How long to treat bacterial meningitis

[The duration of antibiotic therapy in bacterial meningitis with pyogenic ventriculitis]

A 68-year-old man visited our hospital emergency department with consciousness disturbance. He was diagnosed as bacterial meningitis with septic shock, and initial empirical antibacterial therapy was initiated immediately. Streptococcus pneumoniae. was cultured from the cerebrospinal fluid (CSF), and brain MRIs showed pyogenic ventriculitis. Even though CSF findings improved, he was still in coma and finally died with pneumonia. It is unknown how pyogenic ventriculitis affects the course of bacterial meningitis. We analyzed total 11 inpatients with bacterial meningitis associated with or without the pyogenic ventriculitis, including the present patient, in our hospital. Severity of clinical symptoms and CSF findings might determine the duration of antimicrobial administration, regardless of whether pyogenic ventriculitis existed or not.

Treatment ofPseudomonas aeruginosainfection in critically ill patients

Critically ill patients are on the increase in the present clinical setting. Aging of our population and increasingly aggressive medical and therapeutic interventions, including implanted foreign bodies, organ transplantation and advances in the chemotherapy of malignant diseases, have created a cohort of particularly vulnerable patients. Pseudomonas aeruginosa is one of the leading gram-negative organisms associated with nosocomial infections. This organism is frequently feared because it causes severe hospital-acquired infections, especially in immunocompromised hosts, and is often antibiotic resistant, complicating the choice of therapy. The epidemiology, microbiology, mechanisms of resistance and currently available and future treatment options for the most relevant infections caused by P. aeruginosa are reviewed.

Bacterial Meningitis in Children

Acute bacterial meningitis is still an important cause of morbidity and mortality in children worldwide. Recently, Haemophilus influenzae type b (Hib), once a common cause of meningitis, has virtually disappeared in developed nations, reflecting the overwhelming success of Hib vaccination. Unfortunately, Hib remains a significant pathogen in resource-poor countries. The introduction of the conjugated pneumococcal vaccine in 2000 may lead to similar future trends as witnessed with Hib. As the resistance of Streptococcus pneumoniae to penicillin and cephalosporins continues to evolve, vancomycin has become an important antibacterial in the treatment of bacterial meningitis. The unreliable penetration of this agent into cerebrospinal fluid is of concern, which is compounded by the controversial use of corticosteroids in paediatric meningitis. Some data suggest that in certain situations the addition of rifampicin (rifampin) to ceftriaxone may be a better choice. While dexamethasone is now considered the standard adjunctive therapy in the treatment of pneumococcal meningitis in adult patients, the benefit in children is not so clear and remains controversial; thus, there is no definitive paediatric recommendation. Several anti-inflammatory agents currently under investigation may be used in the future as adjunctive therapy for bacterial meningitis. It is clear that the current concepts in the treatment of childhood bacterial meningitis are evolving, and other antibacterial options and possible alternatives such as carbapenems and fluoroquinolones should be considered. Fluid restriction because of the Syndrome of Inappropriate Antidiuretic Hormone Secretion is widely advocated and used. Yet, this practice was recently challenged. It seems that most patients with meningitis do not need fluid restriction. The overwhelming success of the conjugated Hib vaccine and the encouraging results of the new conjugated pneumococcal and meningococcal vaccines suggest that the ideal management of bacterial meningitis is prevention and vaccines development against the most common bacterial agents are the best solution.

Antibiotic treatment for bacterial meningitis in children in developing countries

Bacterial meningitis causes 125,000 deaths each year in infants and young children and 96% of these occur in less developed countries where up to 50% of children with this disease die and 25-50% of survivors have neurological sequelae. Although 3rd-generation cephalosporins are optimal empirical therapy for bacterial meningitis, they are unaffordable in many developing countries. The majority of children worldwide are currently treated with cheaper alternatives. This paper reviews the challenges facing clinicians treating bacterial meningitis in developing countries, highlighting the problem of changing patterns of antibiotic resistance. In particular, it details the evidence for the use of chloramphenicol and 3rd-generation cephalosporins.

Bacterial meningitis: current controversies in approaches to treatment

Acute bacterial meningitis continues to be a disease with unacceptably high mortality and morbidity rates in both adults and children worldwide, despite advances in antibacterial therapy. Death or permanent disability occurs frequently. The causative organism varies with age, immune function and immunisation status. Infection with Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) is associated with the majority of cases, with Listeria monocytogenes and Streptococcus agalactiae being more prevalent pathogens at the extremes of age (<3 months or >50 years). Antibacterial resistance is an increasing problem, particularly in pneumococcal bacteria but increasingly in other organisms. The increasing prevalence of resistance of pneumococcus to penicillin and the cephalosporins complicates therapy and may have an important impact on treatment outcome. Increased understanding of the pathophysiology has allowed advances in diagnosis and therapy. The use of adjunctive corticosteroids remains controversial, but is probably beneficial in reducing neurological sequelae in children. In adults the evidence is less clear. Vaccination has virtually eradicated Hib meningitis in some countries. Recent introduction of a conjugate vaccine against serogroup C meningococci in the UK has caused a dramatic reduction in the incidence of invasive disease due to this organism. A 7-valent pneumococcal vaccine promises a similar reduction in the incidence of invasive pneumococcal disease. In the meantime, the emergence of widespread resistance of organisms to antibacterial agents, in particular among the common organisms causing bacterial meningitis, remains the biggest challenge in therapy.

The use of liver grafts from donors with bacterial meningitis

BACKGROUND

The shortage of suitable donors for transplantation is a worldwide problem. The use of cadaveric donors with bacterial meningitis may be associated with an increased risk of sepsis. We report the results of orthotopic liver transplantation (OLT) from 33 such donors between 1989 and 1999.

METHODS

The hospital records of recipients from cadaveric donors with meningitis (study group) were retrospectively reviewed and compared with matched recipients from cadaveric donors dying from causes other than meningitis (recipient-matched control group).

RESULTS

A total of 34 recipients underwent 21 whole, 10 reduced, and 3 split liver transplants from 33 cadaveric donor livers with bacterial meningitis. The donor meningitis pathogens were Neisseria meningitidis (n=14), Streptococcus pneumoniae (n=4), Haemophilus influenzae (n=1), Streptococcus species (n=2), and unknown (n=12). Twenty-seven patients had an elective OLT and seven patients had an emergency OLT. Adequate antimicrobial therapy before organ procurement and after transplant was administrated. The mean posttransplant follow-up was 37 months (range: 1 day-106 months). There was no difference in recipient and graft survival rates between the study and the recipient-matched groups. In the study group, there were no infectious complications caused by the meningeal pathogens. Overall patient survival rates were 79%, 76%, 72%, and 72% at 1, 6, 12, and 60 months, respectively. Graft survival was 77%, 70%, 65%, and 65% at 1, 6, 12, and 60 months, respectively. The survival rate in elective cases was significantly better than emergency cases (P<0.05).

CONCLUSION

Liver transplantation from donors with bacterial meningitis is a safe procedure provided both donors and recipients receive adequate antimicrobial therapy.

Treatment of bacterial meningitis

Major epidemiological changes have altered the empiric therapy of patients with bacterial meningitis, a disease with significant morbidity and mortality. We offer recommendations for empiric management decisions and specific antibiotic choices for patients with bacterial meningitis.

C-reactive protein is a useful marker for guiding duration of antibiotic therapy in suspected neonatal bacterial infection

OBJECTIVE

To determine whether C-reactive protein (CRP) can be used as a parameter to identify the time point when antibiotic treatment can safely be discontinued in a defined major subgroup of neonates treated for suspected bacterial infection.

PATIENTS

One hundred seventy-six newborns with birth weights of greater than 1500 g and without central lines and mechanical ventilation who had suspected bacterial infection were enrolled in a prospective study.

SETTING

Tertiary care neonatal reference center.

DESIGN

Serum concentrations of CRP were determined 24 to 48 hours after the first dose of antibiotics. If CRP levels were less than 10 mg/L, infants were considered unlikely to be infected, and the antibiotic treatment was stopped using CRP as the single decision criterion in 84 of 94 newborns (group 1). Infants with CRP levels of 10 mg/L or greater were considered likely to be infected and randomized to two study groups. In 38 of 39 neonates (group 2a), CRP was determined daily, and antibiotic therapy was discontinued as soon as CRP returned to less than 10 mg/L. Forty-three neonates with likely infection (group 2b) were treated for at least 5 days, and relapse rates of bacterial infections were compared between groups 2a and 2b.

OUTCOME MEASURES

The primary outcome variable of the study was the number of infectious relapses of the primary infection. This was assessed by the need for a second course of antibiotics within 4 weeks of the first one. The value of CRP for guiding treatment duration was determined by calculating the negative predictive value of CRP with respect to further treatment in study groups 1 and 2a. Treatment durations and relapse incidence in the two groups of neonates with likely infection (groups 2a and 2b) were compared.

RESULTS

Within the 4-week follow-up period, one infant in group 1 and no infant in group 2a received a second course of antibiotics for bacterial infection. CRP levels of less than 10 mg/L determined later than 24 hours after beginning the antibiotic treatment thus correctly identified 120 of 121 infants as not needing further antibiotics. This corresponds to a negative predictive value with respect to further treatment of 99% (95% confidence interval, 95.4% to 99.9%). The mean treatment duration was 3.7 (median, 4; range, 3 to 6) days in the CRP-guided group and 5.5 (median, 5; range, 5 to 7) days in the at least 5-day study group. In the latter group, one infant was treated for a potential relapse, and one infant was treated for a likely relapse. The low relapse rates in both treatment groups are a preliminary indication that relapses may not occur more frequently if patients are treated until CRP is negative rather than for a 5-day or longer treatment period.

CONCLUSIONS

We conclude that CRP could be a key parameter for individually guiding the duration of antibiotic treatment in a major subgroup of newborns with suspected bacterial infection. This approach would allow considerably shorter courses of antibiotic therapy.