Acute meningococcal meningitis: analysis of features of the disease according to the age of 255 patients. Copenhagen Meningitis Study Group

A Daily Operational Huddle and a Real-Time Communication Application Improve Efficiency of Laboratory Processes

CONTEXT.—

Clinical laboratory processes that require cooperation among geographically distinct sections often face challenges. We describe these challenges as related to the Gram staining of cerebrospinal fluid, a key test in the management of patients with suspected central nervous system infections, and our attempts to improve quality outcomes.

OBJECTIVE.—

To evaluate multiple tools and strategies for their effectiveness in optimizing the turnaround time of tests sharing a specimen or workflow.

DESIGN.—

Over the course of 5 years, the turnaround time of cerebrospinal fluid Gram stain was studied at one of the largest children's health systems in the US. Baseline data showed suboptimal compliance to targeted turnaround times. A conventional approach to process standardization, and 2 innovative tools that facilitate horizontal integration were applied to the main campus laboratory as follows: a daily huddle and a novel electronic communication application that was interfaced with the laboratory information system. Turnaround time and its variation were assessed. Two other hospital laboratories within the health system that did not undergo these quality interventions served as controls.

RESULTS.—

Standardization of processes reduced the variability of turnaround time but only minimally shortened it. In contrast, an interteam daily huddle that monitored key quality metrics together with the communication application, improved turnaround time significantly and sustainably.

CONCLUSIONS.—

Communication strategies involving a physical or virtual gathering of laboratory representatives encourage horizontal communication and improve turnaround times. These tools are generally applicable and could be used to improve other processes in healthcare, especially those where a workflow is shared between 2 geographically distinct areas of a health system.

Case Report: Prolonged CSF PCR Positivity in a Neonate With GBS Meningitis

Bacterial meningitis is one of the critical diseases that needs to be diagnosed and treated promptly. Recent diagnostics of high sensitivity and specificity rates, such as PCR, helped with such presentation, especially in cases with prior antibiotics that led to culture negativity. However, the time window of PCR positivity is not well-studied, with scattered reports of different periods of positivity. Here, we report a case of neonatal GBS meningitis with positive PCR for more than 80 days from starting antibiotics.

Self Mutilating Behaviour in Severe Meningococcal Infection; An Interesting Association

Neisseria meningitidis most commonly manifests as asymptomatic colonization in the nasopharynx of healthy adolescents and adults. It may rarely present as invasive disease which may be either bacterial meningitis or meningococcal septicaemia. Hereby we report a case presented with fever and rashes, irritability followed by self mutilating behaviour who was diagnosed as a case of invasive meningococcal infection. He responded well to treatment with intravenous ceftriaxone and self mutilating behaviour was subsided completely after treatment. Necrosed tissues of fingers were amputated. With best of our knowledge, no similar case of self-mutilation associated with meningococcal infection has been reported yet.

Bacterial meningitis in children under 15 years of age in Nepal

BACKGROUND

Bacterial meningitis in children is a life-threatening problem resulting in severe morbidity and mortality. For the prompt initiation of antibacterial therapy, rapid and reliable diagnostic methods are of utmost importance. Therefore, this study was designed to find out the rate of bacterial pathogens of meningitis from suspected cases by performing conventional methods and latex agglutination.

METHODS

A descriptive type of study was carried out from May 2012 to April 2013. Cerebrospinal fluid (CSF) specimens from 252 suspected cases of meningitis were subjected for Gram staining, bacterial culture and latex agglutination test. The identification of growth of bacteria was done following standard microbiological methods recommended by American Society for Microbiology. Antibiotic sensitivity testing was done by modified Kirby-Bauer disk diffusion method.

RESULTS

From the total 252 suspected cases, 7.2 % bacterial meningitis was revealed by Gram staining and culture methods whereas latex agglutination method detected 5.6 %. Gram-negative organisms contributed the majority of the cases (72.2 %) with Haemophilus influenzae as the leading pathogen for meningitis. Overall, 33.3 % mortality rate was found.

CONCLUSIONS

In conclusion, a significant rate of bacterial meningitis was found in this study prompting concern for national wide surveillance.

Prognostic indicators in bacterial meningitis: a case–control study

This was a case–control study to identify prognostic indicators of bacterial meningitis in a reference hospital in Pernambuco/Brazil. The data were collected from charts of 294 patients with bacterial meningitis between January 2000 and December 2004. Variables were grouped in biological, clinical, laboratory and etiologic agent/treatment. Variables selected in each step were grouped and adjusted for age. Two models were created: one containing clinical variables (clinical model) and other containing laboratory variables (laboratory model). In the clinical model the variables associated with death due to bacterial meningitis were dyspnea (p = 0.006), evidence of shock (p = 0.051), evidence of altered mental state (p = 0.000), absence of headache (p = 0.008), absence of vomiting (p = 0.052), and age ≥40 years old (p = 0.013). In the laboratory model, the variables associated with death due to bacterial meningitis were positive blood cultures (p = 0.073) and thrombocytopenia (p = 0.019). Identification of prognostic indicators soon after admission may allow early specific measures, like admission of patients with higher risk of death to Intensive Care Units.

Accuracy of real-time PCR, Gram stain and culture for Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae meningitis diagnosis

BACKGROUND

Although cerebrospinal fluid (CSF) culture is the diagnostic reference standard for bacterial meningitis, its sensitivity is limited, particularly when antibiotics were previously administered. CSF Gram staining and real-time PCR are theoretically less affected by antibiotics; however, it is difficult to evaluate these tests with an imperfect reference standard.

METHODS AND FINDINGS

CSF from patients with suspected meningitis from Salvador, Brazil were tested with culture, Gram stain, and real-time PCR using S. pneumoniae, N. meningitidis, and H. influenzae specific primers and probes. An antibiotic detection disk bioassay was used to test for the presence of antibiotic activity in CSF. The diagnostic accuracy of tests were evaluated using multiple methods, including direct evaluation of Gram stain and real-time PCR against CSF culture, evaluation of real-time PCR against a composite reference standard, and latent class analysis modeling to evaluate all three tests simultaneously.

RESULTS

Among 451 CSF specimens, 80 (17.7%) had culture isolation of one of the three pathogens (40 S. pneumoniae, 36 N. meningitidis, and 4 H. influenzae), and 113 (25.1%) were real-time PCR positive (51 S. pneumoniae, 57 N. meningitidis, and 5 H. influenzae). Compared to culture, real-time PCR sensitivity and specificity were 95.0% and 90.0%, respectively. In a latent class analysis model, the sensitivity and specificity estimates were: culture, 81.3% and 99.7%; Gram stain, 98.2% and 98.7%; and real-time PCR, 95.7% and 94.3%, respectively. Gram stain and real-time PCR sensitivity did not change significantly when there was antibiotic activity in the CSF.

CONCLUSION

Real-time PCR and Gram stain were highly accurate in diagnosing meningitis caused by S. pneumoniae, N. meningitidis, and H. influenzae, though there were few cases of H. influenzae. Furthermore, real-time PCR and Gram staining were less affected by antibiotic presence and might be useful when antibiotics were previously administered. Gram staining, which is inexpensive and commonly available, should be encouraged in all clinical settings.

Meningococcal vaccine: a new vaccine to combat meningococcal disease in India

Meningococcal meningitis is caused by Neisseria meningitidis, a gram-negative, aerobic, encapsulated diplococcus. Meningococci are divided into numerous serogroups based on the composition of their capsular polysaccharide (Ps) antigens. At least 13 serogroups have been described: A, B, C, D, 29E, H, I, K, L, W-135, X, Y and Z. Out of these 13, six (A, B, C, W135, X and Y) can cause epidemics. The incubation period averages 3-4 d (range 1-10 d), which is the period of communicability. Bacteria can be found for 2-4 d in the nose and pharynx, and for up to 24 h after starting antibiotics. N. meningitidis is a leading cause of meningitis worldwide and a significant public health problem and dreaded disease in most countries. Morbidity and mortality rates from the disease remain high. Apart from epidemics, at least 1.2 million cases of bacterial meningitis are estimated to occur every year, 135,000 of which are fatal--of these, ~500,000 and ~50,000 respectively are caused by meningococci. Many outbreaks of meningococcal meningitis have been documented, with major outbreaks mainly seen in large cities of northern, western and eastern India like New Delhi, Mumbai, Kolkata and northeastern states. In 2011, 245 people died in India, the vast majority (179) in West Bengal, while 467 and 341 people in 2009 and 2010 respectively died of this disease. The meningococcal conjugate vaccines (MCV) are preferred for reasons of immunogenicity and persistence of immunity but are unavailable in India. Only the quadrivalent and bivalent meningococcal Ps vaccines (MPV) are available in India. The quadrivalent MPV is preferred for Haj pilgrims, international travelers and students in that it provides protection against emerging W-135 and Y disease in these areas. A single-dose 0.5mL injection is recommended.

Acute bacterial meningitis in infants and children

Bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has changed the epidemiology of bacterial meningitis. Suspected bacterial meningitis is a medical emergency and needs empirical antimicrobial treatment without delay, but recognition of pathogens with increasing resistance to antimicrobial drugs is an important factor in the selection of empirical antimicrobial regimens. At present, strategies to prevent and treat bacterial meningitis are compromised by incomplete understanding of the pathogenesis. Further research on meningitis pathogenesis is thus needed. This Review summarises information on the epidemiology, pathogenesis, new diagnostic methods, empirical antimicrobial regimens, and adjunctive treatment of acute bacterial meningitis in infants and children.

[Managing adult patients with acute community-acquired meningitis presumed of bacterial origin]

Early clinical data must lead to suspect bacterial meningitis if fever, the most frequent sign, is present and if it is associated with more or less constant neurological and meningeal signs (consciousness impairment, headache, neck stiffness, focal neurological deficit, seizure, etc.). A skin rash is frequent in case of meningococcal meningitis whereas cranial nerve palsy is more in favor of tuberculous or Listeria meningitis. Presence of otitis, sinusitis, pneumonia, or a recent head trauma strongly suggests a pneumococcal involvement. Tuberculous meningitis is generally characterized by a slow evolution of meningeal signs together with aspecific signs. The main prognostic factors are consciousness impairment, circulatory instability, focal neurological signs, and advanced age. Morbidity and mortality are increased in case of pneumococcal compared to meningococcal meningitis. Cranial tomodensitometry gives further information about intracranial complications of meningitis. In some cases, particularly if focal neurological or intracranial hypertension signs are present, it must be performed before a lumbar puncture. The risk factors of meningitis must be investigated and treated if possible according to the bacterium. The management of patient after hospital discharge depends on evolution after treatment. The presence of neurological sequels imposes a specialized ambulatory follow-up. Neuropsychological sequels (cognitive dysfunction, memory impairment) can also persist for years even in absence of other neurological disorders.

Fever and Rash: A Changing Landscape in the 21st Century

Although “fever and rash” is a common complaint in the pediatric emergency department, most causes are benign. Of the more severe causes, several have been greatly reduced by vaccination programs. In addition, new vaccines such as those for invasive meningococcal disease hold promise for an even brighter future. Although meningococcemia remains an important concern when evaluating a child with fever and a rash, the resurgence of measles, the emergence of invasive group A streptococcal disease and antibiotic-resistant Staphylococcus aureus, as well as the fear of agents of bioterrorism (anthrax, smallpox) have changed the landscape of fever and rash in the 21st century. The purpose of this article is not to offer a comprehensive differential of febrile exanthema, but rather to highlight some new concerns related to the evaluation of fever and rash in today's emergency department.

Infektionen

Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus. Als Folge dieser Komplikationen kommt es häufig zu einem Anstieg des intrakraniellen Drucks. Bei schweren, komplizierten klinischen Verläufen der bakteriellen Meningitis kommen oft adjuvante Therapiemaßnahmen (z. B. intravenöse Gabe von hyperosmolaren Substanzen, externe Ventrikeldrainage) zum Einsatz. Bei Nachweis einer meningitisassoziierten septischen Sinus-/Venenthrombose erfolgt die dosisadaptierte intravenöse Heparintherapie.

Doença meningocócica: comparação entre formas clínicas

Visando avaliar formas clínicas da doença meningocócica, foram revistos 201 casos diagnosticados como doença meningocócica, em Hospital Universitário da Universidade Federal Fluminense; durante o período de 1971 a 1996, dos quais 185 preencheram os critérios de inclusão. A caracterização clínico-laboratorial permitiu reagrupá-los nas formas de doença meningocócica com meningite, 18%, meningite e septicemia, 62%, e septicemia, 20%. Dados epidemiológicos disponíveis não diferenciaram formas clínicas. Na meningite meningocócica foi significativamente maior: tempo de história clínica; freqüência de manifestações neurológicas; e positividade da bacterioscopia, cultura e teste do látex no líquor. Na septicemia menigocócica, houve predomínio significativamente de: choque; letalidade e níveis maiores de tempo parcial de tromboplastina. Septicemia meningogócica e septicemia com meningite se diferenciaram da meningite meningocócica quanto a: tempo de história clínica; ocorrência de sinais neurológicos focais; coagulação intravascular disseminada e artrite. Dados clínico-laboratoriais levam a admitir meningite como forma localizada de doença meningocócica, e septicemia com meningite e septicemia como variações de gravidade da forma sistêmica da doença.

Genomic polymorphic profiles in an Irish population with meningococcaemia: is it possible to predict severity and outcome of disease?

Patients with meningococcal disease have increased plasma levels of proinflammatory cytokines IL-6, IL-1beta, and TNF-alpha, with higher levels associated with fatal outcome. This study investigated whether polymorphisms in genes encoding these cytokines, and in those encoding anti-inflammatory IL-10 and IL-1Ra, are associated with the outcome in patients with meningococcal disease. Seven polymorphisms were genotyped in 183 meningococcal disease patients and 389 controls. The IL-6 -174 G/G and IL-10 -1082 A/A genotypes were more frequent in nonsurvivors compared with survivors (P=0.023 IL-6, 0.25 IL-10), and in patients with severe disease compared to those with mild disease (P=0.037 IL-6, 0.0078 IL-10). An association was also found between meningococcal disease and the IL-1RN VNTR polymorphism, but no association was observed with the LTA +252, TNF -308, IL-10 -592, or IL-1B +3953 polymorphisms. We conclude that genetic variability in the IL-6, IL-10, and IL-1RN genes is associated with a poor outcome in meningococcal disease.

Enterococcal meningitis: a clinical study of 39 cases and review of the literature

To describe the clinical features and outcome of enterococcal meningitis, we retrospectively reviewed the charts of 39 cases seen at 2 tertiary hospitals during a 25 years and collected 101 additional, previously reported cases for review. Among these 140 cases, there were 82 cases (59%) of postoperative meningitis and 58 cases (41%) of spontaneous meningitis. Eighty-six patients (61%) were adults and 54 (39%) were children. Patients with spontaneous meningitis had a higher frequency of community-acquired infection (50% versus 18%; p < 0.01), severe underlying diseases (67% versus 22%; p < 0.01), and associated enterococcal infection (29% versus 8%; p < 0.01) than patients with postoperative meningitis. The clinical presentation was similar in both groups, but patients with spontaneous infection had a higher frequency of bacteremia (58% versus 12%; p < 0.01), and a lower frequency of mixed infection (9% versus 29%; p < 0.01). Spontaneous meningitis in children was associated with a significantly lower frequency of fever, altered mental status, headache, and meningeal signs (p < 0.01), probably explained by the high proportion of neonates in this age-group. Most infections were caused by Enterococcus faecalis, which accounted for 76% of the isolates identified at the species level. Fifteen of the 25 cases due to Enterococcus faecium were produced by vancomycin-resistant strains. Most patients were treated with ampicillin, penicillin, or vancomycin, with or without aminoglycosides, for a median period of 18 days (range, 1-85 d). Overall mortality was 21%. The mortality rate was higher in spontaneous than in postoperative meningitis (33% versus 12%; p < 0.01), but was similar in patients treated with beta-lactams (18%), glycopeptides (14%), or other antibiotics (25%), as well as in patients treated with monotherapy (16%) or combination therapy (22%). An adverse outcome correlated significantly with advanced age, the presence of severe underlying diseases, associated enterococcal infection, bacteremia, septic shock, and the absence of fever at presentation. Shunt removal was associated with a lower mortality. Multivariate analysis showed that the presence of severe underlying diseases was the only prognostic factor associated with mortality (odds ratio = 6.8, 95% confidence intervals = 2.7-17.5, p < 0.01).

Clinical predictors of bacterial meningitis in infants and young children in The Gambia

BACKGROUND

Bacterial meningitis is an important cause of childhood morbidity and mortality world-wide. In the developing world, where the burden of acute meningitis and its long-term sequelae are especially high, staff with limited training at primary health care facilities must be able to recognize the symptoms and signs of meningitis, so that suspected cases can be referred urgently to hospitals.

METHODS

Children who presented with possible invasive bacterial infection to health facilities in The Gambia, West Africa, between 1993 and 1995 were investigated in a standardized manner and clinical findings were documented. Bacterial meningitis was defined as the growth of bacteria from the cerebrospinal fluid. Clinical findings were compared between cases of meningitis and other children.

RESULTS

Of 2097 children between 2 months and 3 years of age investigated, 51 had a confirmed diagnosis of bacterial meningitis. In multivariate analysis using a model adjusting for age but not including respiratory signs, the variables associated independently with meningitis were appearance of being very sick (odds ratio for meningitis vs. no meningitis or no lumbar puncture performed (OR) 4.1, 95% CI 1.5-11.1), being lethargic or unconscious (OR 5.2, 95% CI 2.1-13), a stiff neck (OR 29.3, 95% CI 12.2-70.3), a bulging fontanel (OR 3.2, 95% CI 1.2-8.5) and reduced feeding as a prompted complaint (OR 2.9, 95% CI 1.3-6.7). A combination model of a history of convulsions, or being lethargic or unconscious, or having a stiff neck, as used in the WHO-Integrated Management of Childhood Illness (IMCI) guidelines, had a sensitivity of 98% and a specificity of 72% to predict meningitis.

CONCLUSIONS

A combination of a limited number of signs is sufficient to predict meningitis with high sensitivity, without a large number of children who do not have meningitis being unnecessarily referred.

Clinical features, laboratory findings and management of meningococcal meningitis in England and Wales: report of a 1997 survey. Meningococcal meningitis: 1997 survey report

OBJECTIVES

To describe the epidemiological, clinical and laboratory features of meningococcal meningitis and the effects of antibiotics on laboratory investigations under current clinical practices in England and Wales.

METHODS

Using a telephone questionnaire, information was gathered on 103 cases with a clinical diagnosis of meningococcal meningitis. Included were cases with samples submitted to the Public Health Laboratory Service (PHLS), Meningococcal Reference Unit (MRU) over a 5-month period in 1997. Tests included microscopic examination, latex agglutination and culture for Neisseria meningitidis, and at MRU confirmation of identification and characterization of isolates and meningococcal polymerase chain reaction (PCR) analysis on blood and cerebrospinal fluids (CSF).

RESULTS

Clinically 45% of the cases had predominantly meningitis and 55% had septicaemia and meningitis. Only 29% of the cases received pre-admission benzylpenicillin, and 66% were given antibiotics within an hour of hospital attendance. Microbiological confirmation was achieved in 97 cases, 46 (44%) by traditional tests and 92 (89%) by PCR assay, including some with both. The blood culture positive rate was 23 (22%), but in predominant meningitis the rate was only 10% (5/46). PCR was the sole method of confirmation in 48 cases. Seventy percent of the plasma samples referred were reactive by PCR assay, but all samples taken more than 24 h after hospital antibiotics were non-reactive. PCR-based techniques increased the overall number of cases with a serogroup identified by 44%. Lumbar punctures were performed in 73 of the cases and microbiological confirmation was achieved in 67 (92%) of these cases, compared to 26/30 without lumbar puncture (LP). Eighty-nine percent of the CSF samples referred were reactive by PCR; 50% of the CSF samples taken more than 24 h after hospital antibiotics were reactive, whilst none were positive by culture or microscopy.

CONCLUSION

Due to variable clinical manifestations, early diagnosis and treatment was difficult. Laboratory confirmation has been improved by the introduction of PCR-based techniques. Meningococcal DNA was detected by molecular methods in CSF samples taken up to 72 h after commencement of antibiotics. During this period patients could be stabilized and the chances of complications attendant upon early LP reduced. In addition to providing accurate epidemiological information, confirming the diagnosis may alter the extent and length of follow-up.

Meningitis caused by streptococci other than Streptococcus pneumoniae: a retrospective clinical study

We reviewed the medical records of 26 patients (median age 62 years, range 5-76 years) admitted to our institution during 1978-98 with acute bacterial meningitis (ABM) caused by streptococci other than Streptococcus pneumoniae (comprising 1.9% of all patients with ABM). 19 cases were community-acquired and 7 were nosocomial. 73% had comorbid or predisposing conditions and 73% had an identifiable extracerebral focus; only in 2 patients no comorbid disease, primary focus or predisposing condition was present. Five patients had cerebral abscesses, and 5 had endocarditis. Beta-haemolytic streptococci were grown in 14 cases (serotype A: 4, B: 5, C: 1, G: 4) and were predominant among patients with endocarditis, whereas alpha- or non-haemolytic strains grew in 12 cases (S. mitis: 4, S. constellatus: 2, E. faecalis: 2, S. bovis: 1, unspecified: 3) and were predominant in patients with a brain abscess. Staphylococcus aureus grew together with a streptococcus in 2 cases. Blood culture was positive in 9 cases (35%). Neurologic complications occurred in 11 patients (42%) and extraneurologic complications in 18 patients (69%). Adverse outcomes occurred in 10 patients (38%), including 3 patients who died. Occurrence of seizures at any time of disease was significantly associated with an adverse outcome; no other clinical or paraclinical features appeared to affect outcome.

Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis

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

Acute Meningitis

Recent major epidemiologic trends in bacterial meningitis include a dramatic decline in the incidence of Haemophilus influenzae meningitis since the introduction of the protein-conjugated H. influenzae vaccines, and a worldwide increase in infections with antibiotic-resistant strains of bacterial pathogens. Cases of meningitis caused by resistant strains require an alternative therapeutic strategy. Animal studies have identified inflammatory mediators, eg, chemokines, excitatory amino acids, and endothelins, which are involved in the pathophysiology of bacterial meningitis. There is increasing evidence that reactive oxygen species (ROS), reactive nitrogen species, peroxynitrite, and matrix metalloproteinases contribute to brain damage during bacterial meningitis. The cytotoxic effects of ROS and peroxynitrite include the initiation of lipid peroxidation and the induction of DNA single-strand breakage. Damaged DNA activates poly(ADP-ribose) polymerase (PARP). Recent experimental data suggest that lipid peroxidation and PARP activation play a role in the development of meningitis-associated intracranial complications and brain injury. Agents that interfere with the production of ROS and peroxynitrite, and interfere with lipid peroxidation and PARP activation, may represent novel, therapeutic strategies by which meningitis-associated brain damage can be limited, therefore improving the outcome of this serious disease.

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

OBJECTIVE

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

DESIGN

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

POPULATION

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

RESULTS

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

CONCLUSION

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