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Ferner RE, Aronson JK. Competing Benefits and Competing Hazards: The Benefit to Harm Balance in Individual Patients in Rational Therapeutics. Drug Saf 2024:10.1007/s40264-024-01428-2. [PMID: 38691321 DOI: 10.1007/s40264-024-01428-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 05/03/2024]
Abstract
For any therapeutic intervention in an individual, there is a balance between the potential benefits and the possible harms. The extent to which the benefits are desirable in a given condition depends on the efficacy of the intervention, the chance of obtaining it and the seriousness and intensity of the condition. The extent to which the harms are undesirable depends on the nature of the hazard that can lead to harm, the chance that the harm will occur and its seriousness and intensity. Rational therapeutic decisions require clinicians to consider competing courses of action, with potential benefits of different desirability and potential harms of different undesirability. They also have a duty to explain to the patient, for the contemplated interventions, both the possible benefits and the potential harms that the patient may consider significant. In an individual patient, it is necessary to consider (a) the probabilities of benefit from both intervention and non-intervention and (b) the probabilities of harm from both intervention and non-intervention. However, there are several potential problems. Here, we consider how failure to distinguish maximum benefits from probable benefits, or hazards (potential harms) from probable harms, and failure to consider all the competing probabilities may lead to imperfect therapeutic decisions. We also briefly discuss methods to assess the benefit to harm balance.
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Affiliation(s)
- Robin E Ferner
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
- Clinical Pharmacology Section, University College London, London, UK.
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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Sudo RYU, Câmara MCC, Kieling SV, Marques IR, Mesquita Y, Piepenbrink BE, Mari PC. Shorter versus longer duration of antibiotic treatment in children with bacterial meningitis: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:61-71. [PMID: 37870611 DOI: 10.1007/s00431-023-05275-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023]
Abstract
The optimal duration of antibiotic treatment for the most common bacterial meningitis etiologies in the pediatric population, namely Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, is not well-established in the literature. Therefore, we aimed to perform an updated meta-analysis comparing shorter versus longer antibiotic treatment in children with meningitis. PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) that compared shorter (up to 7 days) versus longer (10 days or double the days of the equivalent short course) duration of antibiotic treatment in children with meningitis and reported the outcomes of treatment failure, death, neurologic sequelae, non-neurologic complications, hearing impairment, nosocomial infection, and relapse. Heterogeneity was examined with I2 statistics. RevMan 5.4.1 was used for statistical analysis and RoB-2 (Cochrane) for risk of bias assessment. Of 684 search results, 6 RCTs were included, with a cohort of 1333 children ages 3 weeks to 15.5 years, of whom 49.51% underwent a short antibiotic course. All RCTs included monotherapy with ceftriaxone, except one, which added vancomycin as well. No differences were found comparing the short and long duration of therapy concerning treatment failure, relapse, mortality, and neurologic complications at discharge and at follow-up. Conclusion: Because no statistically significant differences were found between groups for the analyzed outcomes, the results of this meta-analysis support shorter therapy. However, generalizing these results to complicated meningitis and infections caused by other pathogens should be made with caution. (PROSPERO identifier: CRD42022369843). What is Known: • Current recommendations on the duration of antibiotic therapy for bacterial meningitis are mostly based on clinical practice. • Defining an optimal duration of antibiotic therapy is essential for antimicrobial stewardship achievement, improving patient outcomes, and minimizing adverse effects. What is New: • There are no differences between shorter versus longer antibiotic treatment duration in regard to treatment failure, relapse, mortality, neurologic complications, and hearing impairment at discharge and at follow-up.
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Affiliation(s)
- Renan Yuji Ura Sudo
- Division of Medicine, Federal University of Grande Dourados, Dourados, MS, Brazil.
| | | | | | - Isabela Reis Marques
- Division of Medicine, Universitat Internacional de Catalunya, Barcelona, CAT, Spain
| | - Yasmin Mesquita
- Division of Medicine, Federal University of Rio de Janeiro, Macaé, RJ, Brazil
| | - Blake Earl Piepenbrink
- Division of Internal Medicine, Primary Care, University of Connecticut, Farmington, CT, USA
| | - Paula Chaves Mari
- Pediatric Division, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
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Gulholm T, Kim MG, Lennard K, Mirdad F, Overton K, Martinello M, Maley MW, Konecny P, Andresen D, Post JJ. Clinical variation in the early assessment and management of suspected community-acquired meningitis: a multicentre retrospective study. Intern Med J 2023; 53:2298-2306. [PMID: 36951401 DOI: 10.1111/imj.16076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Bacterial meningitis is a medical emergency and timely management has been shown to improve outcomes. The aim of this study was to compare the early assessment and management of adults with suspected community-onset meningitis between hospitals and identify opportunities for clinical practice improvement. METHODS This retrospective cohort study was conducted at three principal referral hospitals in Sydney, Australia. Adult patients with suspected meningitis undergoing cerebrospinal fluid sampling between 1 July 2018 and 31 June 2019 were included. Relevant clinical and laboratory data were extracted from the medical record. Differences between sites were analysed and factors associated with time to antimicrobial therapy were assessed by Cox regression. RESULTS In 260 patients, the median time from triage to antibiotic administration was 332 min with a difference of up to 147 min between hospitals. Median time from triage to lumbar puncture (LP) was 366 min with an inter-hospital difference of up to 198 min. Seventy per cent of patients had neuroimaging prior to LP, and this group had a significantly longer median time to antibiotic administration (367 vs 231 min; P = 0.001). Guideline concordant antibiotics were administered in 84% of patients, with only 39% of those administered adjunctive corticosteroids. Seven (3%) patients had confirmed bacterial meningitis. Modifiable factors associated with earlier antimicrobial administration included infectious diseases involvement (adjusted hazard ratio [aHR], 1.50 [95% confidence interval (CI), 1.01-2.24]) and computed tomography (CT) scanning (aHR, 0.67 [95% CI, 0.46-0.98]). CONCLUSION Opportunities for improvement include reducing the time to LP and antibiotic administration, improving coadministration of corticosteroids and avoiding potentially unnecessary CT scanning.
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Affiliation(s)
- Trine Gulholm
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
- School of Clinical Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - Myong Gyu Kim
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Kate Lennard
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Feras Mirdad
- Department of Microbiology and Infectious Diseases, NSW Health Pathology and South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Kristen Overton
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
- School of Clinical Medicine, UNSW Sydney, Kensington, New South Wales, Australia
| | - Marianne Martinello
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Kirby Institute, UNSW Sydney, Kensington, New South Wales, Australia
| | - Michael W Maley
- Department of Microbiology and Infectious Diseases, NSW Health Pathology and South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Pamela Konecny
- Department of Infectious Diseases and Immunology, St George Hospital, Kogarah, New South Wales, Australia
| | - David Andresen
- Departments of Infectious Diseases and Microbiology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- St Vincent's Hospital Clinical School, University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Jeffrey J Post
- Department of Infectious Diseases, Prince of Wales Hospital, Randwick, New South Wales, Australia
- School of Clinical Medicine, UNSW Sydney, Kensington, New South Wales, Australia
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Klein M, Abdel-Hadi C, Bühler R, Grabein B, Linn J, Nau R, Salzberger B, Schlüter D, Schwager K, Tumani H, Weber J, Pfister HW. German guidelines on community-acquired acute bacterial meningitis in adults. Neurol Res Pract 2023; 5:44. [PMID: 37649122 PMCID: PMC10470134 DOI: 10.1186/s42466-023-00264-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION The incidence of community-acquired acute bacterial meningitis has decreased during the last decades. However, outcome remains poor with a significant proportion of patients not surviving and up to 50% of survivors suffering from long-term sequelae. These guidelines were developed by the Deutsche Gesellschaft für Neurologie (DGN) under guidance of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) to guide physicians through diagnostics and treatment of adult patients with acute bacterial meningitis. RECOMMENDATIONS The most important recommendations are: (i) In patients with suspected acute bacterial meningitis, we recommend that lumbar cerebrospinal fluid (with simultaneous collection of serum to determine the cerebrospinal fluid-serum glucose index and blood cultures) is obtained immediately after the clinical examination (in the absence of severely impaired consciousness, focal neurological deficits, and/or new epileptic seizures). (ii) Next, we recommend application of dexamethasone and empiric antibiotics intravenously. (iii) The recommended initial empiric antibiotic regimen consists of ampicillin and a group 3a cephalosporin (e.g., ceftriaxone). (iv) In patients with severely impaired consciousness, new onset focal neurological deficits (e.g. hemiparesis) and/or patients with newly occurring epileptic seizures, we recommend that dexamethasone and antibiotics are started immediately after the collection of blood; we further recommend that -if the imaging findings do not indicate otherwise -a lumbar CSF sample is taken directly after imaging. (v) Due to the frequent occurrence of intracranial and systemic complications, we suggest that patients with acute bacterial meningitis are treated at an intensive care unit in the initial phase of the disease. In the case of impaired consciousness, we suggest that this is done at an intensive care unit with experience in the treatment of patients with severe CNS diseases. CONCLUSIONS The German S2k-guidelines give up to date recommendations for workup, diagnostics and treatment in adult patients with acute bacterial meningitis.
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Affiliation(s)
- Matthias Klein
- Department of Neurology, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
- Emergency Department, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | | | - Robert Bühler
- Department of Neurology, Bürgerspital, Solothurn, Switzerland
| | - Beatrice Grabein
- Klinische Mikrobiologie und Krankenhaushygiene, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
| | - Jennifer Linn
- Department of Diagnostic and Interventional Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Roland Nau
- Department of Neuropathology, Evangelisches Krankenhaus Göttingen-Weende, Georg-August-University, Göttingen, Göttingen, Germany
| | - Bernd Salzberger
- Klinik und Poliklinik für Innere Medizin, University of Regensburg, Regensburg, Germany
| | - Dirk Schlüter
- Institut für Medizinische Mikrobiologie und Krankenhaushygiene, Medizinische Hochschule, Hannover, Germany
| | - Konrad Schwager
- Klinik für Hals-Nasen-Ohrenkrankheiten, Kopf- Hals- und plastische Gesichtschirurgie, Kommunikationsstörungen, Fulda, Germany
| | - Hayrettin Tumani
- Labor für Liquordiagnostik, Neurologische Universitätsklinik Ulm, University of Ulm, Ulm, Germany
| | - Jörg Weber
- Department of Neurology, Klinikum Klagenfurt, Klagenfurt, Austria
| | - Hans-Walter Pfister
- Department of Neurology, LMU Klinikum, Ludwig-Maximilians-University, Munich, Germany
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Hovmand N, Lundbo LF, Kronborg G, Darsø P, Benfield T. Factors associated with treatment delay and outcome in community acquired bacterial meningitis. IJID REGIONS 2023; 7:176-181. [PMID: 37123382 PMCID: PMC10139896 DOI: 10.1016/j.ijregi.2023.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 05/02/2023]
Abstract
Background Community acquired bacterial meningitis (CABM) is a condition associated with significant morbidity and mortality. Treatment delay remains an area of concern and might be improved by awareness of meningitis among health care professionals. Methods Retrospective observational study of patients with CABM between 2016 and 2021 in Eastern Denmark with a population of 2,700,000. Data was extracted from electronic health records. Treatment delay and mortality was analyzed using multivariate logistic regression and expressed as odds ratio (OR) with 95% confidence intervals (CI). Results Of 369 patients 226 (61%) had treatment delayed more than 2 hours. Old age (OR 2.42, CI 1.22;4.77), comorbidity (OR 1.30, CI 1.00;1.70), suspicion of other infections than meningitis (OR 65.93, CI 20.68;210.20), stroke (OR 7.24, CI 3.11;16.86) and other diagnoses (OR 13.00, CI 5.07;33.31) were associated with delayed treatment. Treatment delay was associated with increased 30-day mortality (OR 3.07, 95% CI 1.09;8.67). Most of the treatment delay (82%) was due lack of suspicion of CABM. Conclusions Treatment delay is a common problem associated with 30-day mortality in CABM. Awareness of CABM in undiagnosed patients is vital to achieve timely initiation of appropriate treatment. Special care should be shown for patients suspected of stroke or other infections.
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Affiliation(s)
- Nichlas Hovmand
- Center for Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital – Amager and Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
- Corresponding author: +45 4240 3138.
| | - Lene Fogt Lundbo
- Center for Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital – Amager and Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital – Amager and Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - Perle Darsø
- Center for Health, Capital Region of Denmark, Kongens Vænge 2, 3400, Hillerød, Denmark
| | - Thomas Benfield
- Center for Research & Disruption of Infectious Diseases (CREDID), Department of Infectious Diseases, Copenhagen University Hospital – Amager and Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
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Al Aseri ZAA, Aldawood BA, Altamimi AA, Mosleh HI, Qaw AS, Albatran HI, AlMasri MM, AlRihan TM, AlAithan FB, AlAssaf LS. Accuracy of non-invasive hemoglobin level measurement in the emergency department. Am J Emerg Med 2023; 64:200-203. [PMID: 36424252 DOI: 10.1016/j.ajem.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Zohair Ahmed Ali Al Aseri
- Department of Clinical Sciences, Dar Al Uloom University, Riyadh, Saudi Arabia; Departments of Emergency Medicine and Critical care, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Badr Abdulrahman Aldawood
- Department of Emergency Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Adel Abdullah Altamimi
- Department of Emergency Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Haytam Issa Mosleh
- Department of Emergency Medicine, King Khalid University Hospital, King Saud University Medical City, King Saud University King Khalid University Hospital, Riyadh, Saudi Arabia.
| | - Amnah Samir Qaw
- Department of Clinical Sciences, Dar Al Uloom University, Riyadh, Saudi Arabia.
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Rawson F, Foreman M, Mignan T, Galer J, Fraser A, Crawford A. Clinical presentation, treatment, and outcome of 24 dogs with bacterial meningitis or meningoencephalitis without empyema (2010-2020). J Vet Intern Med 2023; 37:223-229. [PMID: 36639963 PMCID: PMC9889693 DOI: 10.1111/jvim.16605] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/23/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Bacterial meningitis (BM) and meningoencephalitis (BMEM) are associated with high case fatality rates and neurologic sequelae in people, but limited data exists on outcome in dogs. HYPOTHESIS/OBJECTIVES To report the clinicopathologic features, treatment and outcome of BM/BMEM in dogs, with a focus on clinical presentation, relapse and long-term neurological deficits. ANIMALS Twenty-four client-owned dogs diagnosed with BM/BMEM without empyema. METHODS Retrospective case series of dogs diagnosed with BM/BMEM from 5 veterinary referral hospitals between January 2010 and August 2020. RESULTS Twenty-four dogs were included. Median duration of clinical signs was 2 days (range ≤24 hours to 30 days) and signs recorded included pyrexia (3) and cervical hyperesthesia (10). Neurological deficits were present in 18 dogs including altered mentation (12), ataxia (8), nonambulatory status (8), head tilt (8), and cranial nerve deficits (13). Intracellular bacteria were visualized on cerebrospinal fluid (CSF) analysis in 15/24 dogs, with positive CSF bacteriological culture in 8/21. Otitis media/interna (OMI) was diagnosed in 15/24 dogs, of which 6/15 dogs underwent total ear canal ablation and lateral bulla osteotomy. Twenty dogs survived to hospital discharge. Median duration of antibiotic administrations was 8 weeks (range, 2-16 weeks). Glucocorticoids were administered to 15 dogs. Median follow-up time was 92 days (range, 10-2233 days). Residual neurological deficits were reported in 9 dogs, with a single case of suspected relapse. CONCLUSIONS AND CLINICAL IMPORTANCE Clinical signs were variable in dogs with BM/BMEM, the nidus of bacterial infection was often OMI and the majority of dogs made a full recovery with treatment.
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Affiliation(s)
- Faye Rawson
- Royal Veterinary CollegeNorth MymmsUK,Langford Veterinary ServicesUniversity of BristolBristolUK
| | | | | | | | - Anne Fraser
- Davies Veterinary SpecialistsHitchinUK,Anderson Moores Veterinary SpecialistsWinchesterUK
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Dubey AP, Hazarika RD, Abitbol V, Kolhapure S, Agrawal S. Proceedings of the Expert Consensus Group meeting on meningococcal serogroup B disease burden and prevention in India. Hum Vaccin Immunother 2022; 18:2026712. [PMID: 35239455 PMCID: PMC8993054 DOI: 10.1080/21645515.2022.2026712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Meningococcal disease is highly transmissible, life-threatening and leaves significant sequelae in survivors. Every year, India, which has a plethora of risk factors for meningococcal disease, reports around 3000 endemic cases. However, the overall disease burden and serogroup distribution are unknown, creating a setting of general disease negligence and unawareness. Vaccination with quadrivalent meningococcal conjugate vaccine A, C, W, and Y is only recommended for high-risk children, and there is no overall guidance for meningococcal serogroup B (MenB) vaccination. MenB vaccines, which recently have been licensed in many countries but not in India, have significantly aided the fight against meningococcal disease. However, these MenB vaccines are not available in India. An Expert Consensus Group meeting was held with leading meningococcal disease experts to better understand the current disease epidemiology, particularly serogroup B, the prevalence gaps, and feasible ways to bridge them. The proceedings are presented in this paper.
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Affiliation(s)
- Anand P Dubey
- Pediatrics, ESI-PGIMSR & Model Hospital, New Delhi, India
| | - Rashna Dass Hazarika
- Pediatrics, Nemcare Superspeciality Hospital, Bhangagarh, Guwahati, and RIGPA Children's Clinic, Guwahati, India
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Lin GYE, Lin CY, Chi H, Huang DTN, Huang CY, Chiu NC. The experience of using FilmArray Meningitis/Encephalitis Panel for the diagnosis of meningitis and encephalitis in pediatric patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:1180-1187. [PMID: 35987724 DOI: 10.1016/j.jmii.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/02/2022] [Accepted: 07/30/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND/PURPOSE Central nervous system infections can cause severe complications and even death in children. Early diagnosis of the causative pathogen can guide appropriate treatment and improve outcomes. The BioFire® FilmArray® Meningitis/Encephalitis Panel (FA-ME) is a multiplex polymerase chain reaction (PCR) assay targeting 14 pathogens. We aimed to examine FA-ME performance compared with conventional assays and its effect on antimicrobial usage. METHODS We prospectively enrolled 55 pediatric patients with suspected meningitis or encephalitis and simultaneously performed FA-ME and conventional assays. Sixty-three hospitalized patients with CNS infection before implementing FA-ME were considered controls. We compared the FA-ME results with conventional assays and the empiric antimicrobial usage and hospital stay between the two study groups. RESULTS Nine patients (16.4%) tested positive by FA-ME, four were bacterial, and five were viral. Three additional pathogens were detected by conventional assays: Enterococcus faecalis, Leptospira, and herpes simplex virus type 2. In the control group, two bacterial pathogens were detected by CSF culture and four viral pathogens by single PCRs. Compared with the control group, the FA-ME group had a shorter time for pathogen detection, but there were no significant differences in pathogen detection rate, duration of empiric antimicrobial therapy, and length of hospital stay. CONCLUSION Although no significant difference was found in empiric antimicrobial duration and length of stay between patients tested with FA-ME and conventional assays, FA-ME had the advantage of a shorter detection time and early exclusion of potential causative pathogens. The FA-ME results should be interpreted carefully based on the clinical presentation.
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Affiliation(s)
- Grace Yong-En Lin
- Department of Pediatric Infectious Diseases, MacKay Children's Hospital, Taipei, Taiwan; Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan.
| | - Chien-Yu Lin
- Department of Medicine, MacKay Medicine College, New Taipei, Taiwan; Department of Pediatrics, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan.
| | - Hsin Chi
- Department of Pediatric Infectious Diseases, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan.
| | - Daniel Tsung-Ning Huang
- Department of Pediatric Infectious Diseases, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan.
| | - Ching-Ying Huang
- Department of Pediatric Infectious Diseases, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan.
| | - Nan-Chang Chiu
- Department of Pediatric Infectious Diseases, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medicine College, New Taipei, Taiwan.
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11
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Megjhani M, Terilli K, Kalasapudi L, Chen J, Carlson J, Miller S, Badjatia N, Hu P, Velazquez A, Roh DJ, Agarwal S, Claassen J, Connolly ES, Hu X, Morris N, Park S. Dynamic Intracranial Pressure Waveform Morphology Predicts Ventriculitis. Neurocrit Care 2022; 36:404-411. [PMID: 34331206 PMCID: PMC9847350 DOI: 10.1007/s12028-021-01303-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Intracranial pressure waveform morphology reflects compliance, which can be decreased by ventriculitis. We investigated whether morphologic analysis of intracranial pressure dynamics predicts the onset of ventriculitis. METHODS Ventriculitis was defined as culture or Gram stain positive cerebrospinal fluid, warranting treatment. We developed a pipeline to automatically isolate segments of intracranial pressure waveforms from extraventricular catheters, extract dominant pulses, and obtain morphologically similar groupings. We used a previously validated clinician-supervised active learning paradigm to identify metaclusters of triphasic, single-peak, or artifactual peaks. Metacluster distributions were concatenated with temperature and routine blood laboratory values to create feature vectors. A L2-regularized logistic regression classifier was trained to distinguish patients with ventriculitis from matched controls, and the discriminative performance using area under receiver operating characteristic curve with bootstrapping cross-validation was reported. RESULTS Fifty-eight patients were included for analysis. Twenty-seven patients with ventriculitis from two centers were identified. Thirty-one patients with catheters but without ventriculitis were selected as matched controls based on age, sex, and primary diagnosis. There were 1590 h of segmented data, including 396,130 dominant pulses in patients with ventriculitis and 557,435 pulses in patients without ventriculitis. There were significant differences in metacluster distribution comparing before culture-positivity versus during culture-positivity (p < 0.001) and after culture-positivity (p < 0.001). The classifier demonstrated good discrimination with median area under receiver operating characteristic 0.70 (interquartile range 0.55-0.80). There were 1.5 true alerts (ventriculitis detected) for every false alert. CONCLUSIONS Intracranial pressure waveform morphology analysis can classify ventriculitis without cerebrospinal fluid sampling.
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Affiliation(s)
- Murad Megjhani
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America
| | - Kalijah Terilli
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America
| | - Lakshman Kalasapudi
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine
| | - Justine Chen
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America
| | - John Carlson
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America
| | - Serenity Miller
- Department of Anesthesia, Program in Trauma, University of Maryland School of Medicine
| | - Neeraj Badjatia
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine
| | - Peter Hu
- Department of Anesthesia, Program in Trauma, University of Maryland School of Medicine
| | - Angela Velazquez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America
| | - David J. Roh
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America
| | - Sachin Agarwal
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America
| | - Jan Claassen
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America
| | - ES. Connolly
- New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America,Department of Neurosurgery, Columbia University, New York, New York, United States of America
| | - Xiao Hu
- School of Nursing, Duke University, Durham, North Carolina, United States of America,Departments of Electrical and Computer Engineering, Biostatistics and Bioinformatics, Surgery, Neurology, Duke University, Durham, North Carolina, United States of America
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine
| | - Soojin Park
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, United States of America,New York Presbyterian Hospital – Columbia University Irving Medical Center, New York, New York, United States of America
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12
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Hofmaenner DA, Singer M. Challenging management dogma where evidence is non-existent, weak or outdated. Intensive Care Med 2022; 48:548-558. [PMID: 35303116 PMCID: PMC8931587 DOI: 10.1007/s00134-022-06659-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/25/2022] [Indexed: 12/19/2022]
Abstract
Medical practice is dogged by dogma. A conclusive evidence base is lacking for many aspects of patient management. Clinicians, therefore, rely upon engrained treatment strategies as the dogma seems to work, or at least is assumed to do so. Evidence is often distorted, overlooked or misapplied in the re-telling. However, it is incorporated as fact in textbooks, policies, guidelines and protocols with resource and medicolegal implications. We provide here four examples of medical dogma that underline the above points: loop diuretic treatment for acute heart failure; the effectiveness of heparin thromboprophylaxis; the rate of sodium correction for hyponatraemia; and the mantra of "each hour counts" for treating meningitis. It is notable that the underpinning evidence is largely unsupportive of these doctrines. We do not necessarily advocate change, but rather encourage critical reflection on current practices and the need for prospective studies.
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Affiliation(s)
- Daniel A Hofmaenner
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1 6BT, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London, WC1 6BT, UK.
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13
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Eisen DP, Hamilton E, Bodilsen J, Køster-Rasmussen R, Stockdale AJ, Miner J, Nielsen H, Dzupova O, Sethi V, Copson RK, Harings M, Adegboye OA. Longer than 2 hours to antibiotics is associated with doubling of mortality in a multinational community-acquired bacterial meningitis cohort. Sci Rep 2022; 12:672. [PMID: 35027606 PMCID: PMC8758708 DOI: 10.1038/s41598-021-04349-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 12/21/2021] [Indexed: 12/03/2022] Open
Abstract
To optimally define the association between time to effective antibiotic therapy and clinical outcomes in adult community-acquired bacterial meningitis. A systematic review of the literature describing the association between time to antibiotics and death or neurological impairment due to adult community-acquired bacterial meningitis was performed. A retrospective cohort, multivariable and propensity-score based analyses were performed using individual patient clinical data from Australian, Danish and United Kingdom studies. Heterogeneity of published observational study designs precluded meta-analysis of aggregate data (I2 = 90.1%, 95% CI 71.9–98.3%). Individual patient data on 659 subjects were made available for analysis. Multivariable analysis was performed on 180–362 propensity-score matched data. The risk of death (adjusted odds ratio, aOR) associated with treatment after two hours was 2.29 (95% CI 1.28–4.09) and increased substantially thereafter. Similarly, time to antibiotics of greater than three hours was associated with an increase in the occurrence of neurological impairment (aOR 1.79, 95% CI 1.03–3.14). Among patients with community-acquired bacterial meningitis, odds of mortality increase markedly when antibiotics are given later than two hours after presentation to the hospital.
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Affiliation(s)
- Damon P Eisen
- The Townsville University Hospital, Angus Smith Drive, Douglas, QLD, 4814, Australia.,College of Medicine and Dentistry, James Cook University, Discovery Drive, Douglas, QLD, 4814, Australia
| | - Elizabeth Hamilton
- The Townsville University Hospital, Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Rasmus Køster-Rasmussen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, 1014, Copenhagen K, Denmark
| | - Alexander J Stockdale
- Institute of Infection and Global Health, University of Liverpool, Liverpool, L69 7BE, UK
| | - James Miner
- Hennepin County Medical Center, University of Minnesota, Minneapolis, USA
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Olga Dzupova
- Third Faculty of Medicine, Charles University, and University Hospital Bulovka, Prague, Czech Republic
| | - Varun Sethi
- The Townsville University Hospital, Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - Rachel K Copson
- The Townsville University Hospital, Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - Miriam Harings
- The Townsville University Hospital, Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - Oyelola A Adegboye
- Public Health and Tropica Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, 1 James Cook Drive, Douglas, QLD, 4814, Australia. .,Australian Institute of Tropical Health and Medicine, Discovery Drive, James Cook University, Douglas, QLD, 4814, Australia.
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14
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Abstract
PURPOSE OF REVIEW We have highlighted the recent advances in infection in neurocritical care. RECENT FINDINGS Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. SUMMARY Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Alan Blake
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
| | - Daniel Collins
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
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15
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Wald M, Merisor S, Zachary P, Augereau O, Gravier S, Jaulhac B, De Briel D, Velay A, Gregorowicz G, Martinot M. Microbiological Outcomes Associated With Low Leukocyte Counts in Cerebrospinal Fluid. Open Forum Infect Dis 2020; 8:ofaa597. [PMID: 33575417 PMCID: PMC7863864 DOI: 10.1093/ofid/ofaa597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/03/2020] [Indexed: 11/17/2022] Open
Abstract
The significance of low leukocyte counts in cerebrospinal fluid (CSF) remains unclear. We performed a 2-year retrospective study to examine microbiological outcomes associated with CSF leukocytes at 6–10/mm3. Of the 178 samples examined, we detected positive results for 11 samples, including 5 cases of tick-borne encephalitis virus infection.
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Affiliation(s)
- Mathieu Wald
- Infectious Diseases Department, Hôpitaux Civils de Colmar, France
| | - Simona Merisor
- Infectious Diseases Department, Hôpitaux Civils de Colmar, France
| | - Pierre Zachary
- Microbiology Department, Hôpitaux Universitaires de Strasbourg, France
| | | | - Simon Gravier
- Infectious Diseases Department, Hôpitaux Civils de Colmar, France
| | - Benoit Jaulhac
- Microbiology Department, Hôpitaux Universitaires de Strasbourg, France
| | | | - Aurélie Velay
- Virology Department, Hôpitaux Universitaires de Strasbourg
| | | | - Martin Martinot
- Infectious Diseases Department, Hôpitaux Civils de Colmar, France
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16
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Abstract
PURPOSE OF REVIEW Community-acquired bacterial meningitis continues to occur and be associated with significant morbidity and mortality despite the availability of effective conjugate vaccines for the three most important meningeal pathogens. RECENT FINDINGS Indications for cranial imaging in suspected bacterial meningitis varies significantly between guidelines. Cranial imaging is of no clinical utility in those patients without indications and fosters delays in performing a lumbar puncture. Delaying lumbar puncture is associated with increased costs in both adults and children with meningitis and previous antibiotic therapy impacts the yield of microbiological results. Delaying antibiotic therapy is associated with worse clinical outcomes. Adjunctive steroids have reduced the mortality of adults with pneumococcal meningitis but have been associated with increased adverse outcomes in Listeria monocytogenes and Cryptococcus neoformans. SUMMARY Community-acquired bacterial meningitis remains a global health concern with high morbidity and mortality especially in low-income countries. Cranial imaging should be done only in patients with an indication with an attempt to do a prompt lumbar puncture and to initiate antibiotic therapy and adjunctive steroids as soon as possible to improve clinical outcomes.
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17
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Assegu Fenta D, Lemma K, Tadele H, Tadesse BT, Derese B. Antimicrobial sensitivity profile and bacterial isolates among suspected pyogenic meningitis patients attending at Hawassa University Hospital: Cross-sectional study. BMC Microbiol 2020; 20:125. [PMID: 32429892 PMCID: PMC7238580 DOI: 10.1186/s12866-020-01808-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 04/30/2020] [Indexed: 11/25/2022] Open
Abstract
Background Bacterial meningitis is a serious inflammation of the meninges. Antimicrobial therapy on early cerebrospinal fluid (CSF) examination has an important role in diagnosis. The disease is still challenging in developing countries because of poor (diagnostic set-up, socioeconomic conditions, management), and misuse of antimicrobial therapy results in emerging antimicrobial-resistant strains. Therefore, this hospital based cross sectional study was aimed to assess the antimicrobial sensitivity profile and bacterial isolates among patients suspected of pyogenic meningitis at Hawassa University Hospital from February 2017 to 2018. Results A total of 394 patients suspected as meningitis were included. Of these 210 (53.3%) were males and 184 (46.7%) were females. The carriage rate of bacterial pathogens was 27(6.9%). The common clinical presentations were fever 330 (83.8%), headache 205 (52.0%) and neck stiffness 179(45.4%) followed by altered mental status 125(31.7%). Neck stiffness P = 0.001 (AOR = 1.18, 95% CI 1.06–6.53), Hx of seizure P = 0.043, (AOR = 1.39, 95% CI 1.15–5.99), Nuchal rigidity P = 0.001* (AOR = 1.26, 95% CI 1.06–4.48) were significantly associated with culture positivity. The pathogens isolated in this study were N. meningitidis the most frequent isolate 12(44.4%) followed by S. pneumoniae 5 (18.5%), E. coli 4(14.8%), H. influenza 3(13.6%), S. aureus 2(11.1%) and K. pneumoniae 1(3.7%). S. pneumoniae was (100%) resistance to penicillin, (80%) amoxicillin, and (20%) Cefotaxime. S. aureus was (100%) resistant to penicillin, amoxicillin, and ciprofloxacin. N. meningitidis was (100%) resistant to penicillin, (66.7%) Ceftriaxone and (41.7%) chloramphenicol. In this study a single isolate was also resistant to a different antibiotic. Conclusion The prevention of bacterial meningitis needs serious attention since the isolated bacteria showed single and multiple antimicrobial susceptibility patterns and the variable nature of isolated etiological agents makes it reasonable to provide continuous future updates on local resistance of common antibiotics and optimize the most frequent bacteria associated with meningitis in the hospital. Therefore; further, survey study with a better design of antimicrobial susceptibility at large scale to control the spread of antibiotic-resistant bacteria and the change in the causative organism of bacterial meningitis in the study area and at a national level is required.
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Affiliation(s)
- Demissie Assegu Fenta
- School of Medical Laboratory Science, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia.
| | - Kinfe Lemma
- Department of Internal Medicine, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Henok Tadele
- Department of Pediatrics, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Birkneh Tilahun Tadesse
- Department of Pediatrics, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
| | - Birrie Derese
- Department of Neurology, Hawassa University College of Medicine and Health Sciences, Hawassa, Ethiopia
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18
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Glimåker M, Naucler P, Sjölin J. Etiology, clinical presentation, outcome and the effect of initial management in immunocompromised patients with community acquired bacterial meningitis. J Infect 2020; 80:291-297. [PMID: 31911260 DOI: 10.1016/j.jinf.2019.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/27/2019] [Accepted: 12/28/2019] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Martin Glimåker
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet and Department of Infectious Diseases, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Pontus Naucler
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet and Department of Infectious Diseases, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Jan Sjölin
- Section of Infectious Diseases, Department Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
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19
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Tenforde MW, Gertz AM, Lawrence DS, Wills NK, Guthrie BL, Farquhar C, Jarvis JN. Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25416. [PMID: 31957332 PMCID: PMC6970088 DOI: 10.1002/jia2.25416] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region.
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Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
| | - Alida M Gertz
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
| | - David S Lawrence
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Nicola K Wills
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Welcome Centre for Infectious Diseases Research in AfricaInfectious Disease and Molecular Medicine UnitUniversity of Cape TownCape TownSouth Africa
| | - Brandon L Guthrie
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Carey Farquhar
- Division of Allergy and Infectious DiseasesUniversity of Washington School of MedicineSeattleWAUSA
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWAUSA
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Joseph N Jarvis
- Botswana Harvard AIDS Institute PartnershipGaboroneBotswana
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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20
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Glimåker M, Sjölin J, Åkesson S, Naucler P. Lumbar Puncture Performed Promptly or After Neuroimaging in Acute Bacterial Meningitis in Adults: A Prospective National Cohort Study Evaluating Different Guidelines. Clin Infect Dis 2019; 66:321-328. [PMID: 29020334 DOI: 10.1093/cid/cix806] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/08/2017] [Indexed: 11/15/2022] Open
Abstract
Background Early treatment is pivotal for favorable outcome in acute bacterial meningitis (ABM). Lumbar puncture (LP) is the diagnostic key. The aim was to evaluate the effect on outcome of adherence to European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), and Swedish guidelines regarding neuroimaging before LP. Methods The cohort comprised 815 adult ABM patients in Sweden registered prospectively between 2008 and 2015. Primary endpoint was in-hospital mortality and secondary endpoint was favorable outcome at 2-6 months of follow-up. Results Indications for neuroimaging before LP existed in 7%, 32%, and 65% according to Swedish, ESCMID, and IDSA guidelines, respectively. The adjusted odds ratio (aOR) was 0.48 (95% confidence interval [CI], .26-.89) for mortality and 1.52 (95% CI, 1.08-2.12) for favorable outcome if Swedish guidelines were followed. ESCMID guideline adherence resulted in aOR of 0.68 (95% CI, .38-1.23) for mortality and 1.05 (95% CI, .75-1.47) for favorable outcome. Following IDSA recommendations resulted in aOR of 1.09 (95% CI, .61-1.95) for mortality and 0.59 (95% CI, .42-.82) for favorable outcome. Performing prompt vs neuroimaging-preceded LP was associated with aOR of 0.38 (95% CI, .18-.77) for mortality and 2.11 (95% CI, 1.47-3.00) for favorable outcome. The beneficial effect of prompt LP was observed regardless of mental status and immunosuppression. Conclusions Adherence to Swedish guidelines in ABM is associated with decreased mortality and increased favorable outcome in contrast to adherence to ESCMID or IDSA recommendations. Our findings support that impaired mental status and immunocompromised state should not be considered indications for neuroimaging before LP in patients with suspected ABM.
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Affiliation(s)
- Martin Glimåker
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Sjölin
- Section of Infectious Diseases, Department of Medical Sciences, Uppsala University, Sweden
| | - Styrbjörn Åkesson
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Pontus Naucler
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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21
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Soni NJ, Franco-Sadud R, Kobaidze K, Schnobrich D, Salame G, Lenchus J, Kalidindi V, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP. Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:591-601. [PMID: 31251163 PMCID: PMC6817310 DOI: 10.12788/jhm.3197] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.
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Affiliation(s)
- Nilam J Soni
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
- Corresponding Author: Nilam J Soni, MD, MSc; E-mail: ; Telephone: 210-743-6030
| | - Ricardo Franco-Sadud
- Division of Hospital Medicine, Naples Community Hospital, Naples, Florida
- Department of Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Ketino Kobaidze
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta,
Georgia
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Gerard Salame
- Division of Hospital Medicine, University of Colorado and Denver Health and Hospital Authority, Denver, Colorado
| | - Joshua Lenchus
- Division of Hospital Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Michael J Mader
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- White River Junction VA Medical Center, White River Junction, Vermont
| | | | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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22
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Zhao Z, Hua X, Yu J, Zhang H, Li J, Li Z. Duration of empirical therapy in neonatal bacterial meningitis with third generation cephalosporin: a multicenter retrospective study. Arch Med Sci 2019; 15:1482-1489. [PMID: 31749877 PMCID: PMC6855170 DOI: 10.5114/aoms.2018.76938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/08/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The duration of treatment is not well established, especially in the negative cerebrospinal fluid (CSF) culture. The aim of this study is to explore the influence of duration of treatment in neonatal bacterial meningitis. MATERIAL AND METHODS This is a retrospective analysis of 200 CSF specimens. Two hundred full-term neonates with bacterial meningitis admitted to the clinical status were evaluated using the Glasgow Outcome Scale (GOS) on the day of discharge. RESULTS Neonates were identified as having bacterial meningitis based on the results of CSF culture tests of all suspected cases. According to the GOS, neonates were divided into two outcome groups: 77.5% good (GOS = 5) (shorter than 3 weeks' administration) and 22.5% unfavorable (GOS = 1-4) (longer than 3 weeks' administration). The duration of antibiotic treatment ranged from 4 to 43 days, and the mean therapy time was 19.74 ±7.32 days. Duration longer than 3 weeks for neonatal bacterial meningitis with negative CSF culture had no impact on prognosis. The unfavorable outcome group had more prenatal infections and premature rupture of membranes cases than the good outcome group. High CSF protein and CSF glucose and CSF cell count increase were associated with unfavorable outcome in 167 non-prenatal infection infants. High CSF cell count increase was associated with unfavorable outcome in 33 prenatal infection infants. In term infants, the positive rate of blood cultures was 24.5%. CONCLUSIONS Third generation cephalosporin therapy does not have a different prognosis for negative CSF culture of neonatal bacterial meningitis in term infants in this study.
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Affiliation(s)
- Zhi Zhao
- Department of Neonatology, Shanxi Province People’s Hospital, Xi’an, Shanxi Province, China
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xueying Hua
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Key Laboratory of Pediatrics, International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
| | - Jialin Yu
- Department of Pediatrics, Shenzhen University General Hospital, Shenzhen, China
| | - Haibo Zhang
- Department of Neonatology, Children’s Hospital of Xi’an, Xi’an, Shanxi Province, China
| | - Juhua Li
- Department of Neonatology, Children’s Hospital of Xianyang, Xianyang, Shanxi Province, China
| | - Zhankui Li
- Department of Neonatology, Northwest Women and Children’s Hospital, Xi’an, Shanxi Province, China
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23
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Fananapazir N, Dandoy C, Byczkowski T, Lane A, Nagarajan R, Hariharan S. Study of Delayed Antibiotic in Pediatric Febrile Immunocompromised Patients and Adverse Events. Hosp Pediatr 2019; 9:379-386. [PMID: 31015220 DOI: 10.1542/hpeds.2018-0192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Bone marrow transplant (BMT) patients or patients receiving chemotherapy for oncologic diagnoses are at risk for sepsis. The association of time to antibiotics (TTA) with outcomes when adjusting for severity of illness has not been evaluated in the pediatric febrile immunocompromised (FI) population. We evaluated the association of TTA with adverse events in a cohort of FI patients presenting to our pediatric emergency department. METHODS We performed a retrospective review of consecutive FI patients presenting over a 6.5-year period. Adverse events were defined as intensive care admission within 72 hours of emergency department arrival, laboratory signs of acute kidney injury, inotropic support subsequent to antibiotics, and all-cause mortality within 30 days. Vital signs and interventions were used to define severity of illness. Adjusting for severity of illness at presentation, age, and timing of an institutional intervention designed to reduce TTA in FI patients, we analyzed the association of TTA with individual adverse events as well as with adverse events in aggregate. RESULTS We analyzed 1489 patient encounters. In oncology patients, TTA was not associated with the aggregate measure of whether any adverse event subsequently occurred nor with other individual adverse events. For the BMT subpopulation, TTA >60 minutes did show increased odds of intensive care admission within 72 hours as well as for aggregate adverse events. CONCLUSIONS Although TTA >60 minutes did show increased odds of aggregate adverse events in the small subgroup of BMT patients, overall TTA was not associated with adverse events in oncology patients as a whole.
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Affiliation(s)
| | - Christopher Dandoy
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Terri Byczkowski
- Division of Emergency Medicine and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Adam Lane
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Rajaram Nagarajan
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Selena Hariharan
- Division of Emergency Medicine and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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24
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Young N, Thomas M. Meningitis in adults: diagnosis and management. Intern Med J 2019; 48:1294-1307. [PMID: 30387309 DOI: 10.1111/imj.14102] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/05/2018] [Accepted: 08/05/2018] [Indexed: 12/31/2022]
Abstract
Bacterial meningitis is a medical emergency. All clinicians who provide acute medical care require a sound understanding of the priorities of managing a patient with suspected meningitis during the first hour. These include obtaining blood cultures, performing lumbar puncture and initiating appropriate therapy, while avoiding harmful delays such as those that result from not administering treatment until neuroimaging has been performed. Despite the increasing availability of newer diagnostic techniques, the interpretation of cerebrospinal fluid parameters remains a vital skill for clinicians. International and local guidelines differ with regard to initial empirical therapy of bacterial meningitis in adults; the North American guideline recommends ceftriaxone and vancomycin for all patients, while the Australian, UK and European guidelines recommend that vancomycin only be added for patients who are more likely to have pneumococcal meningitis or who have a higher likelihood of being infected with a strain of Streptococcus pneumoniae with reduced susceptibility to ceftriaxone. Patients with risk factors for Listeria meningitis also require an anti-Listeria agent, such as benzylpenicillin, to be added to this treatment regimen. Dexamethasone should be a routine component of empirical therapy due to its proven role in reducing morbidity and mortality from pneumococcal meningitis.
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Affiliation(s)
- Nicholas Young
- Department of Infectious Diseases, Auckland City Hospital, Auckland, New Zealand
| | - Mark Thomas
- Department of Infectious Diseases, Auckland City Hospital, Auckland, New Zealand.,Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
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25
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Long F, Kong M, Wu S, Zhang W, Liao Q, Peng Z, Nan L, Liu Y, Wang M, He C, Wu Y, Lu X, Kang M. Development and validation of an advanced fragment analysis-based assay for the detection of 22 pathogens in the cerebrospinal fluid of patients with meningitis and encephalitis. J Clin Lab Anal 2019; 33:e22707. [PMID: 30666716 PMCID: PMC6818557 DOI: 10.1002/jcla.22707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 02/05/2023] Open
Abstract
Background Meningitis and encephalitis (ME) are central nervous system (CNS) infections mainly caused by bacteria, mycobacteria, fungi, viruses, and parasites that result in high morbidity and mortality. The early, accurate diagnosis of pathogens in the cerebrospinal fluid (CSF) and timely medication are associated with better prognosis. Conventional methods, such as culture, microscopic examination, serological detection, CSF routine analysis, and radiological findings, either are time‐consuming or lack sensitivity and specificity. Methods To address these clinical needs, we developed an advanced fragment analysis (AFA)‐based assay for the multiplex detection of 22 common ME pathogens, including eight viruses, 11 bacteria, and three fungi. The detection sensitivity of each target was evaluated with a recombinant plasmid. The limits of detection of the 22 pathogens ranged from 15 to 120 copies/reaction. We performed a retrospective study to analyze the pathogens from the CSF specimens of 170 clinically diagnosed ME patients using an AFA‐based assay and compared the results with culture (bacteria and fungi), microscopic examination (fungi), polymerase chain reaction (PCR) (Mycobacterium tuberculosis), and Sanger sequencing (virus) results. Results The sensitivity of the AFA assay was 100% for 10 analytes. For Cryptococcus neoformans, the sensitivity was 63.6%. The overall specificity was 98.2%. The turnaround time was reduced to 4‐6 hours from the 3‐7 days required using conventional methods. Conclusions In conclusion, the AFA‐based assay provides a rapid, sensitive, and accurate method for pathogen detection from CSF samples.
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Affiliation(s)
- Fang Long
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Mimi Kong
- Ningbo HEALTH Gene Technologies Co., Ltd., Ningbo, China
| | - Siying Wu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Zhang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Quanfeng Liao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zaisheng Peng
- Enshi Tujia and Miao Autonomous Prefecture Center for Disease Control and Prevention, Enshi, China
| | - Li Nan
- Ningbo HEALTH Gene Technologies Co., Ltd., Ningbo, China
| | - Ya Liu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Minjin Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Chao He
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Wu
- Ningbo HEALTH Gene Technologies Co., Ltd., Ningbo, China
| | - Xiaojun Lu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Mei Kang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
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26
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Rogers T, Sok K, Erickson T, Aguilera E, Wootton SH, Murray KO, Hasbun R. Impact of Antibiotic Therapy in the Microbiological Yield of Healthcare-Associated Ventriculitis and Meningitis. Open Forum Infect Dis 2019; 6:ofz050. [PMID: 30899767 PMCID: PMC6422431 DOI: 10.1093/ofid/ofz050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/30/2019] [Indexed: 11/13/2022] Open
Abstract
The impact of antibiotic therapy on the diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) is unknown. Antibiotics were administered before obtaining cerebrospinal fluid (CSF) in 217 out of 326 (66%) patients with HCAVM, and they impacted the sensitivity of the cerebrospinal fluid Gram stain and culture (P ≤ .004).
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Affiliation(s)
- Thomas Rogers
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
| | - Kevin Sok
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
| | - Timothy Erickson
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Elizabeth Aguilera
- Infectious Disease Division, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Susan H Wootton
- Infectious Disease Division, Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Kristy O Murray
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Hasbun
- Infectious Disease Division, Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, Texas
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27
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Ramasamy R, Willis L, Kadambari S, Kelly DF, Heath PT, Nadel S, Pollard AJ, Sadarangani M. Management of suspected paediatric meningitis: a multicentre prospective cohort study. Arch Dis Child 2018; 103:1114-1118. [PMID: 29436406 DOI: 10.1136/archdischild-2017-313913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/12/2018] [Accepted: 01/20/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To quantify delays during management of children with suspected meningitis. DESIGN Multicentre prospective cohort study. SETTING Three UK tertiary paediatric centres; June 2011-June 2012 PATIENTS: 388 children aged <16 years hospitalised with suspected meningitis or undergoing lumbar puncture (LP) during sepsis evaluation. MAIN OUTCOME MEASURES Time of prehospital and in-hospital assessments, LP, antibiotic treatment and discharge; types of prehospital medical assessment and microbiological results. Data collected from hospital records and parental interview. RESULTS 220/388 (57%) children were seen by a medical professional prehospitalisation (143 by a general practitioner). Median times from initial hospital assessment to LP and antibiotic administration were 4.8 hours and 3.1 hours, respectively; 62% of children had their LP after antibiotic treatment. Median time to LP was shorter for children aged <3 months (3.0 hours) than those aged 3-23 months (6.2 hours, P<0.001) or age ≥2 years (20.3 hours, P<0.001). In meningitis of unknown cause, cerebrospinal fluid (CSF) PCR was performed for meningococcus in 7%, pneumococcus in 10% and enterovirus in 76%. When no pathogen was identified, hospital stay was longer if LP was performed after antibiotics (median 12.5 days vs 5.0 days, P=0.037). CONCLUSIONS Most children had LP after antibiotics were administered, reducing yield from CSF culture, and PCRs were underused despite national recommendations. These deficiencies reduce the ability to exclude bacterial meningitis, increasing unnecessary hospital stay and antibiotic treatment.
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Affiliation(s)
- Roshan Ramasamy
- Department of Emergency Medicine, Northwick Park Hospital, London, UK
| | - Louise Willis
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Seilesh Kadambari
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Dominic F Kelly
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Simon Nadel
- Department of Paediatrics, St Mary's Hospital, London, UK
| | - Andrew J Pollard
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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28
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Heide EC, Bindila L, Post JM, Malzahn D, Lutz B, Seele J, Nau R, Ribes S. Prophylactic Palmitoylethanolamide Prolongs Survival and Decreases Detrimental Inflammation in Aged Mice With Bacterial Meningitis. Front Immunol 2018; 9:2671. [PMID: 30505308 PMCID: PMC6250830 DOI: 10.3389/fimmu.2018.02671] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/29/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ev Christin Heide
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Laura Bindila
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julia Maria Post
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dörthe Malzahn
- mzBiostatistics, Statistical Consultancy, Göttingen, Germany
| | - Beat Lutz
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jana Seele
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Roland Nau
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany.,Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Sandra Ribes
- Institute of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
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29
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Johansson N, Spindler C, Valik J, Vicente V. Developing a decision support system for patients with severe infection conditions in pre-hospital care. Int J Infect Dis 2018; 72:40-48. [PMID: 29753877 DOI: 10.1016/j.ijid.2018.04.4321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/22/2018] [Accepted: 04/26/2018] [Indexed: 10/16/2022] Open
Abstract
OBJECTIVE To develop and validate a pre-hospital decision support system (DSS) for the emergency medical services (EMS), enabling the identification and steering of patients with critical infectious conditions (i.e., severe respiratory tract infections, severe central nervous system (CNS) infections, and sepsis) to a specialized emergency department (ED) for infectious diseases. METHODS The development process involved four consecutive steps. The first step was gathering data from the electronic patient care record system (ePCR) on patients transported by the EMS, in order to identify retrospectively appropriate patient categories for steering. The second step was to let a group of medical experts give advice and suggestions for further development of the DSS. The third and fourth steps were the evaluation and validation, respectively, of the whole pre-hospital DSS in a pilot study. RESULTS A pre-hospital decision support tool (DST) was developed for three medical conditions: severe respiratory infection, severe CNS infection, and sepsis. The pilot study included 72 patients, of whom 60% were triaged to a highly specialized emergency department (ED-Spec) with an attending infectious disease physician (ID physician). The results demonstrated that the pre-hospital emergency nurses (PENs) adhered to the DST in 66 of 72 patient cases (91.6%). For those patients steered to the ED-Spec, the assessment made by PENs and the ID physician at the ED was concordant in 94% of cases. CONCLUSIONS The development of a specific DSS aiming to identify patients with three different severe infectious diseases appears to give accurate decision support to PENs when steering patients to the optimal level of care.
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Affiliation(s)
- Niclas Johansson
- Karolinska Institutet, Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Carl Spindler
- Karolinska Institutet, Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - John Valik
- Karolinska Institutet, Department of Medicine, Solna, Infectious Diseases Unit, Karolinska University Hospital, Stockholm, Sweden; Department of Infectious Diseases, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Veronica Vicente
- Karolinska Institutet, Department of Clinical Science and Education and Section of Emergency Medicine, Södersjukhuset and Academic EMS, Stockholm, Sweden; Ambulanssjukvården i Storstockholm (AISAB, Ambulance Medical Service in Stockholm), Sweden.
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30
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Zhang HK, Kim Y, Lin M, Paredes M, Kannan K, Moghekar A, Durr NJ, Boctor EM. Toward dynamic lumbar puncture guidance using needle-based single-element ultrasound imaging. J Med Imaging (Bellingham) 2018; 5:021224. [PMID: 29651451 DOI: 10.1117/1.jmi.5.2.021224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 03/05/2018] [Indexed: 11/14/2022] Open
Abstract
Lumbar punctures (LPs) are interventional procedures that are used to collect cerebrospinal fluid. Since the target window is small, physicians have limited success conducting the procedure. The procedure is especially difficult for obese patients due to the increased distance between bone and skin surface. We propose a simple and direct needle insertion platform, enabling image formation by sweeping a needle with a single ultrasound element at the tip. The needle-shaped ultrasound transducer can not only sense the distance between the tip and a potential obstacle, such as bone, but also visually locate the structures by combining transducer location tracking and synthetic aperture focusing. The concept of the system was validated through a simulation that revealed robust image reconstruction under expected errors in tip localization. The initial prototype was built into a 14 G needle and was mounted on a holster equipped with a rotation shaft allowing one degree-of-freedom rotational sweeping and a rotation tracking encoder. We experimentally evaluated the system using a metal-wire phantom mimicking high reflection bone structures and human spinal bone phantom. Images of the phantoms were reconstructed, and the synthetic aperture reconstruction improved the image quality. These results demonstrate the potential of the system to be used as a real-time guidance tool for improving LPs.
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Affiliation(s)
- Haichong K Zhang
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
| | - Younsu Kim
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
| | - Melissa Lin
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Mateo Paredes
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Karun Kannan
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Abhay Moghekar
- Johns Hopkins University, Department of Neurology, Baltimore, Maryland, United States
| | - Nicholas J Durr
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States.,Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Emad M Boctor
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States.,Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States.,Johns Hopkins University, Department of Radiology, Baltimore, Maryland, United States
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31
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Salazar L, Hasbun R. Cranial Imaging Before Lumbar Puncture in Adults With Community-Acquired Meningitis: Clinical Utility and Adherence to the Infectious Diseases Society of America Guidelines. Clin Infect Dis 2018; 64:1657-1662. [PMID: 28369295 DOI: 10.1093/cid/cix240] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/14/2017] [Indexed: 12/27/2022] Open
Abstract
Background. The Infectious Diseases Society of America (IDSA) guidelines delineate criteria for the use of computed tomography (CT) scan of the head before lumbar puncture (LP) in adults with community-acquired meningitis (CAM). There are limited data to document adherence to these guidelines and assess the clinical utility of brain imaging. Methods. This was a retrospective analysis from January 2005 to January 2010 in Houston, Texas. Results. Among 614 adults with CAM, 407 patients (66.3%) did not have an indication for a head CT scan and 207 (33.7%) did. Patients with a CT scan indication were older, had more comorbidities, were sicker, and had more urgent treatable etiologies and adverse clinical outcomes (P < .001). A CT scan was ordered before the LP in 549 patients (89%). Overall, clinicians did not adhere to clinical guidelines in 368 of 614 (60%) subjects. A CT of the head was ordered when not indicated in 355 of 549 patients (64%), and not done when indicated in 13 of 207 patients (0.6%). CT of the head revealed intracranial abnormalities in 35 of 193 patients (18.1%) with an indication for brain imaging, compared with only 2 of 356 (0.05%) with no indication (P < .05). Major intracranial findings were seen in only 15 of 549 (2.7%) patients, all with an indication for brain imaging. Furthermore, only 8 patients had abnormalities that affected clinical management. Conclusions. Most clinicians do not adhere to IDSA guidelines, delaying diagnostic LP and increasing costs. Usefulness of head CT in patients with CAM without an indication for imaging is limited and has no impact in clinical management.
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Affiliation(s)
- Lucrecia Salazar
- Department of Internal Medicine, University of Texas Health Science Center at Houston
| | - Rodrigo Hasbun
- Department of Internal Medicine, University of Texas Health Science Center at Houston
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32
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Capillary glucose meters cannot substitute serum glucose measurement to determine the cerebrospinal fluid to blood glucose ratio. Eur J Anaesthesiol 2017; 34:854-856. [DOI: 10.1097/eja.0000000000000677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Ko BS, Ryoo SM, Ahn S, Sohn CH, Seo DW, Kim WY. Usefulness of procalcitonin level as an outcome predictor of adult bacterial meningitis. Intern Emerg Med 2017; 12:1003-1009. [PMID: 27460950 DOI: 10.1007/s11739-016-1509-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 07/19/2016] [Indexed: 12/31/2022]
Abstract
Acute bacterial meningitis is rare, but can be fulminant unless rapidly evaluated and treated. The aim of this study was to evaluate whether serum procalcitonin (PCT) levels could predict unfavorable outcomes of bacterial meningitis. We retrospectively reviewed the medical records of 604 meningitis patients from the emergency department (ED) of our tertiary care, university-affiliated hospital over a five-year period. We analyzed the ability of blood PCT levels on admission to predict the outcome at discharge (defined as Glasgow Outcome Scale scores of 1-4). Of 71 patients with acute bacterial meningitis, 28 (39 %) experienced an unfavorable outcome at discharge (overall mortality: 5 %). The serum PCT level at admission was a predictive indicator of an unfavorable outcome [adjusted odds ratio: 1.04, 95 % confidence interval (CI) 1.01-1.09, p = 0.05]. As assessed using receiver operating characteristic curves for an unfavorable outcome, the area under the PCT curve was 0.708 (95 % CI 0.58-0.84, p < 0.01). When the PCT cutoff value was ≥1.10 ng/mL, the sensitivity, specificity, positive predictive value and negative predictive value for an unfavorable outcome were 75, 70, 62, and 81 %, respectively. An association between the serum PCT level and an unfavorable outcome is observed.
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Affiliation(s)
- Byuk Sung Ko
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea.
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Abbott AN, Fang FC. Clinical Impact of Multiplex Syndromic Panels in the Diagnosis of Bloodstream, Gastrointestinal, Respiratory, and Central Nervous System Infections. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.clinmicnews.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
Community-acquired meningitis can be classified into acute and subacute presentations by the duration of illness of ≤ or >5 days, respectively. There are currently no studies comparing the clinical features, management decisions, etiologies, and outcomes between acute and subacute presentations.It is a retrospective study of adults with community-acquired meningitis hospitalized in Houston, TX between January 2005 and January 2010. An adverse clinical outcome was defined as a Glasgow Outcome Scale score of ≤4.A total of 611 patients were identified, of which 458 (75%) were acute and 153 subacute (25%). The most common etiologies were unknown in 418 (68.4%), viral in 94 (15.4%), bacterial in 47 (7.7%), fungal in 42 patients (6.9%), and other noninfectious etiologies in 6 (1%). Patients with subacute meningitis were more likely to be immunosuppressed or have comorbidities, had fungal etiologies, and had higher rates of hypoglycorrachia and abnormal neurological findings (P <.05). Patients with an acute presentation were more likely to be treated empirically with intravenous antibiotics and had higher cerebrospinal fluid pleocytosis and serum white blood cell counts (P <.05). On logistic regression, age >65 years and abnormal neurological findings were predictive of an adverse clinical outcome in both acute and subacute meningitis, whereas fever was also a significant prognostic factor in acute meningitis. (P <.05).Acute and subacute meningitis differ in regards to clinical presentations, etiologies, laboratory findings, and management decisions, but did not differ in rates of adverse clinical outcomes. Future studies including thoroughly investigated patients with new diagnostic molecular methods may show different results and outcomes.
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Emergency Medicine Myths: Computed Tomography of the Head Prior to Lumbar Puncture in Adults with Suspected Bacterial Meningitis - Due Diligence or Antiquated Practice? J Emerg Med 2017; 53:313-321. [PMID: 28666562 DOI: 10.1016/j.jemermed.2017.04.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/05/2017] [Accepted: 04/25/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. OBJECTIVE To review the evidence regarding the utility of obtaining head CT prior to lumbar puncture in adults with suspected bacterial meningitis. DISCUSSION Observational studies report a risk of post-lumbar puncture brainstem herniation in the presence of intracranial mass effect (1.5%) that is significantly lower than that reported among all patients with bacterial meningitis (up to 13.3%). It is unclear from existing literature whether identifying patients with intracranial mass effect decreases herniation risk. Up to 80% of patients with bacterial meningitis experiencing herniation have no CT abnormalities, and approximately half of patients with intracranial mass effect not undergoing lumbar puncture herniate. Decision rules to selectively perform CT on only those individuals most likely to have intracranial mass effect lesions have not undergone validation. Despite recommendations for immediate antimicrobial therapy prior to imaging, data indicate an association between pre-lumbar puncture CT and antibiotic delays. Recent data demonstrate shortened door-to-antibiotic times and lower mortality from bacterial meningitis after implementation of new national guidelines, which restricted generally accepted CT indications by removing impaired mental status as imaging criterion. CONCLUSIONS Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.
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Vanderway J, Vincent C, Walsh SM, Obrecht J. Implementation of a Pathway for the Treatment of Fever and Neutropenia in Pediatric Patients With Cancer. J Pediatr Oncol Nurs 2017; 34:315-321. [PMID: 28812473 DOI: 10.1177/1043454217691231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fever and neutropenia is an oncologic emergency. Time-to-antibiotics (TTA) refers to the amount of time from initial provider evaluation for fever and neutropenia to intravenous antibiotic administration. Research supports that rapid time-to-antibiotics (RTTA) is associated with improved patient outcomes. This quality improvement project evaluated the success of implementing an RTTA pathway in pediatric oncology patients with fever and neutropenia. The setting was an advanced practice nurse-managed pediatric ambulatory infusion center where patients with fever and neutropenia were often evaluated and treated. In order to improve TTA, a multidisciplinary pathway was implemented with a goal of TTA that was less than 60 minutes from initial provider evaluation. Implementation of the RTTA pathway included discussion of shared expectations with the pharmacy and education departments and discussion of shared expectations with the bedside nurses and advanced practice nurses staffing the unit. Additionally, a preliminary lab test was utilized. Success of the implementation was evaluated through 2 measures: TTA and nurses' knowledge of fever and neutropenia and the importance of RTTA. The aims of this project were to improve TTA as well as nurses' knowledge of fever and neutropenia and the importance of RTTA, and both these aims were successfully attained.
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Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock*. Crit Care Med 2016; 44:2145-2153. [DOI: 10.1097/ccm.0000000000001868] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Buchholz G, Koedel U, Pfister HW, Kastenbauer S, Klein M. Dramatic reduction of mortality in pneumococcal meningitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:312. [PMID: 27716447 PMCID: PMC5045860 DOI: 10.1186/s13054-016-1498-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
Abstract
Background Acute bacterial meningitis is still a life threatening disease. Methods We performed a retrospective observational study on the clinical characteristics of consecutively admitted patients with acute pneumococcal meningitis in a single tertiary care center in central Europe (from 2003 until 2015). Data were compared with a previously published historical group of 87 patients treated for pneumococcal meningitis at the same hospital (from 1984 until 2002). Results Fifty-five consecutive patients with microbiologically proven pneumococcal meningitis were included. Most striking, mortality was down to 5.5 %, which was significantly lower than in the historical group where 24.1 % of the patients did not survive. Intracranial complications during the course of the disease were common and affected half of the patients. Unlike in the historic group, most of the intracranial complications (except ischemic stroke) were no longer associated with a low Glasgow Outcome Score at discharge. Conclusion The drastic reduction of mortality proves there have been important advances in the treatment of pneumococcal meningitis. Nevertheless, the fact that only 44.2 % of survivors had a full recovery indicates that the search for new adjunctive treatment options must be ongoing.
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Affiliation(s)
- Grete Buchholz
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | | | - Matthias Klein
- Emergency Department, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr, 15, 81377, Munich, Germany.
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Klein M, Pfister HW. Bakterielle Meningitis bei Erwachsenen im Notfall- und Rettungswesen. Med Klin Intensivmed Notfmed 2016; 111:647-659. [DOI: 10.1007/s00063-016-0209-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Bodilsen J, Dalager-Pedersen M, Schønheyder HC, Nielsen H. Time to antibiotic therapy and outcome in bacterial meningitis: a Danish population-based cohort study. BMC Infect Dis 2016; 16:392. [PMID: 27507415 PMCID: PMC4977612 DOI: 10.1186/s12879-016-1711-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-acquired bacterial meningitis (CABM) is a life-threatening disease and timing of antibiotic therapy remains crucial. We aimed to analyse the impact of antibiotic timing on the outcome of CABM in a contemporary cohort. METHODS We conducted a population-based cohort study based on chart reviews of all adult cases (>16 years of age) of CABM in North Denmark from 1998 to 2014 excluding patients given pre-hospital parenteral antibiotics. We used modified Poisson regression analyses to compute the adjusted risk ratio (adj. RR) with 95 % confidence intervals (CIs) for in-hospital mortality and unfavourable outcome at discharge by time after arrival to hospital to adequate antibiotic therapy. RESULTS We identified 195 adults with CABM of whom 173 patients were eligible for further analyses. The median door-to-antibiotic time was 2.0 h (interquartile range (IQR) 1.0-5.5). We observed increased adjusted risk ratios for in-hospital mortality of 1.6 (95 % CI 0.8-3.2) and an unfavourable outcome at discharge of 1.5 (95 % CI 1.0-2.2, p = 0.03) when treatment delays exceeded 6 h versus treatment within 2 h of admission. These findings corresponded to adjusted risk ratios of in-hospital mortality of 1.1 per hour of delay (95 % CI 0.8-1.5) and an unfavourable outcome at discharge of 1.1 per hour of delay (95 % CI 1.0-1.3) within the first 6 h of admission. Some patients (31 %) were diagnosed after admission and had more delays in antibiotic therapy and correspondingly increased in-hospital mortality (30 vs 14 %, p = 0.01) and unfavourable outcome (62 vs 37 %, p = 0.002). CONCLUSIONS Delay in antibiotic therapy was associated with unfavourable outcome at discharge.
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Affiliation(s)
- Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9100, Aalborg, Denmark. .,Department of Medicine, Vendsyssel Hospital, Hjørring, Denmark.
| | - Michael Dalager-Pedersen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9100, Aalborg, Denmark
| | - Henrik Carl Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Mølleparkvej 4, 9100, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Gaskell KM, Feasey NA, Heyderman RS. Management of severe non-TB bacterial infection in HIV-infected adults. Expert Rev Anti Infect Ther 2016; 13:183-95. [PMID: 25578883 DOI: 10.1586/14787210.2015.995631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite widespread antiretroviral therapy use, severe bacterial infections (SBI) in HIV-infected adults continue to cause significant morbidity and mortality globally. Four main pathogens account for the majority of documented SBI: Streptococcus pneumoniae, non-typhoidal strains of Salmonella enterica, Escherichia coli and Staphylococcus aureus. The epidemiology of SBI is dynamic, both in developing countries where, despite dramatic successes in antiretroviral therapy, coverage is far from complete, and in settings in both resource-poor and resource-rich countries where antiretroviral therapy failure is becoming increasingly common. Throughout the world, this complexity is further compounded by rapidly emerging antimicrobial resistance, making management of SBI very challenging in these vulnerable patients. We review the causes and treatment of SBI in HIV-infected people and discuss future developments in this field.
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Affiliation(s)
- Katherine M Gaskell
- Malawi Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
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Bakterielle Meningitis bei Erwachsenen im Not- und Rettungswesen. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0148-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Viallon A, Botelho-Nevers E, Zeni F. Clinical decision rules for acute bacterial meningitis: current insights. Open Access Emerg Med 2016; 8:7-16. [PMID: 27307768 PMCID: PMC4886299 DOI: 10.2147/oaem.s69975] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acute community-acquired bacterial meningitis (BM) requires rapid diagnosis so that suitable treatment can be instituted within 60 minutes of admitting the patient. The cornerstone of diagnostic examination is lumbar puncture, which enables microbiological analysis and determination of the cerebrospinal fluid (CSF) cytochemical characteristics. However, microbiological testing is not sufficiently sensitive to rule out this diagnosis. With regard to the analysis of standard CSF cytochemical characteristics (polymorphonuclear count, CSF glucose and protein concentration, and CSF:serum glucose), this is often misleading. Indeed, the relatively imprecise nature of the cutoff values for these BM diagnosis markers can make their interpretation difficult. However, there are two markers that appear to be more efficient than the standard ones: CSF lactate and serum procalcitonin levels. Scores and predictive models are also available; however, they only define a clinical probability, and in addition, their use calls for prior validation on the population in which they are used. In this article, we review current methods of BM diagnosis.
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Affiliation(s)
- Alain Viallon
- Emergency Department, University Hospital, Saint-Etienne, France
| | | | - Fabrice Zeni
- Intensive Care Unit, University Hospital, Saint-Etienne, France
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The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016; 72:405-38. [PMID: 26845731 DOI: 10.1016/j.jinf.2016.01.007] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/14/2016] [Accepted: 01/23/2016] [Indexed: 02/06/2023]
Abstract
Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.
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Clinical Prognosis in Neonatal Bacterial Meningitis: The Role of Cerebrospinal Fluid Protein. PLoS One 2015; 10:e0141620. [PMID: 26509880 PMCID: PMC4625018 DOI: 10.1371/journal.pone.0141620] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/09/2015] [Indexed: 11/19/2022] Open
Abstract
Neonates are at high risk of meningitis and of resulting neurologic complications. Early recognition of neonates at risk of poor prognosis would be helpful in providing timely management. From January 2008 to June 2014, we enrolled 232 term neonates with bacterial meningitis admitted to 3 neonatology departments in Shanghai, China. The clinical status on the day of discharge from these hospitals or at a postnatal age of 2.5 to 3 months was evaluated using the Glasgow Outcome Scale (GOS). Patients were classified into two outcome groups: good (167 cases, 72.0%, GOS = 5) or poor (65 cases, 28.0%, GOS = 1–4). Neonates with good outcome had less frequent apnea, drowsiness, poor feeding, bulging fontanelle, irritability and more severe jaundice compared to neonates with poor outcome. The good outcome group also had less pneumonia than the poor outcome group. Besides, there were statistically significant differences in hemoglobin, mean platelet volume, platelet distribution width, C-reaction protein, procalcitonin, cerebrospinal fluid (CSF) glucose and CSF protein. Multivariate logistic regression analyses suggested that poor feeding, pneumonia and CSF protein were the predictors of poor outcome. CSF protein content was significantly higher in patients with poor outcome. The best cut-offs for predicting poor outcome were 1,880 mg/L in CSF protein concentration (sensitivity 70.8%, specificity 86.2%). After 2 weeks of treatment, CSF protein remained higher in the poor outcome group. High CSF protein concentration may prognosticate poor outcome in neonates with bacterial meningitis.
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Shrestha GS, Acharya S, Keyal N, Paneru H, Shrestha P. Successful lumbar puncture with Taylor′s approach for the diagnostic workup of meningitis in a patient with Ankylosing spondylitis. Indian J Crit Care Med 2015; 19:618-20. [PMID: 26628829 PMCID: PMC4637964 DOI: 10.4103/0972-5229.167053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Meningitis and encephalitis are the neurological emergencies. As the clinical findings lack specificity, once suspected, cerebrospinal fluid (CSF) analysis should be performed and parenteral antimicrobials should be administered without delay. Lumbar puncture can be technically challenging in patients with ankylosing spondylitis due to ossification of ligaments and obliteration of interspinous spaces. Here, we present a case of ankylosing spondylitis where attempts for lumbar puncture by conventional approach failed. CSF sample was successfully obtained by Taylor's approach.
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Turtle L, Jung A, Beeching NJ, Cocker D, Davies GR, Nicolson A, Beadsworth MB, Miller AR, Solomon T. An integrated model of care for neurological infections: the first six years of referrals to a specialist service at a university teaching hospital in Northwest England. BMC Infect Dis 2015; 15:387. [PMID: 26399536 PMCID: PMC4581475 DOI: 10.1186/s12879-015-1109-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 09/02/2015] [Indexed: 11/27/2022] Open
Abstract
Background A specialist neurological infectious disease service has been run jointly by the departments of infectious disease and neurology at the Royal Liverpool University Hospital since 2005. We sought to describe the referral case mix and outcomes of the first six years of referrals to the service. Methods Retrospective service review. Results Of 242 adults referred to the service, 231 (95 %) were inpatients. Neurological infections were confirmed in 155 (64 %), indicating a high degree of selection before referral. Viral meningitis (35 cases), bacterial meningitis (33) and encephalitis (22) accounted for 38 % of referrals and 61 % of confirmed neurological infections. Although an infrequent diagnosis (n = 19), neurological TB caused the longest admission (median 23, range 5 – 119 days). A proven or probable microbiological diagnosis was found in 100/155 cases (64.5 %). For the whole cohort, altered sensorium, older age and longer hospital stay were associated with poor outcome (death or neurological disability); viral meningitis was associated with good outcome. In multivariate analysis altered sensorium remained significantly associated with poor outcome, adjusted odds ratio 3.04 (95 % confidence interval 1.28 – 7.22, p = 0.01). Conclusions A service of this type provides important specialist care and a focus for training and clinical research on complex neurological infections.
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Affiliation(s)
- Lance Turtle
- Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK. .,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, L69 7BE, UK.
| | - Agam Jung
- Leeds General Infirmary, Leeds, LS1 3EX, UK.
| | - Nick J Beeching
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK. .,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, L69 7BE, UK. .,Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Derek Cocker
- Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK.
| | - Gerry R Davies
- Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK.
| | - Andy Nicolson
- Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, L9 7LJ, UK.
| | - Michael Bj Beadsworth
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK. .,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, L69 7BE, UK.
| | - Alastair Ro Miller
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK.
| | - Tom Solomon
- Institute of Infection and Global Health, University of Liverpool, Ronald Ross Building, 8 West Derby Street, Liverpool, L69 7BE, UK. .,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Liverpool, L69 7BE, UK. .,Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, L9 7LJ, UK.
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Abstract
BACKGROUND In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response. OBJECTIVES To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis. SEARCH METHODS We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015), EMBASE (1974 to February 2015), Web of Science (2010 to February 2015), CINAHL (2010 to February 2015) and LILACS (2010 to February 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality. MAIN RESULTS We included 25 studies involving 4121 participants (2511 children and 1517 adults; 93 mixed population). Four studies were of high quality with no risk of bias, 14 of medium quality and seven of low quality, indicating a moderate risk of bias for the total analysis. Nine studies were performed in low-income countries and 16 in high-income countries.Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P value = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P value = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events. AUTHORS' CONCLUSIONS Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
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Affiliation(s)
- Matthijs C Brouwer
- Academic Medical Center University of AmsterdamDepartment of Neurology, Center for Infection and Immunity Amsterdam (CINIMA)P.O. Box 22660AmsterdamNetherlands1100 DE
| | - Peter McIntyre
- Children's Hospital at Westmead and University of SydneyNational Centre for Immunisation Research and Surveillance of Vaccine Preventable DiseasesLocked Bag 4001WestmeadSydneyNSWAustralia2145
| | - Kameshwar Prasad
- All India Institute of Medical Sciences (AIIMS)Department of NeurologyAnsarinagarNew DelhiIndia110029
| | - Diederik van de Beek
- University of AmsterdamDepartment of Neurology, Academic Medical CentreP.O. Box 22660AmsterdamNetherlands1100 DE
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