology and outcome of bacterial meningitis in South African children

OBJECTIVE

To define the impact that the human immunodeficiency virus type 1 (HIV-1) epidemic has had on the burden and outcome of bacterial meningitis in an area with a high prevalence of pediatric HIV-1 infection.

METHODS

Children less than 12 years of age with proven or suspected bacterial meningitis were enrolled in this study between March 1997 and February 1999, and their hospital records were retrospectively reviewed for clinical data.

RESULTS

Sixty-two (42.2%) of the 147 children tested for HIV-1 infection were infected. Streptococcus pneumoniae (Pnc) exceeded Haemophilus influenzae type b (Hib) as the most important cause of meningitis in HIV-1-infected (74.2% vs. 12.9%, respectively) compared with uninfected children (29.4% vs. 42.3%, respectively, P less than 10(-5)). The estimated relative risk of Pnc meningitis was greater in HIV-1-infected than in uninfected children under 2 years of age (relative risk [RR] = 40.4; 95% confidence intervals [CI] = 17.7-92.2). Overall, HIV-1-infected children had a higher rate of mortality than uninfected children (30.6% vs. 11.8%, respectively, P = 0.01), and in particular, HIV-1-infected children with Pnc meningitis (60.8% vs. 36.0%, respectively, P = 0.04) had a poorer outcome.

CONCLUSIONS

Streptococcus pneumoniae has exceeded Hib as the most important pathogen causing bacterial meningitis in HIV-1-infected compared with uninfected children. Effective vaccination against Hib and Pnc should be evaluated to reduce the overall burden of bacterial meningitis in HIV-1-infected children.

Fever interval before diagnosis, prior antibiotic treatment, and clinical outcome for young children with bacterial meningitis

In young children, meningitis due to Streptococcus pneumoniae is preceded by a long interval from onset of fever to diagnosis of bacterial meningitis (hereafter known as "fever interval"), during which time the patient frequently contacts a clinician. By means of retrospective chart review, we compared the fever interval that preceded diagnosis with the complication rate among 288 young children (age, 3--36 months) who had bacterial meningitis (1984--1996), as stratified by causative organism and prior antibiotic treatment. Pathogens included S. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Pneumococcus species were associated with the longest fever interval prior to diagnosis of meningitis, the highest frequency of contact with a clinician before hospitalization, and the highest rate of documented morbidity or mortality. For S. pneumoniae, there was an association between antibiotic treatment received at prior meetings with a clinician and a reduced rate of meningitis-related complications (odds ratio, 0.14; P=.02). Antibiotic treatment during such meetings is associated with a substantial reduction in disease-related sequelae.

Burden of meningitis and other severe bacterial infections of children in africa: implications for prevention

Apart from meningococcal disease in the sub-Saharan meningitis belt, the incidence and impact of life-threatening bacterial diseases in children across Africa have not been quantified. The clinical and epidemiological data on pneumococcal, Haemophilus influenzae type b (Hib), and other forms of bacterial meningitis, as well as data on other severe bacterial infections throughout the continent were scrutinized. Pneumococci were the leading causative agents of nonepidemic meningitis and other bacteremic diseases, followed by Hib. Meningococcal diseases were less common. Mortality rates associated with pneumococcal, Hib, and meningococcal meningitis were 549 (45%) of 1211 patients, 389 (29%) of 1352 patients, and 104 (8%) of 1236 patients, respectively; sequelae occurred in 50%, 40%, and 10% of cases. At 0-4 years of age, the estimated incidences of Hib meningitis and all classic Hib diseases were 70 and 100 cases per 100,000 population per year, accounting for approximately 90,000 and 120,000 cases per year, respectively. Including older age groups and, especially, nonbacteremic Hib pneumonia in the estimates of Hib disease in Africa increased the overall numbers manifold; the numbers of pneumococcal infections were even greater. The only realistic way to combat these severe infections efficaciously would be through widespread vaccination, starting with Hib conjugates.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis

The clinical presentations of children and adults with bacterial meningitis have not changed over the past several decades, and a high index of suspicion remains critical for timely identification of infected patients. With the virtual disappearance of H. influenzae type B meningitis (Hib) in areas of the world where Hib conjugate vaccine is administered routinely, the utility of commercially available tests for rapid detection of bacterial polysaccharides has diminished. Detection of gene products of meningeal pathogens in cerebrospinal fluid or blood is still experimental. The prognostic findings of recent studies are not different from those previously described, despite advances in the supportive care of critically ill patients.

Variation in plasminogen-activator-inhibitor-1 gene and risk of meningococcal septic shock

BACKGROUND

Some patients infected with Neisseria meningitidis develop septic shock accompanied by fibrin deposition and microthrombus formation in various organs, whereas others develop bacteraemia or meningitis without septic shock. We investigated whether genetic differences in the fibrinolytic system influence the development of meningococcal septic shock.

METHODS

We investigated 50 patients who survived meningococcal infection, and 131 controls from the same geographical region. Because we had no information on genotypes of patients who died, we also genotyped 183 first-degree relatives of a consecutive series of patients with meningococcal infection for the 4G/5G deletion/insertion polymorphism in the promoter region of the plasminogen-activator-inhibitor-1 gene (PAI-1). The 4G allele is associated with increased gene transcription in cell lines in vitro and with increased PAI-1 concentrations in carriers in vivo.

FINDINGS

The allele frequencies of 4G and 5G were similar between patients and controls. However, the 4G/4G genotype was present in only 9% of relatives of patients with meningitis compared with 36% of relatives of patients with septic shock. The 5G/5G genotype was more common among relatives of patients with meningitis (31 vs 11%, p=0.001). Patients whose relatives were carriers of the 4G/4G genotype had a six-fold higher risk of developing septic shock than meningitis (odds ratio 5.9 [95% CI 1.9-18.0]) compared with all other genotypes.

INTERPRETATION

Variation in the PAI-1 gene does not affect the probability of contracting meningococcal infection, but does influence the development of septic shock.

Risk factors for an adverse outcome in bacterial meningitis in the tropics: a reappraisal with focus on the significance and risk of seizures

The relationship of presentation to outcome in children with meningitis was analysed. The relative risk (95% confidence interval) of an adverse outcome (death or neurological sequelae) associated with presentation with at least three of ten features (age < or = 2 yrs, ill for > 7 days, antibiotic treatment, focal nerve deficits, abnormal posturing, abnormal muscle tone, lack of typical meningeal signs, shock, unrousable coma and seizures) was 4.9 (2.7, 8.8), p < 0.0001. The first six features were particularly associated with neurological sequelae, and shock and coma with death. Seizures were associated with either outcome. Two seizure types could be distinguished: seizures which occurred before or on diagnosis only (type I seizures) and seizures which occurred before and/or after diagnosis (type II seizures). Death occurred in 0/41 children without seizures and in 14/34 and 11/34 children with type I and type II seizures, respectively (p < 0.0001). Neurological sequelae occurred in 3/42 children without seizures and in 5/20 and 14/23 with type I and type II seizures, respectively (p < 0.0001).

C-reactive protein is useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children

OBJECTIVE

To clarify to what extent Gram stain-negative bacterial meningitis can be distinguished from viral meningitis by assessment of cerebrospinal fluid (CSF) and blood indices and serum C-reactive protein (CRP) in children over 3 months of age.

DESIGN

Common CSF indices, blood leukocyte counts, and serum CRP values were compared between patients with bacterial meningitis who had a positive CSF bacterial culture but a negative Gram stain and patients with viral meningitis.

POPULATION

Three hundred twenty-five consecutive patients with CSF culture-proven bacterial meningitis, for whom Gram stain was negative in 55 cases, and 182 children with proven or presumed viral meningitis.

RESULTS

Significant differences between patients with bacterial and viral meningitis were found in all indices with large overlap in all except serum CRP. In patients with bacterial meningitis, the mean CSF glucose concentration, protein concentration, leukocyte count, blood leukocyte count, and serum CRP were 2.9 mmol/L (52 mg/dL), 1.88 g/L, 4540 x 10(6)/L, 18.0 x 10(9)/L, and 115 mg/L; and in those with viral meningitis, mean values were 3.3 mmol/L (59 mg/dL), 0.52 g/L, 240 x 10(6)/L, 10.6 x 10(9)/L, and <20 mg/L, respectively. Of the tests investigated in this study, only serum CRP was capable of distinguishing Gram stain-negative bacterial meningitis from viral meningitis on admission with high sensitivity (96%), high specificity (93%), and high negative predictive value (99%).

CONCLUSION

Exclusion of bacterial meningitis with only the conventional tests is difficult. Combined with careful physical examination and CSF analyses, serum CRP measurement affords substantial aid.

Current Concepts of Therapy for Otitis Media

The therapy for acute otitis media is currently a topic in evolution. What was once a straightforward approach of matching middle ear pathogens to appropriate antibiotics has become a complex calculus that attempts to balance multiple terms such as spontaneous cure, emergence of resistance, pharmacokinetics-dynamics, antibiotic therapeutic efficacy, suppurative complications, and cost. This review highlights new developments in our understanding of this complex interaction of the issues surrounding a physician's decision to begin antibiotic therapy for acute otitis media.

Genetic basis for biosynthesis, structure, and function of meningococcal lipooligosaccharide (endotoxin)

The exclusive human pathogen Neisseria meningitidis expresses lipooligosaccharide (LOS), an endotoxin that is structurally distinct from the lipopolysaccharides (LPS) of enteric Gram-negative bacilli. Differences that appear to be biologically important occur in the composition and attachment of acyl chains to lipid A, phosphorylation patterns of lipid A, and the incorporation and phosphorylation of sugar residues in the LOS inner core. Further, unlike most enteric LPS, only two to five sugar residues are attached to the meningococcal LOS inner core, and there are no multiple repeating units of O-antigens. In contrast to Escherichia coli, where the LPS biosynthesis genes are organized as large operons, the meningococcal LOS biosynthesis genes are organized into small operons or are located individually in the chromosome. Some of these genetic loci in meningococci and gonococci display polymorphisms caused by localized chromosomal rearrangements. One mechanism of antigenic variation of meningococci LOS is the regulation of glycosyltransferase activity by slipped strand mispairing of homopolymeric tracts within the 5' end of the genes encoding these enzymes, resulting in the addition of different sugar residues to the LOS molecule. Meningococcal LOS is a critical virulence factor in N. meningitidis infections and is involved in many aspects of pathogenesis, including the colonization of the human nasopharynx, survival after bloodstream invasion, and the inflammation associated with the morbidity and mortality of meningococcemia and meningitis. Meningococcal LOS, which is a component of serogroup B meningococcal vaccines currently in clinical trials, has been proposed as a candidate for a new generation of meningococcal vaccines. The rapidly expanding knowledge of the genetic basis for biosynthesis, structure, and regulation of meningococcal LOS provides insights into unique endotoxin structures and the precise role of LOS in the pathogenesis of meningococcal disease.

Risk factors analysis for early fatality in children with acute bacterial meningitis

To identify the cause of early fatality and to delineate the clinical findings on admission associated with this early fatality, a retrospective study of 101 children with bacterial meningitis was performed in southern Taiwan. Risk factors for early fatality are compared between patients with and without acute death in the first 3 days after admission. The overall patient fatality is 27%. Eighty-five percent of them (23 patients) occur at an average of 16.5 hours after admission despite proper antibiotic treatment. The causes of early death are predominantly hemodynamic in 14 patients (61%) and predominantly neurologic in nine (39%). Analysis of clinical parameters available on admission indicated a significant risk of early death in patients who have tachycardia, tachypnea, hypothermia, poor skin perfusion, metabolic acidosis, leukopenia, thrombocytopenia, low cerebrospinal fluid leukocyte count, and high cerebrospinal fluid lactate level. Multivariate analysis demonstrates that metabolic acidosis, poor skin perfusion, and low cerebrospinal fluid leukocyte count are independently and significantly associated with early fatality. In conclusion, two thirds of early fatalities in children with bacterial meningitis are the result of septic shock. Close surveillance for signs of septic shock, as well as of brain herniation should be continued, especially within 3 days after antibiotic treatment.

How long is too long? Determining the early management of meningococcal disease in Birmingham

OBJECTIVE

To determine the length of time cases of meningococcal disease wait before receiving parenteral antibiotic therapy in hospital.

METHOD

The hospital case notes of residents of Birmingham who were admitted to local hospitals in 1993 and discharged with a diagnosis of meningitis or meningococcal disease were reviewed. This information was combined with that held by the West Midlands Ambulance Service.

RESULTS

Forty out of the 82 patients (49%) who met the case definition had meningococcal infection. Twenty one patients (26%) were admitted by ambulance, 11 of whom had meningococcal infection. The mean time from a request for an ambulance to the patient reaching hospital was 52 min for those with meningococcal infection compared to 55 min for those without. Nineteen patients (47.5%) with meningococcal infection waited more than one hour after admission for antibiotic treatment. Seven had an initial diagnosis of meningitis or meningococcal infection. Ten out of 27 patients with a meningococcal rash (37%), 13 out of 22 patients aged under five years (59%) and 13 out of 24 patients with microbiologically confirmed meningococcal infection (54%) waited more than one hour for treatment. Seven patients with meningococcal infection received benzyl penicillin before admission. Six received hospital antibiotic treatment within the hour.

CONCLUSION

The assumption that patients suspected of having meningitis or meningococcal disease are treated promptly once in hospital is not always correct. The results of this study reinforce the need for all doctors to give benzyl penicillin promptly to patients they suspect have meningococcal disease.

Long-term sequelae of pneumococcal meningitis in children

The purpose of this study was to assess the long-term effects of pneumococcal meningitis in children. From 1967 to 1988, a total of 90 children were admitted to the Hospital for Infectious Diseases, Thessaloniki, Greece, with the diagnosis of pneumococcal meningitis. Sixteen patients died in the hospital as a direct result of meningitis. Eleven others were excluded from the study (neurologic deficits prior to onset of meningitis, two; death subsequent to hospitalization, two; recurrent meningitis, seven). Of the remaining 63 survivors, we were able to evaluate 47 patients (75%). Evaluation was performed 4 to 23 years (mean 12.3 +/- 5.8 years) after discharge. Forty patients returned to hospital for evaluation, and seven were evaluated by their primary physicians, who sent information by a standardized questionnaire. The following examinations were carried out: history, physical and neurologic examination, ophthalmologic and hearing evaluation, and psychometric testing. Fourteen patients (30%) had at least one neurologic handicap; nine (19%) had mental retardation, eight (17%) hearing loss, seven (15%) seizure disorder, five (11%) motor defects, and one each (2%) behavioral problems and visual impairment. The presence of coma was the strongest predictor of increased morbidity. The high frequency of long-term sequelae observed in our study supports the need of an effective vaccine.

Prognostic factors in childhood bacterial meningitis

The purpose of this study was to identify possible risk factors associated with a poor prognosis in childhood bacterial meningitis. We also analysed the influence of duration of symptoms and prehospital antibiotic therapy on outcome. Ninety-two children aged 1 month to 13.8 years were included, of whom 4 died (4.3%) and 14 (15.2%) experienced permanent neurological sequelae. Hearing impairment was the most frequent sequela and was strongly associated with the length of history. Multiple logistic regression revealed duration of symptoms > 48 h, pre-hospital seizures, peripheral vasoconstriction, < 1000 x 10(6)/l leucocytes in cerebrospinal fluid and temperature < or = 38.0 degrees C on admission as risk factors independently associated with later death or sequelae. There was no association between pre-hospital oral or parenteral antibiotic therapy and outcome. These risk factors may be of value in selecting patients for more intensive therapy and in identifying possible candidates for new treatment strategies.

Clinical manifestations and outcome of Haemophilus influenzae type b disease

OBJECTIVE

To document clinical manifestations, laboratory findings and outcome of childhood Haemophilus influenzae type b (Hib) infections.

METHODOLOGY

Medical records of 235 children with Hib disease admitted to hospital during a 2 year period were reviewed; additional information was obtained by questionnaire and follow up 6 weeks after discharge.

RESULTS

Three-quarters of patients presented with either meningitis or epiglottitis. Children with epiglottitis were older, had shorter illnesses and were less likely to have had antibiotics before admission than those with meningitis; 38% of the latter had been given some antibiotic therapy, with no apparent effect on the outcome. Fever persisted for 7 days or more in 23% of patients with meningitis. Death from meningitis occurred in 3.8% of patients and was due to fulminating disease.

CONCLUSIONS

These data will assist in recognition and appropriate management of Hib disease as the clinical manifestations become less familiar following the introduction of immunization. Specific laboratory diagnosis is required for accurate surveillance, which should be maintained in order to ensure high immunization rates.

Bacterial meningitis in Swaziland: an 18 month prospective study of its impact

STUDY OBJECTIVE

To describe the epidemiology, clinical features, and outcome of bacterial meningitis in Swaziland.

DESIGN

Prospective study of patients diagnosed as having meningitis of nonviral aetiology during an 18 month period from February 1991 to July 1992.

SETTING

Four regional hospitals covering the population of the four districts in Swaziland.

SUBJECTS

All patients with non-viral meningitis admitted to hospital within the study period.

MAIN RESULTS

Altogether 85 patients were reported to have bacterial meningitis: 48.3% were aged under 1 year. Causative organisms were identified in 60% of cases, and Streptococcus pneumoniae was found to be the commonest (49% of cases). Overall, case fatality was 38.8% for all age groups, and 62.5% (15 of 25) for adults. Neurological sequelae occurred in 22.4%. Three of the adult cases were HIV seropositive. Seizures, but not duration of symptoms before admission, were associated with a poor prognosis. There was a significant rise in incidence related to a period of drought. Fifteen patients were reported with tuberculous meningitis, of whom five were known to be HIV seropositive; the case fatality was 73.3%.

CONCLUSIONS

The aetiology and age distribution of cases of meningitis differs greatly from that in developed countries. Rising HIV infection may have an important impact on the future incidence of meningitis. The high case mortality found should encourage efforts towards earlier diagnosis and treatment, and strengthens the need to develop appropriate vaccines.

Smoking, the environment and meningococcal disease: a case control study

This case control study investigated environmental factors in 74 confirmed cases of meningococcal disease (MD). In children aged under 5, passive smoking in the home (30 or more cigarettes daily) was associated with an odds ratio (OR) of 7.5 (95% confidence interval (CI) 1.46-38.66). ORs increased both with the numbers of cigarettes smoked and with the number of smokers in the household, suggesting a dose-response relationship. MD in this age group was also significantly associated with household overcrowding (more than 1.5 persons per room) (OR 6.0, 95% CI 1.10-32.8), with kisses on the mouth with 4 or more contacts in the previous 2 weeks (OR 2.46, 95% CI 1.09-5.56), with exposure to dust from plaster, brick or stone in the previous 2 weeks (OR 2.24, 95% CI 1.07-4.65); and with changes in residence (OR 3.0, 95% CI 1.0-8.99), marital arguments (OR 3.0, 95% CI 1.26-7.17) and legal disputes in the previous 6 months (OR 3.10, 95% CI 1.24-7.78). These associations were independent of social class. Public health measures to lower the prevalence of cigarette smoking by parents of young children may reduce the incidence of MD. The influence of building dust and stressful life events merits further investigation.