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

Economic evaluation of childhood pneumococcal conjugate vaccination programs in Qinghai and Hainan provinces, China

BACKGROUND

The burden of pneumococcal disease varies regionally in China, disproportionately affecting children in many provinces such as Qinghai and Hainan. Nevertheless, the absence of a pneumococcal conjugate vaccine (PCV) in the National Immunization Program (NIP) or local programs presents limited coverage. This study evaluated the health and economic impact of including PCV in immunization programs in Qinghai and Hainan.

RESEARCH DESIGN AND METHODS

A decision tree Markov model was constructed to simulate health outcomes and lifetime costs among children under different 13-valent PCV (PCV13) vaccination strategies compared to current practices, from societal and healthcare perspectives. Data on epidemiology, vaccine efficacy, cost, and utility were obtained from the literature and open databases. Sensitivity analyses were conducted to explore parameter uncertainty.

RESULTS

Including three-dose PCV13 in provincial programs at NIP coverage (98.91%) could avert 7100 episodes and 118 deaths in Qinghai, and 6200 episodes and 66 deaths in Hainan. It was cost-effective at the $68.2/dose in private market and cost-saving at the United Nations Children's Fund (UNICEF) recommended $25/dose for both provinces. Increasing coverage to 50% or 75% was also cost-effective. Sensitivity analyses confirmed the robustness of the results despite parameter uncertainty.

CONCLUSIONS

Prioritizing PCV13 in immunization programs in Qinghai and Hainan could effectively reduce disease burden, improve population health, and promote health equity.

Adjunctive dexamethasone and 30-day all-cause death after hospital admission in paediatric pneumococcal meningitis: a propensity score analysis

BACKGROUND

Pneumococcal meningitis is a leading cause of bacterial meningitis and the most deadly pneumococcal disease in children worldwide. There is a paucity of evidence concerning the benefit of dexamethasone to prevent death in paediatric pneumococcal meningitis. We aimed to compare the effect of early adjunctive therapy with dexamethasone versus no dexamethasone on death in children with pneumococcal meningitis.

METHODS

We did a non-randomised, comparative, multicentre, retrospective, quasi-experimental, propensity score-based study using data from a French national surveillance system of pneumococcal meningitis in children that collates data for 238 French paediatric wards working with 168 microbiology laboratories. We compared outcomes of adjunctive therapy with dexamethasone treatment (0·15 mg/kg every 6 h, for 4 days, per national guidelines) given within 12 h of antibiotic treatment versus no dexamethasone among all children aged 0-17 years with confirmed pneumococcal meningitis who had been hospitalised in one of the participating centres between Jan 1, 2005, and Nov 1, 2022. The primary outcome was 30-day all-cause death after hospital admission. The main propensity score analysis was based on inverse probability treatment weighting (IPTW), allowing adjustment for initial severity and baseline characteristics. Sensitivity analyses, such as propensity score matching, were done to assess the robustness of the results.

FINDINGS

Between Jan 1, 2005, and Nov 1, 2022, 1765 cases of pneumococcal meningitis were reported to the National Surveillance System of Paediatric Bacterial Meningitis. 534 were excluded from the analysis and 1231 were included, with a median age of 1·1 years (IQR 0·5-5·0, range 0-17·9). 495 (40%) of 1231 patients were female, 716 (58%) were male, and 20 (1%) were missing data for sex. 650 (53%) of 1231 children received dexamethasone and 581 (47%) children did not receive dexamethasone. 108 (9%) of 1231 patients died. Within 30 days of hospitalisation, 105 (9%) patients died, 36 (6%) of 650 in the dexamethasone group and 69 (12%) of 581 in the no dexamethasone group. After IPTW, the adjusted 30-day death rate was 6% in the dexamethasone group and 12% in the no dexamethasone group (marginal odds ratio 0·39, 95% CI 0·23-0·65). All sensitivity analyses gave similar results.

INTERPRETATION

Adjunctive dexamethasone within 12 h of starting antibiotic treatment was associated with a reduced 30-day risk of death in children hospitalised with pneumococcal meningitis. Our findings support the use of dexamethasone to reduce the risk of death in paediatric pneumococcal meningitis.

FUNDING

Pfizer, ACTIV, and National Institute of Health and Medical Research (Inserm) Centre.

WHO defeating meningitis symposium, 3rd international symposium on Streptococcus agalactiae disease (ISSAD) in Rio de Janeiro, Brazil: State-of-the-art overview of S. agalactiae meningitis

A World Health Organization (WHO) Defeating Meningitis Symposium took place as part of the 3rd International Symposium on Streptococcus agalactiae disease (ISSAD) conference which was held in Rio de Janeiro, Brazil, from October 16-18, 2023. The symposium highlighted WHO's Defeating meningitis by 2030 global road map focusing on Group B Streptococcus (GBS) meningitis and provided an overview of the meningitis burden and main challenges faced to tackle the disease across the Americas, Africa, and Asia.

Streptococcus suis: A Possible Emerging Zoonotic Pathogen in Romania

Streptococcus suis is a common germ in pig populations, with high carrier rates. Recent studies identify it as an emerging zoonotic pathogen, particularly in Southeast Asia, where raw pork is traditionally consumed. Data on Streptococcus suis infection in Europe, especially Eastern European countries like Romania, are limited. Our study reviewed data from an infectious diseases tertiary hospital in Bucharest between 2001 and 2024, including eight patients diagnosed with a Streptococcus suis invasive infection. The median age was 53.3 years, with a male-to-female ratio 3:1. Three patients had risk factors such as contact with pigs or handling fresh pork. Seven patients were initially diagnosed with meningitis and one with endocarditis. During hospitalization, an additional endocarditis case was identified among the meningitis patients. Laboratory samples indicated bacterial infection, with Streptococcus suis isolated from CSF in six cases and blood cultures in two cases. All strains tested were susceptible to beta-lactam antibiotics, but resistant to lincosamides and macrolides. There were no deaths, but half of our patients experienced severe meningitis-related sequelae, mainly hearing loss. Clinicians should be aware of Streptococcus suis as an etiologic agent of meningitis in non-endemic areas like Romania, especially in patients with risk factors (contact with pigs, pork).

Comparative Histopathologic Analysis of Inner Ear Damage in Meningitis: Otogenic Versus Meningogenic Routes

OBJECTIVE

To distinguish the patterns of inner ear changes between meningogenic and otogenic routes in meningitis cases. Our hypothesis is that pinpointing distinct patterns linked to each route could aid in the development of diagnostic strategies and targeted therapies.

METHODS

Temporal bones (TBs) from patients with a history of meningitis and histopathological evidence of labyrinthitis were divided into two groups (otogenic and meningogenic). Inner ear histopathological examination was performed to identify qualitative and semi-quantitative changes. This assessment encompassed inflammation patterns, indications of early ossification, hair cell loss, and alterations in the lateral wall, round window membrane, cochlear aqueduct and vestibular aqueduct.

RESULTS

Thirty-six TBs were included in the study (otogenic, 21; meningogenic, 15). Generalized labyrinthitis was more common in otogenic cases (100% vs. 53%, p < 0.001). Early signs of cochlear ossification were exclusively observed in otogenic cases (9 TBs). The spiral ligament of otogenic cases has shown a uniform loss of fibrocytes across all cochlear turns, while meningogenic cases showed more severe loss in the apical turn. Otogenic cases exhibited a higher prevalence of severe inflammation of the cochlear aqueduct and endolymphatic sac. Meningogenic cases showed more severe loss of vestibular hair cells in the otolithic organs.

CONCLUSION

Otogenic cases displayed a higher prevalence of changes in the spiral ligament and signs of early ossification, whereas meningogenic cases were associated with a higher degree of vestibular damage. Our findings emphasize the importance of considering the infection route and its implications for timely diagnosis and development of pathology-oriented treatment strategies.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:864-872, 2025.

[Community acquired bacterial meningitis in adults]

Bacterial meningitis is a rare but severe disease with a high mortality. The most frequent pathogens in adults are pneumococcus, meningococcus and Listeria. The most important key symptoms are headache, meningism and fever; however, the absence of individual cardinal symptoms does not exclude the diagnosis. The empirical treatment consists of ceftriaxone and ampicillin, supplemented with dexamethasone as needed. It should be initiated without delay if bacterial meningitis is suspected. Before this, two pairs of blood cultures should be obtained followed by a lumbar puncture. An elevated intracranial pressure must be excluded via cerebral computed tomography before performing a lumbar puncture only in patients with confirmation of impaired consciousness, focal neurological deficits or epileptic seizures. In such cases treatment is initiated immediately after obtaining blood cultures but before the lumbar puncture. The identification and management of a focus are essential and should be conducted on the day of admission.

[Clinical characteristics and long-term follow-up study of basal ganglia infarction after minor head trauma in infants and young children]

OBJECTIVES

To investigate the clinical characteristics and prognosis of infants and young children with basal ganglia infarction after minor head trauma (BGIMHT).

METHODS

A retrospective analysis was conducted on the clinical data and follow-up results of children aged 28 days to 3 years with BGIMHT who were hospitalized at Children's Hospital of Soochow University from January 2011 to January 2022.

RESULTS

A total of 45 cases of BGIMHT were included, with the most common symptom being limb movement disorders (96%, 43/45), followed by facioplegia (56%, 25/45). Cerebral imaging showed that 72% (31/43) had infarction accompanied by basal ganglia calcification. After conservative treatment, 42 children (93%) showed significant symptom improvement, while 3 children (7%) experienced recurrent strokes. The median follow-up time was 82 months (range: 17-141 months). At the last follow-up, 97% (29/30) had residual basal ganglia softening lesions. Among 29 cases participating in questionnaire follow-up, 66% (19/29) recovered normally, 17% (5/29) showed significant improvement in symptoms, and 17% (5/29) had poor improvement. According to the grading of the Global Burden of Disease Control Projects, only 1 child (3%) had severe sequelae. There were no significant differences in age at onset, gender, or presence of concomitant basal ganglia calcification between children with and without neurological sequelae (P>0.05).

CONCLUSIONS

The most common initial symptom of BGIMHT is limb movement disorder, and imaging results indicate that most children have concurrent intracranial calcifications. Most infarct lesions later transform into softening lesions, resulting in a generally good prognosis.

Risk of psychiatric neurodevelopmental disorders after meningitis in childhood: a nationwide, population-based cohort study

BACKGROUND

Few studies have investigated the risk of psychiatric neurodevelopmental disorders (PNDD) after childhood meningitis.

METHODS

Nationwide population-based cohort study (Denmark, 1995-2021) of children with positive cerebrospinal fluid for bacteria or enterovirus, stratified on age as young infants (0 to <90 days, n = 637) or older children (≥90 days to <17 years, n = 1,218). We constructed a comparison cohort from the general population (n = 18,550), and cohorts of siblings of participants. As risk estimates of PNDD we calculated age- and sex-adjusted hazard ratios (aHRs) with 95% confidence intervals (95%CI).

RESULTS

Children with bacterial meningitis had increased risks of PNDD, especially learning and intellectual developmental disorders (young infants: aHR 4.2, 95%CI: 2.4-7.1; older children: aHR 1.5, 95%CI: 1.0-2.3), attention deficit disorder (ADHD) (young infants: aHR 2.8, 95%CI: 1.5-5.2; older children: 1.4, 95%CI: 0.9-2.2) and redemption of ADHD medication (young infants: aHR 2.2, 95%CI: 1.0-4.7; older children: 1.5, 95%CI: 1.0-2.3). Young infants with bacterial meningitis additionally had increased risks of autism spectrum disorders (aHR 1.9, 95%CI: 0.9-4.1) and behavioural and emotional disorders (aHR 2.0, 95%CI: 1.0-3.9). In young infants, the excess risk of PNDD was especially observed in premature children. Siblings of older children with bacterial meningitis also had increased risks of PNDD. Children with enteroviral meningitis at any age did not have increased risks of PNDD or redemption of ADHD medication.

CONCLUSIONS

Bacterial meningitis in childhood is associated with subsequent diagnosis of PNDD, while enteroviral meningitis is not. The association appears to be partly explained by prematurity and familial and socioeconomic factors.

Cost-effectiveness analysis of vaccination strategies against meningococcal disease for children under nine years of age in China

Meningococcal vaccination strategies in China are intricate, including multiple vaccines targeting different serogroups. The current National Immunization Program (NIP) includes two polysaccharide vaccines for serogroups A and C (MPV-A and MPV-AC), covering limited serogroups and requiring adaptation. This study aims to evaluate the cost-effectiveness of replacing the current strategy with alternative strategies utilizing non-NIP vaccines to inform policy decisions. From a societal perspective, a decision tree-Markov model was constructed to simulate the economic and health consequences of meningococcal disease in a 2019 birth cohort with four vaccination strategies. Epidemiology, vaccine efficacy, cost, and other parameters were derived from previous studies. We conducted sensitivity analyses to assess the robustness of the findings and explored prices for non-NIP vaccines that enable cost-effective strategies. Compared to the current strategy, alternative strategies using quadrivalent polysaccharide vaccine (MPV-4), bivalent conjugate vaccine (MCV-AC), and quadrivalent conjugate vaccine (MCV-4) could avoid 91, 286, and 455 more meningococcal cases. The ICERs were estimated at approximately $250 thousand/QALY, $450 thousand/QALY, and $1.5 million/QALY, all exceeding the threshold of three times GDP per capita. The alternative strategies were not cost-effective. However, if vaccine prices were reduced to $3.9 for MPV-4, $9.9 for MCV-AC, and $12 for MCV-4, the corresponding strategy would be cost-effective. The current meningococcal vaccination strategy in China could effectively prevent the disease at a low cost, but with limited serogroup coverage. Strategies using MPV-4, MCV-AC, or MCV-4 could increase health benefits at a substantial cost, and might become cost-effective if vaccine prices decrease.

Biomarkers in paediatric bacterial meningitis: a systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Biomarkers for paediatric bacterial meningitis are essential for an accurate diagnosis.

OBJECTIVES

To perform a systematic review of diagnostic accuracy on cerebrospinal fluid (CSF) and blood biomarkers for paediatric bacterial meningitis.

DATA SOURCES

Databases Medline, Excerpta Medica Database, Scopus, and Web of Science were used.

STUDY ELIGIBILITY CRITERIA

Eligible studies were those on novel diagnostic CSF and blood biomarkers from which data on biomarker concentration or diagnostic accuracy could be abstracted.

PARTICIPANTS

Paediatric patients (0-18 years) suspected of a central nervous system (CNS) infection.

ASSESSMENT OF RISK OF BIAS

The Quality Assessment tool for Diagnostic Accuracy Studies (QUADAS)-2 tool was used to assess risk of bias.

METHODS OF DATA SYNTHESIS

The difference in biomarker concentrations were assessed by calculating standardized and weighted mean differences. A random-effects meta-analysis model was used. Hierarchical summary receiver-operating characteristic curves were constructed.

RESULTS

We identified 3435 studies, of which 112 articles on 113 individual biomarkers (CSF n = 90 and blood n = 23) were included. In CSF, C-reactive protein (CRP), Interleukin (IL)-6, Tumor necrosis factor (TNF)-α, and Interleukin (IL)-8 showed the largest mean differences between bacterial meningitis and viral meningitis and IL-6, TNF-α, and IL-8 between bacterial meningitis and no CNS infection/inflammation. CSF CRP and ferritin showed excellent discrimination for bacterial versus viral meningitis (summary area under the curve [sAUC] 0.94; 95% CI, 0.92-0.97, sAUC 0.94; 95% CI, 0.90-1.0). CSF IL-6 and procalcitonin showed excellent discrimination for bacterial versus nonbacterial meningitis and versus no CNS infection/inflammation (sAUC IL-6: 0.98; 95% CI, 0.96-1.00, sAUC procalcitonin: 0.96; 95% CI, 0.94-0.99). Procalcitonin in blood showed good discrimination (AUC, 0.89; 95% CI, 0.68-1.00).

DISCUSSION

We identified several CSF biomarkers with high diagnostic accuracy for the diagnosis of bacterial meningitis, including IL-6, procalcitonin, CRP, and ferritin. None of the blood biomarkers exhibited excellent discrimination for paediatric bacterial meningitis. Validation of these biomarkers in prospective, well-designed studies of diagnostic accuracy performed in children with suspected meningitis is needed.

Adult Work Ability Following Diagnosis of Bacterial Meningitis in Childhood

Importance

A diagnosis of bacterial meningitis in childhood can lead to permanent neurological disabilities. Few studies have examined long-term consequences for work ability in adulthood.

Objective

To compare earnings, work loss, and educational attainment between adults diagnosed with bacterial meningitis in childhood and population comparators.

Design, Setting, and Participants

This nationwide registry-based matched cohort study included individuals in Sweden diagnosed with bacterial meningitis in childhood (aged <18 years) from January 1, 1987, to December 31, 2019, and general population comparators matched 1:9 on age, sex, and place of residence. Follow-up was completed December 31, 2020. Data were analyzed from February 7 to September 12, 2023.

Exposure

A diagnosis of bacterial meningitis in childhood recorded in the National Patient Register.

Main Outcomes and Measures

Annual taxable earnings (in 2020 US dollars), work loss (sum of sick leave and disability insurance), and educational attainment.

Results

The cohort included 2534 individuals diagnosed with bacterial meningitis in childhood (mean [SD] age at diagnosis, 4.7 [5.3] years) and 22 806 comparators (13 510 [53.3%] male). Among those with childhood bacterial meningitis, 812 (32.0%) were diagnosed at younger than 1 year and 1351 (53.3%) were male. From 18 to 34 years of age, those with childhood meningitis had lower adjusted earnings relative to comparators and higher adjusted work loss. When pooling observations for individuals 28 years or older, the annual mean reduction in earnings was -$1295 (95% CI, -$2587 to -$4), representing a 4.0% (95% CI, 0%-8.0%) reduction relative to comparators, and the annual increase in work loss was 13.5 (95% CI, 8.6-18.5) days. There was a larger reduction in earnings for those with childhood meningitis relative to comparators with pneumococcal (Streptococcus pneumoniae) vs meningococcal (Neisseria meningitidis) meningitis. For work loss, there was a difference among all 3 major causes of meningitis, with the largest increase for pneumococcal meningitis. Individuals diagnosed at a younger age (below the median) had lower earnings relative to comparators and higher work loss than individuals diagnosed at an older age (above the median). Fewer individuals with childhood meningitis relative to comparators had obtained a high school degree at age 30 years (adjusted odds ratio, 0.68 [95% CI, 0.56-0.81]).

Conclusions and Relevance

In this cohort study of adults diagnosed with bacterial meningitis in childhood, findings suggest that work ability decreases relative to population comparators, with lower earnings and higher work loss, especially among adults diagnosed with pneumococcal meningitis or diagnosed at a young age, with long-lasting costs for the individual patient and society at large.

Global Meningococcal Initiative: Insights on antibiotic resistance, control strategies and advocacy efforts in Western Europe

In Western Europe, many countries have robust and well-established surveillance systems and case reporting mechanisms. IMD incidence across Western Europe is low with a predominance of meningococcal serogroup B (MenB). Case confirmation and antimicrobial susceptibility testing is often standardised in this region, with many countries also having robust vaccination programmes in place. Both MenB and MenACWY vaccines form part of National Immunisation Programmes (NIPs) in most European countries, with Sweden only offering vaccination in special circumstances. Despite these established programmes, there remains a critical need for advocacy efforts in affecting change in diagnosis, testing, and treatment. Recent campaigns, such as the World Meningitis Day digital toolkit, have helped raise awareness and draw attention to meningococcal disease. Awareness around antibiotic resistance has also led to the identification of antibiotic-resistant meningococcal strains, with an increase, albeit small, in these strains noted across the region. Countries such as Spain, Portugal, Germany, Switzerland, and France have either reported strains resistant to penicillin, ciprofloxacin and/or isolates with a reduced susceptibility to third-generation cephalosporins.

Study of pediatric invasive pneumococcal disease in the 13-pneumococcal conjugated vaccine era

BACKGROUND

Invasive pneumococcal disease (IPD) remains a significant concern among children under 5, despite vaccination efforts. This study assessed IPD prevalence and associated risks in pediatric population.

METHODS

An observational, retrospective, multicenter study in Comunidad Valenciana, Spain, of IPD cases in children under 13 from January 2012 to September 2022. Data from the CV Microbiology Surveillance Network (RedMIVA) and medical records were reviewed.

RESULTS

A total of 379 IPD cases in 377 patients were analyzed, predominantly males (54.11 %) under 5 (81.17 %). PCV13 vaccination notably reduced PCV13-serotypes IPD (p=0.0002), except serotype 3. Pneumonia was common, with half having underlying conditions (50.40 %). Worse outcomes occurred in patients with neurological disorders (ANOVA, p=0.57). Vaccine failures often involved underlying conditions (63 %) and serotypes 3 and 19A. Immunodeficiencies may relate to recurrent IPD, but evidence is limited.

CONCLUSION

Despite vaccination, IPD still impacts children, influenced by immunological status, affecting severity and mortality.

Self-Reported Executive Functioning in Young Adult Survivors of Childhood Bacterial Meningitis

OBJECTIVE

This study investigated executive functions (EFs) in young adult survivors of childhood bacterial meningitis (BM). These skills are important for normal development, and their potential vulnerability in early years suggests that childhood BM could affect executive functions in the longer term.

METHOD

The adult self-report Behavior Rating Inventory of Executive Function was administered to 474 young adult survivors of childhood BM who participated in the 20|30 Dutch Postmeningitis study. Average scores were compared to population-norm group scores. Subgroup scores were compared according to causative pathogen and age at onset.

RESULTS

Young adult survivors of childhood BM scored lower on overall metacognition than the age-matched population norm group. Young adult survivors of childhood BM caused by Streptococcus pneumoniae, S. agalactiae, or Escherichia coli had lower scores than cases caused by Neisseria meningitidis. Survivors with age-at-onset below 12 months had a higher (worse) overall EF score than survivors with age-at-onset above 12 months.

CONCLUSIONS

Young adult survivors of childhood BM experience difficulties in EF. However, most of the self-reported EF scores were within the norm. Future studies need to additionally assess EF in adult survivors of childhood BM using performance-based tests.

Epidemiological Manifestations of Purulent Bacterial Meningitis in the Russian Federation

Relevance. Although meningitis is largely preventable, it still causes hundreds of thousands of deaths worldwide each year. Significant progress has been made in reducing meningitis mortality over the past three decades. The incidence of meningococcal, pneumococcal, and Haemophilus influenzae type b meningitis has declined due to the introduction of vaccination into national immunization programs in countries around the world. Aim. To determine the epidemiological manifestations of purulent bacterial meningitis (GBM) in the Russian Federation (RF) in 2023. Materials and methods. An in-depth personalized system for recording purulent bacterial meningitis cases has been established at the Russian Reference Center for Bacterial Meningitis Monitoring. Since 2010, all territories of the Russian Federation have been included in the monitoring system. In 2023, the Reference Center received information on 1,837 cases of purulent bacterial meningitis. The paper uses a descriptive and evaluative epidemiological method: retrospective analysis. Results and discussion. The incidence of GBM in the Russian Federation over a fourteen-year observation period has a downward trend. Meningococcus, pneumococcus and Haemophilus influenzae are the causes of 85% of GBM cases in the Russian Federation, while the infections they cause are potentially vaccine-preventable. Meningococcus continues to occupy a leading position in the etiology of GBM in the Russian Federation, causing 50% of all laboratory-confirmed cases. Despite a slight decrease in the incidence of meningococcal infection in 2023, its increase in the age group at risk, children under 5 years of age, by 39% was noted. In the serogroup characteristics of meningococcus, for the first time in the studied period, the predominance of meningococcus serogroup W was revealed. In 2023, the highest mortality rate from meningococcal infection was noted – 21%. The incidence rate of pneumococcal meningitis in the age group at risk, children under 5 years old, increased to 28% in 2023, and categories of adults are defined as risk groups for mortality. The incidence of meningitis caused by Haemophilus influenzae among children under 5 years old decreased by 44%, and all cases of death, with the exception of one, were noted in this age group. Conclusion. The data obtained make it possible to track the etiology of GBM, age groups and risk areas, which can serve as a basis for developing tactics to combat the disease with priority use of vaccines.

Post-Meningitic Syndrome: Pathophysiology and Consequences of Streptococcal Infections on the Central Nervous System

Streptococcus species represent a significant global cause of meningitis, leading to brain damage through bacterial virulence factors and the host inflammatory response. Upon entering the central nervous system (CNS), excessive inflammation leads to various neurological and psychological complications. This review explores the pathophysiological mechanisms and associated outcomes of streptococcal meningitis, particularly its short- and long-term neurological sequelae. Neurological symptoms, such as cognitive impairment, motor deficits, and sensory loss, are shown to vary in severity, with children being particularly susceptible to lasting complications. Among survivors, hearing loss, cognitive decline, and cranial nerve palsies emerge as the most frequently reported complications. The findings highlight the need for timely intervention, including neurorehabilitation strategies that focus on optimizing recovery and mitigating long-term disabilities. Future recommendations emphasize improving early diagnosis, expanding vaccine access, and personalizing rehabilitation protocols to enhance patient outcomes. As a novel contribution, this review proposes the term "post-meningitic syndrome" to showcase the broad spectrum of CNS complications that persist following streptococcal meningitis, providing a framework for a future clinical and research focus.

Ophthalmic diseases in meningitis within the pediatric population

OBJECTIVE

Meningitis may lead to ophthalmic complications in pediatric populations. The visual aftermath in developed countries has been poorly studied. This study aims to highlight the potential ocular and neuro-ophthalmic sequela of meningitis in the pediatric population of a tertiary pediatric hospital.

DESIGN

A retrospective chart review of all pediatric patients, between 2006 and 2015, diagnosed with meningitis at the Montreal Children's Hospital was conducted. Study approval was obtained by the Institutional Review Board of the McGill University Health Centre and adhered to the tenets of the Declaration of Helsinki.

METHODS

Records of all pediatric meningitis patients were extracted and further refined by isolating all who received an ophthalmology consultation. Relevant demographic data, general medical information, ocular findings, and imaging results were extracted. The proportion of ocular abnormalities was calculated and analyzed.

RESULTS

Seventy-two of 861 meningitis patients (8.4%) received an ophthalmology consultation. Forty-six patients met the inclusion criteria, and 31 of those (67.4%) demonstrated ocular abnormalities. Children presented most frequently with abnormalities involving visual acuity (8 of 32), extraocular movements and alignment (14 of 28), optic nerve (10 of 41), pupillary reactivity (4 of 35), and periorbital/orbital cellulitis (4 of 46). Older patients were more likely to have ophthalmologic findings.

CONCLUSION

This chart review highlights the ocular abnormalities found in children who suffer from meningitis and present to a tertiary-care centre in a high sociodemographic index country. Complications may be lasting. Treating ophthalmologists should be cognizant of potential ocular abnormalities among meningitis patients. We advocate for increased awareness of this association among health care providers.

Neurodevelopmental Outcomes Following Childhood Viral Meningitis in Canterbury New Zealand

BACKGROUND

Most childhood meningitis is viral in countries with widespread conjugate vaccine use. This study assessed clinical features and neurodevelopmental outcomes in preschool children following enteroviral and parechoviral meningitis.

METHODS

Children 18-42 months of age in Canterbury, New Zealand were included, who had enterovirus (EV) or parechovirus (HPEV) meningitis from 2015 to 2021. Comprehensive neurodevelopmental assessments were completed by a psychologist using the Bayley Scale for Infant Development-3 (BSID-3). Mean composite and scaled scores and proportion below the cutoff were assessed in each domain. Clinical data was analyzed.

RESULTS

There were 79 children 18-42 months old with previous EV or HPEV meningitis. BSID assessments were completed for 33 children (55% male), median age 32 months, from 2019 to 2022 including 23 with EV and 10 HPEV meningitis. At diagnosis, 32 (97%) received intravenous/intramuscular antibiotics, and 6 received a fluid bolus. Parents reported developmental speech concerns in 6 children, and delayed motor milestones in 1 child. There was no reported sensorineural hearing loss. BSID mean composite scores were in the expected range for cognition 102 (confidence interval: 98-106), language 96 (93-100) and motor 102 (98-106) domains. Overall, 12/33 (36%) children had below expected scores in 1 developmental domain, including scores 1-2 SD below the normative mean for cognition (2/33; 6%), receptive language (6/33; 18%), expressive language (5/33; 15%) and gross motor (6/33; 18%). There were no differences between scores in EV and HPEV meningitis.

CONCLUSION

Following viral meningitis, more than a third of preschool children had a mild developmental delay with comprehensive neurodevelopmental assessment, suggesting targeted follow-up should be considered.

Economic evaluation on meningococcal vaccination strategies among children under nine years of age in Zhejiang province, China

Meningococcal vaccination in Chinese national immunization program (NIP) includes polysaccharide vaccine against Neisseria meningitidis serogroup A (MPV-A) and polysaccharide vaccine against Neisseria meningitidis serogroup A and C(MPV-AC). This study aimed to assess the cost-effectiveness of an alternative strategy using polysaccharide conjugate vaccine against Neisseria meningitidis serogroup A,C,W,Y(MCV-ACWY) and polysaccharide vaccine against Neisseria meningitidis serogroup A,C,W,Y(MPV-ACWY). From a societal perspective, we constructed a decision tree-Markov model to simulate the economic and health consequences of meningococcal disease in a 2023 birth cohort with the current meningococcal vaccination strategy and the alternative. Parameters of epidemiology, vaccine efficacy, cost, and utility were extracted from database and previous literatures. The sensitivity analysis was implemented to evaluate the robustness of the model. Compared to the current practice, the alternative strategy could avoid 513 meningococcal disease cases, 53 sequelae and 47 deaths. The ICER was estimated at $16899.81 /QALY, under the threshold of one time of the GDP per capita of Zhejiang province in 2023. The incidence of meningococcemia, the incidence of meningococcal meningitis, the case fatality of meningococcemia, the vaccine efficacy of MCV-ACWY and the price of MCV-ACWY would influence the cost-effectiveness of the meningococcal vaccination strategies. At the threshold, the probability of cost-effectiveness was 14.76% for the current strategy and 55.98% for the alternative strategy, respectively. The current meningococcal vaccination strategy had effectively prevented meningococcal disease at a low cost, but with limited serogroup coverage. Strategy using MCV-ACWY and MPV-ACWY could increase health benefits at a substantial cost at a cost-effective manner.

Optimization of the Diagnosis of Central Nervous System Infections in Vietnamese Hospitals: Results From a Retrospective Multicenter Study

Introduction

Central nervous system infections pose significant health challenges, particularly in low- and middle-income countries, because of high morbidity and mortality rates. Rapid and accurate diagnosis is essential for effective treatment to prevent adverse outcomes. Traditional culture-based diagnostics are often slow and lack specificity. This study evaluates the BioFire FilmArray Meningitis/Encephalitis (FAME) Panel against standard diagnostics in Vietnam to assess its clinical impact and suitability for local epidemiology.

Methods

We conducted a prospective study involving 330 patients with suspected central nervous system infections at 4 hospitals in northern Vietnam from July 2022 to April 2023. Cerebrospinal fluid samples were analyzed using routine culture methods and FAME. We compared pathogen detection rates and assessed the potential clinical impact of FAME results on patient management.

Results

Of the 330 cerebrospinal fluid specimens, 64 (19%) were positive by either conventional diagnostics (n = 48) and/or FAME (n = 33). The agreement between FAME and conventional diagnostics was 87%. Key pathogens Mycobacterium tuberculosis (n = 7), Klebsiella pneumoniae (n = 5), Streptococcus suis (n = 5), Epstein-Barr virus (n = 3), Acinetobacter baumannii (n = 1), and Trichosporon asahii (n = 1) were not detected by FAME. Classical meningitis parameter clinical symptoms, altered glucose, protein, and pleocytosis were good predictors of FAME positivity, indicating their utility in optimizing local diagnostic algorithms.

Conclusions

FAME complements traditional diagnostics by offering rapid and broad pathogen detection, crucial for timely and appropriate therapy. However, its effectiveness varies with local epidemiology, and it should not replace conventional methods entirely. Tailoring diagnostic panels to regional pathogen prevalence is recommended to enhance diagnostic accuracy and clinical outcomes in low- and middle-income countries.

Re-evaluating the impact and cost-effectiveness of pneumococcal conjugate vaccine introduction in 112 low-income and middle-income countries in children younger than 5 years: a modelling study

BACKGROUND

Streptococcus pneumoniae has been estimated to cause 9·18 million cases of pneumococcal pneumonia, meningitis, and invasive non-pneumonia non-meningitis disease and 318 000 deaths among children younger than 5 years in 2015. We estimated the potential impact and cost-effectiveness of pneumococcal conjugate vaccine (PCV) introduction.

METHODS

We updated our existing pseudodynamic model to estimate the impact of 13-valent PCV (PCV13) in 112 low-income and middle-income countries by adapting our previously published pseudodynamic model with new country-specific evidence on vaccine coverage, burden, and post-introduction vaccine impact from WHO-UNICEF estimates of national immunisation coverage and a global burden study. Deaths, disability-adjusted life-years (DALYs), and cases averted were estimated for children younger than 5 years born between 2000 and 2030. We used specific PCV coverage in each country and a hypothetical scenario in which coverage increased to diphtheria-tetanus-pertussis (DTP) levels. We conducted probabilistic uncertainty analyses.

FINDINGS

Using specific vaccine coverage in countries, we estimated that PCV13 could prevent 697 000 (95% credibility interval 359 000-1 040 000) deaths, 46·0 (24·0-68·9) million DALYs, and 131 (89·0-172) million cases in 112 countries between 2000 and 2030. PCV was estimated to prevent 5·3% of pneumococcal deaths in children younger than 5 years during 2000-30. The incremental cost of vaccination would be I$851 (510-1530) per DALY averted. If PCV coverage were increased to DTP coverage in 2020, PCV13 could prevent an additional 146 000 (75 500-219 000) deaths.

INTERPRETATION

The inclusion of real-world evidence from lower-income settings revealed that delays in PCV roll-out globally and low PCV coverage have cost many lives. Countries with delays in vaccine introduction or low vaccine coverage have experienced many PCV-preventable deaths. These findings underscore the importance of rapidly scaling up PCV to achieve high coverage and maximise vaccine impact.

FUNDING

Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.

Probable Causative Agents and Demographic Patterns of Encephalitis, Meningitis, and Meningoencephalitis in a Single Tertiary Care Center

Introduction Encephalitis, meningitis, and meningoencephalitis present significant challenges in clinical management owing to their diverse etiologies and potential complications. A high suspicion index is critical for guiding treatment strategies and improving patient outcomes. Understanding the demographic characteristics and frequency of causes of these conditions is essential to deliver optimized care. Objective This study aimed to investigate epidemiological causes and relative outcomes, including mortality, based on cultures, laboratory investigations, and demographic factors among patients with encephalitis, meningitis, and meningoencephalitis in a Saudi Arabian tertiary care center. Methods A retrospective cross-sectional study was conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Saudi Arabia. Data were collected from patients admitted between April 2016 and December 2022 who met the specified inclusion criteria. Results Among 233 patients, meningitis was the most prevalent diagnosis (65.77%), with bacterial agents being the predominant causative agents (79.74%). Higher mortality was significant with pediatrics <5 years and adults >60 years. Conclusion This study provides valuable insights into the epidemiology and clinical outcomes of central neurological infections based on a Saudi Arabian cohort. These findings underscore the importance of an accurate diagnosis and tailored management strategies. Further studies are warranted to enhance our understanding and to inform more predictable characteristics targeted in optimizing healthcare delivery for patients with such conditions.

Burden and bacterial etiology of neonatal meningitis at Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia

BACKGROUND

Meningitis poses a significant challenge to public health in low-income nations, such as Ethiopia, with a particular impact on newborns. The magnitude and etiologies of meningitis vary based on geographic location and age of patients. There is limited data regarding the magnitude and etiology of meningitis from Sidama Regional State, Ethiopia. This study aimed to determine the magnitude and bacterial profile of meningitis among newborns aged less than 90 days at Hawassa University Comprehensive Specialized Hospital (HUCSH).

METHODS

A retrospective cross-sectional study was conducted among newborns under 90 days who were suspected of meningitis at HUCSH from January 2019 to July 2023, and for whom Cerebrospinal fluid (CSF) culture was performed. At HUCSH, bacteria are isolated and identified using standard microbiological techniques. Socio-demographic characteristics and culture results were extracted from the laboratory register. Data were entered into Excel and exported it to SPSS version 20 for analysis.

RESULTS

Overall 1061 newborns suspected of meningitis were included in the study. Among the participants, 767 individuals (72.3%) fell within the age range of 8 to 90 days. Of the total participants, 437 (41.2%) were females. The magnitude of culture-confirmed meningitis was 90(8.5%) 95% CI: 6.8%-10.1%. The magnitude of culture-confirmed meningitis among newborns aged 0-7 days and 8-90 days were 1.6% and 6.9% respectively. The proportion of bacteria among newborns aged 0-7 days and 8-90 days were 18.9% and 81.1% respectively. Coagulase-negative Staphylococci (CONS) were the most common bacteria (n = 26; 28.9%) recovered followed by Acinetobacter species (n = 12, 13.3%), Escherichia coli (n = 9; 10%), and Klebsiella pneumoniae (n = 7; 7.8%). K. pneumoniae was the predominant bacteria among newborns within the age group of 0 to 7 days while Acinetobacter species was the most common among newborns within the 8 to 90 days age group. The prevalence of culture-confirmed neonatal meningitis was found to be greater in male newborns (x2 = 1.74, p = 0.18), newborns aged between 8 to 90 days (x2 = 0.07, p = 3.4), and newborns admitted in 2022 (x2 = 2.4, p = 0.66).

CONCLUSIONS

In this study, the overall magnitude of culture-confirmed meningitis was relatively high. Culture-confirmed meningitis was high in newborns within the age range of 8 to 90 days. The most common bacteria were CONS in both age groups followed by Acinetobacter species, E. coli, and K. pneumoniae.

Sustainability of pneumococcal conjugate vaccination in Ghana: a cost-effectiveness analysis in the context of donor transition

Background

Streptococcus pneumonia is responsible for 18% of infant deaths in Ghana. With co-financing from Gavi in 2012, Ghana introduced the PCV13 into the childhood immunization programme to reduce the burden of Streptococcus pneumonia. However, Ghana will graduate to the Gavi fully self-financing phase in 2026, when the nation assumes full responsibility of paying for the PCV13. This research aims to evaluate the health impact and cost-effectiveness of PCV13 immunization in Ghana since its implementation and after the cessation of support from Gavi.

Methods

We used the UNIVAC tool to evaluate two main scenarios of cost-effectiveness, from vaccine introduction (2012-2025) and after Gavi transition (2026-2031) in comparison with no vaccination. The sources of data include national data, international estimates and expert opinion. Cost was considered from both the government and societal perspectives. We discounted health outcomes at 3%. Currency values were stated in US Dollars. We tested the robustness of the base case results by performing scenario and sensitivity analyses.

Results

PCV13 will reduce the pneumococcal disease burden by 48% from 2012 to 2031. The vaccination programme costs are USD 130 million and USD 275 million in 2012-2025 and 2026-2031 respectively. It also has a budget impact of USD 280 million for the 2026-2031 period from the perspective of government. The incremental cost-effectiveness ratios are USD 89 and USD 73 respectively from the perspectives of government and society in 2012-2025. The incremental cost-effectiveness ratios are USD 530 and USD 510 respectively from the perspectives of government and society in 2026-2031.

Conclusion

The PCV13 vaccination programme in Ghana is cost-effective at 50% GDP per capita threshold even when Gavi withdraws co-financing support from 2026 onwards.

How common is otogenic meningitis? A retrospective study in southern Sweden over 18 years

BACKGROUND

Bacterial meningitis is a rare, but life-threatening disease, which sometimes occurs as a complication to acute otitis media (AOM). The proportion of meningitis cases originating from AOM is not clear.

PURPOSE

The aim of this study was to investigate the proportion of meningitis cases caused by AOM, to compare risk factors, bacteriology and outcome between otogenic and non-otogenic meningitis, and to analyse the incidence of bacterial meningitis after the introduction of conjugate pneumococcal vaccines (PCV).

METHODS

The medical charts of all patients admitted to hospitals in southern Sweden with bacterial meningitis between 2000 and 2017 were retrieved. Based on otoscopy and/or imaging, the proportion of otogenic meningitis cases was calculated, as were annual incidences.

RESULTS

A total of 216 patients were identified, 25 of whom died. The proportion of otogenic meningitis was 31% but varied from 6% among teenagers to 40% among adults. Before PCV, 23% of all meningitis cases were children < 2 years, compared to 1% post-PCV. The average incidence in the adult population, on the other hand, increased post-PCV, though there were large annual variations. S. pneumoniae was the most commonly identified pathogen in everyone but teenagers, in whom N. meningitidis was predominant.

CONCLUSION

AOM is an important cause of meningitis in children and adults. Though bacterial meningitis almost disappeared in children < 2 years after the introduction of PCV, the incidence of pneumococcal meningitis in adults seems to have increased.

Inequitable Distribution of Global Economic Benefits from Pneumococcal Conjugate Vaccination

Many low- and middle-income countries have been slow to introduce the pneumococcal conjugate vaccine (PCV) into their routine childhood immunization schedules despite a high burden of disease. We estimated the global economic surplus of PCV, defined as the sum of the net value to 194 countries (i.e., monetized health benefits minus net costs) and to vaccine manufacturers (i.e., profits). We further explored the distribution of global economic surplus across country income groups and manufacturers and the effect of different pricing strategies based on cross-subsidization, pooled procurement, and various tiered pricing mechanisms. We found that current PCV pricing policies disproportionately benefit high-income countries and manufacturers. Based on the 2021 birth cohort, high-income countries and manufacturers combined received 76.5% of the net economic benefits generated by the vaccine. Over the two decades of PCV availability, low- and middle-income countries have not received the full economic benefits of PCV. Cross-subsidization of the vaccine price for low- and middle-income countries and pooled procurement policies that would relate the vaccine price to the value of economic benefits generated for each country could reduce these inequalities. This analysis offers important considerations that may improve the equitable introduction and use of new and under-utilized vaccines.

Recent increase in atypical presentations of invasive meningococcal disease in France

BACKGROUND

Invasive meningococcal disease (IMD) cases declined upon the implementation of non-pharmaceutical interventions (NPI) (social distancing and mask wearing) to control the COVID-19 pandemic but rebounded in 2022 in numbers with genotypical changes of the strains. We explored here associated modifications in the clinical presentations of IMD.

METHODS

We conducted a retrospective descriptive study using the Database of the French National Reference Centre for meningococci and Haemophilus influnezae for IMD cases between 2015 and 2022. We scored serogroups, sex, age groups, clinical presentations and clonal complexes of the corresponding patients and isolates.

FINDINGS

Non-meningeal forms of IMD increased significantly upon easing of NPI, such as bacteremic meningococcal pneumonia and bacteremic abdominal forms. They represented 6% and 8% of all IMD forms and were significantly linked to serogroups Y and W respectively, to older adults for bacteremic pneumonia and to young adults for bacteremic abdominal presentations. These forms were significantly associated with more early mortality and clonal complexes 23, 11 and 9316.

INTERPRETATION

The increase in atypical IMD forms may lead to higher burden of IMD due to delayed diagnosis and management. Updating prevention may be needed through by adapting the current vaccination strategies to epidemiological changes.

Exploring the Health-Related Quality of Life and the Lived Experience of Adolescents Following Invasive Meningococcal Disease

BACKGROUND

Data on the health-related quality of life (HRQoL) for invasive meningococcal disease (IMD) survivors, particularly among adolescents and young adults (AYAs), are limited. This study aimed to investigate the in-depth experiences and impacts of IMD on AYAs.

METHODS

Participants were recruited from two Australian states, Victoria and South Australia. We conducted qualitative, semi-structured interviews with 30 patients diagnosed with IMD between 2016 and 2021. The interview transcripts were analyzed thematically.

RESULTS

Of the participants, 53% were aged 15-19 years old, and 47% were aged 20-24. The majority (70%) were female. Seven themes relating to the participants' experience of IMD were identified: (1) underestimation of the initial symptoms and then rapid escalation of symptoms; (2) reliance on social support for emergency care access; (3) the symptoms prompting seeking medical care varied, with some key symptoms missed; (4) challenges in early medical diagnosis; (5) traumatic and life-changing experience; (6) a lingering impact on HRQoL; and (7) gaps in the continuity of care post-discharge.

CONCLUSION

The themes raised by AYA IMD survivors identify multiple areas that can be addressed during their acute illness and recovery. Increasing awareness of meningococcal symptoms for AYAs may help reduce the time between the first symptoms and the first antibiotic dose, although this remains a challenging area for improvement. After the acute illness, conducting HRQoL assessments and providing multidisciplinary support will assist those who require more intensive and ongoing assistance during their recovery.

Clinical Picture and Risk Factors for Poor Outcome in Streptococcus pneumoniae Meningitis of Childhood on Three Continents

BACKGROUND

Streptococcus pneumoniae meningitis (SpM) remains a major health burden worldwide, particularly in low- and middle-income countries. Identifying the patients at highest risk for mortality and disabling sequelae may reveal potentially avoidable predisposing factors and identify patients most in need of intensive care. We searched for factors that do not require laboratory facilities.

METHODS

This study was a secondary analysis of prospectively collected data from 5 clinical trials of childhood bacterial meningitis on 3 continents between 1984 and 2017. SpM cases were analyzed by study site and predictors for poor outcome (death or severe sequelae) were identified from the whole series, Latin America and Angola.

RESULTS

Among a total of 1575 children (age range: 2 months to 15 years), 505 cases were due to pneumococci. Compared to other etiologies, SpM doubled the death rate (33% vs. 17%) and tripled poor outcome (15% vs. 6%). In SpM, Glasgow Coma Score <13 [odds ratio (OR): 4.73] and previous antibiotics in Angola (OR: 1.70) were independent predictors for death. Predictors for poor outcome were age <1 year (OR: 2.41) and Glasgow Coma Score <13 (OR: 6.39) in the whole series, seizures in Latin America (OR: 3.98) and previous antibiotics in Angola (OR: 1.91). Angolan children had a 17-fold increased risk for poor outcome when compared with Finnish children ( P = 0.011).

CONCLUSIONS

Our study proved the severity of SpM when compared with other etiologies. The outcome was especially poor in Angola. Most patients at risk for poor outcome are easily identified by clinical factors on admission.

Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology

OBJECTIVES

The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes.

METHODS

Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology.

RESULTS

The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis.

CONCLUSIONS

Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis.

FUNDING

This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

Molecular characteristics and antimicrobial resistance of invasive pneumococcal isolates from children in the post-13-valent pneumococcal conjugate vaccine era in Shenzhen, China

OBJECTIVES

This study aimed to evaluate the molecular epidemiology and antimicrobial resistance of invasive pneumococcal isolates from children in Shenzhen, China, in the early stage of the pneumococcal 13-valent conjugated vaccine (PCV-13) era from 2018 to 2020.

METHODS

Invasive pneumococcal strains were isolated from hospitalized children with invasive pneumococcal diseases (IPDs) from January 2018 to December 2020. The serotype identification, multilocus sequence typing (MLST), and antibiotic susceptibility tests were performed on all culture-confirmed strains.

RESULTS

Sixty-four invasive strains were isolated mainly from blood (70.3%). Prevalent serotypes were 23F (28.1%), 14 (18.8%), 19F (15.6%), 6A/B (14.1%), and 19A (12.5%), with a serotype coverage rate of 96.9% for PCV13. The most common sequence types (STs) were ST876 (17.1%), ST271 (10.9%), and ST320 (7.8%). Half of the strains were grouped in clonal complexes (CCs): CC271 (21.9%), CC876 (20.3%), and CC90 (14.1%). Meningitis isolates showed a higher resistance rate (90.9% and 45.5%) to penicillin and ceftriaxone than the rate (3.8% and 9.4%) of non-meningitis isolates. The resistance rates for penicillin (oral), cefuroxime, and erythromycin were 53.13%, 73.4%, and 96.9%, respectively. The dual ermB and mefA genotype was found in 81.3% of erythromycin-resistant strains. The elevated minimum inhibitory concentration (MIC) of β-lactam antibiotics and dual-genotype macrolide resistance were related mainly to three major serotype-CC combinations: 19F-CC271, 19A-CC271, and 14-CC876.

CONCLUSION

Invasive pneumococcus with elevated MICs of β-lactams and increased dual ermB and mefA genotype macrolide resistance were alarming. Expanded PCV13 vaccination is expected to reduce the burden of paediatric IPD and to combat antibiotic-resistant pneumococcus in Shenzhen.

An unusual imaging presentation of pediatric bacterial meningoencephalitis: a case-report study

Background

Bacterial meningoencephalitis is a serious infection affecting the brain and its surrounding membranes. While imaging studies play a crucial role in diagnosing this condition, the typical radiological findings are well-documented. However, this case report describes an unusual imaging presentation that deviates from the expected patterns, emphasizing the need for awareness of such variations.

Case presentation

A 7-year-old female with no prior medical history was referred to our hospital with fever, seizure, and loss of Consciousness. She had mild flu a week before admission. The duration of seizure episodes were 2-3 min, with tonic-clonic uncontrollable jerky movements. Brudzinski and Kernig signs were positive and plantar reflex was upward bilaterally in the physical examination. The computed tomography (CT) scan showed brain ventriculomegaly/hydrocephalus, and MRI findings indicated multiple foci located at cerebellum, basal ganglia, and thalamus alongside intensely restricted diffusion of the layering debris, suggesting pyogenic ventriculitis. Cerebrospinal fluid (CSF) analysis showed severe hypoglycorrhachia, despite non-significant increase of protein. The patient was undergone antibiotic therapy with ceftriaxone, vancomycin and rifampin, resulting in normalization of CSF values.

Conclusion

This case report highlights the importance of recognizing and interpreting unusual imaging presentations of bacterial meningoencephalitis in paediatric patients. It emphasizes the need for a comprehensive diagnostic approach, including clinical evaluation, laboratory tests, and imaging studies, to ensure accurate diagnosis and appropriate management of this potentially life-threatening condition. Further research and awareness of atypical imaging findings are warranted to enhance our understanding and improve patient outcomes.

Multiplex real-time PCR FilmArray performance in the diagnosis of meningoencephalitis: lights and shadows

PURPOSE

We aimed to evaluate the performance of the FilmArray (FA) meningitis/encephalitis (ME) panel. Secondarily, we analyzed the false positive (FP) and false negative (FN) results, as well as the predictive values of the technique, regarding the cerebrospinal fluid (CSF) characteristics.

METHODS

FA is a multiplex real-time PCR detecting 14 of the most common ME pathogens in CSF. All FA performed at our hospital (2018-2022) were retrospectively reviewed. FA was compared to conventional techniques and its performance was assessed based on the final diagnosis of the episode.

RESULTS

FA was performed in 313 patients with suspicion of ME. Most patients had altered mental status (65.2%) and fever (61%). Regarding CSF characteristics, 49.8% and 53.7% presented high CSF proteins and pleocytosis, respectively. There were 84 (26.8%) positive FA results, mainly for HSV-1 (10.9%), VZV (5.1%), Enterovirus (2.6%), and S. pneumoniae (1.9%). In the 136 cases where both FA and routine methods were performed, there was a 25.7% lack of agreement. We identified 6.6% FN results, but 28.6% FP, mainly due to HSV-1. This resulted in a high negative predictive value (NPV) of 93.4%, but a positive predictive value (PPV) of 73%. Remarkably, PPV as low as 36.9%, and 70.2%, were found in cases without pleocytosis, or lack of high CSF protein levels, respectively.

CONCLUSION

FA was associated with high NPV, but frequent FP results and low PPV, particularly for HSV-1, and especially in patients without high CSF protein levels or pleocytosis.

Priorities for hearing loss prevention and estimates of global cause-specific burdens of hearing loss: a systematic rapid review

BACKGROUND

Hearing loss affects approximately 1·6 billion individuals worldwide. Many cases are preventable. We aimed to estimate the annual number of new hearing loss cases that could be attributed to meningitis, otitis media, congenital rubella syndrome, cytomegalovirus, and ototoxic medications, specifically aminoglycosides, platinum-based chemotherapeutics, and antimalarials.

METHODS

We used a targeted and a rapid systematic literature review to calculate yearly global incidences of each cause of hearing loss. We estimated the prevalence of hearing loss for each presumed cause. For each cause, we calculated the global number of yearly hearing loss cases associated with the exposure by multiplying the estimated exposed population by the prevalence of hearing loss associated with the exposure, accounting for mortality when warranted.

FINDINGS

An estimated 257·3 million people per year are exposed to these preventable causes of hearing loss, leading to an estimated 33·8 million new cases of hearing loss worldwide per year. Most hearing loss cases were among those with exposure to ototoxic medications (19·6 million [range 12·6 million-27·9 million] from short-course aminoglycoside therapy and 12·3 million from antimalarials). We estimated that 818 000 cases of hearing loss were caused by otitis media, 346 000 by meningitis, 114 000 by cytomegalovirus, and 59 000 by congenital rubella syndrome.

INTERPRETATION

The global burden of preventable hearing loss is large. Hearing loss that is attributable to disease sequelae or ototoxic medications contributes substantially to the global burden of hearing loss. Prevention of these conditions should be a global health priority.

FUNDING

The US National Institute on Deafness and Other Communication Disorders and the US National Institute on Aging.

Increased Risk of Long-Term Disabilities Following Childhood Bacterial Meningitis in Sweden

Importance

Few studies have examined the incidence of long-term disabilities due to bacterial meningitis in childhood with extended follow-up time and a nationwide cohort.

Objective

To describe the long-term risks of disabilities following a childhood diagnosis of bacterial meningitis in Sweden.

Design, Setting, and Participants

This nationwide retrospective registry-based cohort study included individuals diagnosed with bacterial meningitis (younger than 18 years) and general population controls matched (1:9) by age, sex, and place of residence. Data were retrieved from the Swedish National Patient Register from January 1, 1987, to December 31, 2021. Data were analyzed from July 13, 2022, to November 30, 2023.

Exposure

A diagnosis of bacterial meningitis in childhood recorded in the National Patient Register between 1987 and 2021.

Main Outcomes and Measures

Cumulative incidence of 7 disabilities (cognitive disabilities, seizures, hearing loss, motor function disorders, visual disturbances, behavioral and emotional disorders, and intracranial structural injuries) after bacterial meningitis in childhood.

Results

The cohort included 3623 individuals diagnosed with bacterial meningitis during childhood and 32 607 controls from the general population (median age at diagnosis, 1.5 [IQR, 0.4-6.2] years; 44.2% female and 55.8% male, median follow-up time, 23.7 [IQR, 12.2-30.4] years). Individuals diagnosed with bacterial meningitis had higher cumulative incidence of all 7 disabilities, and 1052 (29.0%) had at least 1 disability. The highest absolute risk of disabilities was found for behavioral and emotional disorders, hearing loss, and visual disturbances. The estimated adjusted hazard ratios (HRs) showed a significant increased relative risk for cases compared with controls for all 7 disabilities, with the largest adjusted HRs for intracranial structural injuries (26.04 [95% CI, 15.50-43.74]), hearing loss (7.90 [95% CI, 6.68-9.33]), and motor function disorders (4.65 [95% CI, 3.72-5.80]). The adjusted HRs for cognitive disabilities, seizures, hearing loss, and motor function disorders were significantly higher for Streptococcus pneumoniae infection (eg, 7.89 [95% CI, 5.18-12.02] for seizure) compared with Haemophilus influenzae infection (2.46 [95% CI, 1.63-3.70]) or Neisseria meningitidis infection (1.38 [95% CI, 0.65-2.93]). The adjusted HRs for cognitive disabilities, seizures, behavioral and emotional disorders, and intracranial structural injuries were significantly higher for children diagnosed with bacterial meningitis at an age below the median.

Conclusions and Relevance

The findings of this cohort study of individuals diagnosed with bacterial meningitis during childhood suggest that exposed individuals may have had an increased risk for long-term disabilities (particularly when diagnosed with pneumococcal meningitis or when diagnosed at a young age), highlighting the need to detect disabilities among surviving children.

Diagnostic Accuracy of Cerebrospinal Fluid Multiplex Polymerase Chain Reaction Panel Testing in Patients With Suspected Central Nervous System Infections: A Multi-Center Study in the United Arab Emirates

Background Delays in diagnosis and treatment of central nervous system (CNS) infections can lead to significant morbidity and mortality among children and adults. Prior antibiotic treatment is a major hurdle to accurate diagnosis due to falsely negative cerebrospinal fluid (CSF) cultures in partially treated patients. Increasingly, molecular diagnostic methods using multiplex polymerase chain reaction (mPCR) testing on CSF samples are being utilized in clinical practice for timely and accurate diagnosis. However, there is no data regarding the diagnostic accuracy or clinical impact of CSF mPCR testing in the Middle East region. We sought to compare the diagnostic accuracy of an automated mPCR CSF panel with routine CSF culture, the current gold standard, in the United Arab Emirates (UAE).  Methods This single-gated, multi-center, diagnostic accuracy study included patients from birth onwards who were admitted to any of the three participating hospitals with an initial diagnosis of meningitis or encephalitis, between January 2017 and March 2021, and had CSF samples collected for mPCR and culture. Sociodemographic, clinical, and molecular data were collected for all. Results A total of 353 CSF samples were collected from patients from 0-90 years old hospitalized for suspected CNS infection. Children constituted 51% of the study population, and males were slightly over-represented (55.2%). Pathogens were detected by mPCR in 78 (22%) CSF samples, of which 19 (24%) were bacteria and 59 (76%) were viruses. No fungal pathogens were detected. Enteroviruses were the most prevalent CNS pathogen among our cohort (40%), followed by herpes simplex virus type 2 (HSV-2) (12.5%). Children constituted 69% of positive samples for enterovirus, while HSV-2 was exclusively detected among adults. Using CSF culture as the diagnostic gold standard, the mPCR panel demonstrated high specificity (100%) and sensitivity (96.3%) in diagnosing CNS infection among all age groups. mPCR testing demonstrated a high overall percentage of agreement (OPA) with CSF culture (98.9%). Patients with bacterial meningitis had a significantly longer hospitalization (p=0.004) and duration of antibiotic therapy (p=0.001) compared to those with viral meningitis. Three CSF samples were negative on mPCR testing but positive on culture. These pathogens included: methicillin-sensitive Staphylococcus aureus(MSSA), Bacillus cereus, and Mycobacterium Tuberculosis (MTB). In addition, 13 patients had negative CSF cultures but tested positive on CSF mPCR. These pathogens included Streptococcus pneumoniae (seven patients), Haemophilus influenzae (three patients), Streptococcus agalactiae (two patients), and Escherichia coli (one patient). All discordant results were confirmed by reviewing the patient's clinical presentation, CSF analysis, clinical course, and final diagnosis. Conclusion CSF mPCR panel is a highly sensitive and specific diagnostic tool for the diagnosis of CNS infections among all age groups in the UAE. Routine use of CSF mPCR panels can decrease healthcare costs by reducing the length of stay and can also aid antibiotic stewardship efforts by reducing antibiotic overuse in patients with viral CSF infections. CSF culture and mPCR complement each other by identifying CNS pathogens in patients with prior antibiotic exposure who would otherwise be missed if relying on CSF culture alone. However, concomitant CSF culture samples should be sent to avoid missing unusual CNS pathogens.

Persistent headaches one year after bacterial meningitis: prevalence, determinants and impact on quality of life

BACKGROUND

Little is known on headaches long-term persistence after bacterial meningitis and on their impact on patients' quality of life.

METHODS

In an ancillary study of the French national prospective cohort of community-acquired bacterial meningitis in adults (COMBAT) conducted between February 2013 and July 2015, we collected self-reported headaches before, at onset, and 12 months (M12) after meningitis. Determinants of persistent headache (PH) at M12, their association with M12 quality of life (SF 12), depression (Center for Epidemiologic Studies Depression Scale) and neuro-functional disability were analysed.

RESULTS

Among the 277 alive patients at M12 87/274 (31.8%), 213/271 (78.6%) and 86/277 (31.0%) reported headaches before, at the onset, and at M12, respectively. In multivariate analysis, female sex (OR: 2.75 [1.54-4.90]; p < 0.001), pre-existing headaches before meningitis (OR: 2.38 [1.32-4.30]; p < 0.01), higher neutrophilic polynuclei percentage in the CSF of the initial lumbar puncture (OR: 1.02 [1.00-1.04]; p < 0.05), and brain abscess during the initial hospitalisation (OR: 8.32 [1.97-35.16]; p < 0.01) were associated with M12 persistent headaches. Neither the responsible microorganism, nor the corticoids use were associated with M12 persistent headaches. M12 neuro-functional disability (altered Glasgow Outcome Scale; p < 0.01), M12 physical handicap (altered modified Rankin score; p < 0.001), M12 depressive symptoms (p < 0.0001), and M12 altered physical (p < 0.05) and mental (p < 0.0001) qualities of life were associated with M12 headaches.

CONCLUSION

Persistent headaches are frequent one year after meningitis and are associated with quality of life alteration.

CLINICAL TRIAL

NCT01730690.

A Multicenter Epidemiological and Pathogenic Characteristics Study of Community-Acquired Bacterial Meningitis Children in China: Results from the Chinese Pediatric Bacterial Meningitis Surveillance (CPBMS) 2019-2020

Objective

To explore the epidemiological and pathogenic characteristics of children with community-acquired bacterial meningitis.

Methods

A multicenter, retrospective study was conducted among CABM patients under 15 years old from 33 hospitals in China from 2019 to 2020. The medical record, laboratory, and microbiological data were collected and analyzed.

Results

A total of 1610 children with CABM were identified and presented at a median onset age of 45 days of whom 955 (59.3%) were males. CABM occurred mostly in infants <1 year of age (84.0%, 1352/1610). In etiology-confirmed cases, the pathogens were isolated from CSF culture in 515 (32.0%), 400 (24.8%) in blood culture, and 186 (11.6%) both in CSF and blood culture. In total, 126 pathogens were identified through CSF mNGS in 330 CABM cases; 21 S. pneumoniae isolates were detected in 83 CABM cases by antigen detection method. Major pathogens were E. coli (195, 24.7%), GBS (170, 21.5%), and S. pneumoniae (157, 19.9%). GBS (29.3%, 22/75) was the first pathogen of CABM in neonates aged 0-6 days old, while E. coli (44.7%, 76/170) in 7 to 28 days of age; S. pneumoniae (96.2%, 151/157) was the most common pathogen in >3 months old cases. About 9.7% (19/195) strains of E. coli produced ultra‑broad‑spectrum β‑lactamases. The common intracranial imaging complications were subdural effusion and (or) empyema in 349 (21.7%), hydrocephalus in 233 (14.5%), and cerebral abscess in 178 (11.1%). A total of 389 (24.2%) cases were completely cured and 1088 (67.6%) cases improved. Among 166 patients (10.3%) with adverse outcomes, 32 cases (2.0%) died, and 37 cases (2.3%) relapsed.

Conclusion

The onset age of CABM in children is usually within 1 year of age, especially <3 months. The primary pathogens in infants less than 3 months old are E. coli and GBS, and the dominant pathogen in children older than 3 months old is S. pneumoniae. Subdural effusion and (or) empyema and hydrocephalus are common complications. CABM should not be excluded even if CSF leukocyte counts are within normal range. Due to the low detection rate of pathogens in children with CABM, standardized CSF bacteriological examination should be paid more attention to increase the pathogen detection rate. Non‑culture CSF detection methods may facilitate pathogenic diagnosis.

Trends in laboratory-confirmed bacterial meningitis (2012-2019): national observational study, England

Background

Bacterial meningitis is associated with significant morbidity and mortality worldwide. We aimed to describe the epidemiology, aetiology, trends over time and outcomes of laboratory-confirmed bacterial meningitis in England during 2012-2019.

Methods

UK Health Security Agency routinely receives electronic notifications of confirmed infections from National Health Service hospital laboratories in England. Data were extracted for positive bacterial cultures, PCR-positive results for Neisseria meningitidis or Streptococcus pneumoniae from cerebrospinal fluid and positive blood cultures in patients with clinical meningitis.

Findings

During 2012-19, there were 6554 laboratory-confirmed cases. Mean annual incidence was 1.49/100,000, which remained stable throughout the surveillance period (p = 0.745). There were 155 different bacterial species identified, including 68.4% (106/1550) Gram-negative and 31.6% (49/155) Gram-positive bacteria. After excluding coagulase-negative staphylococci (2481/6554, 37.9%), the main pathogens causing meningitis were Streptococcus pneumoniae (811/4073, 19.9%), Neisseria meningitidis (497/4073, 12.2%), Staphylococcus aureus (467/4073, 11.5%), Escherichia coli (314/4073, 7.7%) and group B streptococcus (268/4073, 6.6%). Pneumococcal meningitis incidence increased significantly during 2012-9, while meningococcal, group A streptococcal and tuberculous meningitis declined. Infants aged <3 months had the highest mean incidence (55.6/100,000; 95% CI, 47.7-63.5) driven mainly by group B streptococci, followed by 3-11 month-olds (8.1/100,000; 95% CI 7.1-9.0), where pneumococcal and meningitis predominated. The 30-day case-fatality rate (CFR) was 10.0% (71/6554). Group A streptococcal meningitis had the highest CFR (47/85, 55.3%). The probability of surviving at 30 days was 95.3% (95% CI, 93.4-97.3%) for infants and 80.0% for older adults (77-84%).

Interpretation

The incidence of bacterial meningitis has remained stable. The high CFR highlights a need for prevention through vaccination.

Funding

PHE.

Cost-effectiveness analysis of a maternal pneumococcal vaccine in low-income, high-burden settings such as Sierra Leone

Maternal pneumococcal vaccines have been proposed as a method of protecting infants in the first few months of life. In this paper, we use results from a dynamic transmission model to assess the cost-effectiveness of a maternal pneumococcal polysaccharide vaccine from both healthcare and societal perspectives. We estimate the costs of delivering a maternal pneumococcal polysaccharide vaccine, the healthcare costs averted, and productivity losses avoided through the prevention of severe pneumococcal outcomes such as pneumonia and meningitis. Our model estimates that a maternal pneumococcal program would cost $606 (2020 USD, 95% prediction interval 437 to 779) from a healthcare perspective and $132 (95% prediction interval -1 to 265) from a societal perspective per DALY averted for one year of vaccine delivery. Hence, a maternal pneumococcal vaccine would be cost-effective from a societal perspective but not cost-effective from a healthcare perspective using Sierra Leone's GDP per capita of $527 as a cost-effectiveness threshold. Sensitivity analysis demonstrates how the choice to discount ongoing health benefits determines whether the maternal pneumococcal vaccine was deemed cost-effective from a healthcare perspective. Without discounting, the cost per DALY averted would be $292 (55% of Sierra Leone's GDP per capita) from a healthcare perspective. Further, the cost per DALY averted would be $142 (27% GDP per capita) from a healthcare perspective if PPV could be procured at the same cost relative to PCV in Sierra Leone as on the PAHO reference price list. Overall, our paper demonstrates that maternal pneumococcal vaccines have the potential to be cost-effective in low-income settings; however, the likelihood of low-income countries self-financing this intervention will depend on negotiations with vaccine providers on vaccine price. Vaccine price is the largest program cost driving the cost-effectiveness of a future maternal pneumococcal vaccine.

Global, regional, and national burden of meningitis and its aetiologies, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by 2030, and assessing trends in the global meningitis burden can help track progress and identify gaps in achieving these goals. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to assess incident cases and deaths due to acute infectious meningitis by aetiology and age from 1990 to 2019, for 204 countries and territories.

METHODS

We modelled meningitis mortality using vital registration, verbal autopsy, sample-based vital registration, and mortality surveillance data. Meningitis morbidity was modelled with a Bayesian compartmental model, using data from the published literature identified by a systematic review, as well as surveillance data, inpatient hospital admissions, health insurance claims, and cause-specific meningitis mortality estimates. For aetiology estimation, data from multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature studies were analysed by use of a network analysis model to estimate the proportion of meningitis deaths and cases attributable to the following aetiologies: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococcus, Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, viruses, and a residual other pathogen category.

FINDINGS

In 2019, there were an estimated 236 000 deaths (95% uncertainty interval [UI] 204 000-277 000) and 2·51 million (2·11-2·99) incident cases due to meningitis globally. The burden was greatest in children younger than 5 years, with 112 000 deaths (87 400-145 000) and 1·28 million incident cases (0·947-1·71) in 2019. Age-standardised mortality rates decreased from 7·5 (6·6-8·4) per 100 000 population in 1990 to 3·3 (2·8-3·9) per 100 000 population in 2019. The highest proportion of total all-age meningitis deaths in 2019 was attributable to S pneumoniae (18·1% [17·1-19·2]), followed by N meningitidis (13·6% [12·7-14·4]) and K pneumoniae (12·2% [10·2-14·3]). Between 1990 and 2019, H influenzae showed the largest reduction in the number of deaths among children younger than 5 years (76·5% [69·5-81·8]), followed by N meningitidis (72·3% [64·4-78·5]) and viruses (58·2% [47·1-67·3]).

INTERPRETATION

Substantial progress has been made in reducing meningitis mortality over the past three decades. However, more meningitis-related deaths might be prevented by quickly scaling up immunisation and expanding access to health services. Further reduction in the global meningitis burden should be possible through low-cost multivalent vaccines, increased access to accurate and rapid diagnostic assays, enhanced surveillance, and early treatment.

FUNDING

Bill & Melinda Gates Foundation.

Childhood Bacterial Meningitis Surveillance in Southern Vietnam: Trends and Vaccination Implications From 2012 to 2021

Background

This retrospective hospital-based surveillance aimed to assess the epidemiology, causative pathogens trend, and serotypes distribution of pneumococcal meningitis among children aged under 5 years with bacterial meningitis in Southern Vietnam after the introduction of pentavalent vaccine in the Expanded Program on Immunization (EPI).

Methods

From 2012 to 2021, cerebrospinal fluid samples were collected from children aged under 5 years with suspected bacterial meningitis at Children's Hospitals 1 and 2 in Ho Chi Minh City. Probable bacterial meningitis (PBM) cases were identified using biochemistry and cytology. Real-time polymerase chain reaction was used to confirm cases of confirmed bacterial meningitis (CBM) caused by Streptococcus pneumoniae, Haemophilus influenzae, or Neisseria meningitidis. Streptococcus pneumoniae serotyping was performed.

Results

Of the 2560 PBM cases, 158 (6.2%) were laboratory-confirmed. The CBM proportion decreased during the 10-year study and was associated with age, seasonality, and permanent residence. Streptococcus pneumoniae was the most common pathogen causing bacterial meningitis (86.1%), followed by H influenzae (7.6%) and N meningitidis (6.3%). The case-fatality rate was 8.2% (95% confidence interval, 4.2%-12.2%). Pneumococcal serotypes 6A/B, 19F, 14, and 23F were the most prevalent, and the proportion of pneumococcal meningitis cases caused by the 10-valent pneumococcal conjugate vaccine (PCV) serotypes decreased from 96.2% to 57.1% during the PCV eras.

Conclusions

Streptococcus pneumoniae is the most frequent causative agent of bacterial meningitis in children aged under 5 years in Southern Vietnam over the last decade. Policymakers may need to consider introducing PCVs into the EPI to effectively prevent and control bacterial meningitis.

Klebsiella pneumoniae invasive syndrome with liver abscess and purulent meningitis presenting as acute hemiplegia: a case report

BACKGROUND

Klebsiella pneumoniae can infect a variety of sites, with the risk of infection being higher in the immunocompromised state such as diabetes mellitus. A distinct invasive syndrome has been detected mostly in Southeast Asia in the past two decades. A common destructive complication is pyogenic liver abscess that can be complicated by metastatic endophthalmitis as well as the involvement of the central nervous system, causing purulent meningitis or brain abscess.

CASE PRESENTATION

We report a rare case of an invasive liver abscess caused by K. pneumoniae, with metastatic infections of meninges. A 68-year-old man with type 2 diabetes mellitus presented to our emergency department as sepsis. Sudden disturbed consciousness was noticed with presentation of acute hemiplegia and gaze preference mimicking a cerebrovascular accident.

CONCLUSIONS

The above case adds to the scarce literature on K. pneumoniae invasive syndrome with liver abscess and purulent meningitis. K. pneumoniae is a rare cause of meningitis and should raise suspicions about the disease in febrile individuals. In particular, Asian patients with diabetes presenting with sepsis and hemiplegia prompt a more thorough evaluation with aggressive treatment.

Understanding barriers to vaccination against invasive meningococcal disease: a survey of the knowledge gap and potential solutions

INTRODUCTION

Invasive meningococcal disease (IMD) is a leading cause of life-threatening bacterial meningitis and septicemia. Evidence points to a knowledge gap among parents, teenagers, and healthcare providers (HCPs) regarding IMD and available vaccines, including those against the highly prevalent serogroup B.

AREAS COVERED

An online survey was conducted between March 27 and April 12, 2019, to gather insights into the knowledge that parents/guardians have about IMD vaccines. The children were aged 2 months-10 years in Australia, Brazil, Germany, Greece, Italy, and Spain, 5-20 years in the UK, and 16-23 years in the US. The findings were discussed in the context of the available literature and solutions were proposed to minimize the knowledge gap and the barriers to vaccination against IMD.

EXPERT OPINION

The survey demonstrated that parents have a good understanding of IMD but a limited understanding of the different serogroups and vaccines. The available literature highlighted multiple barriers to IMD vaccine uptake; these may be reduced through education of HCPs, clear recommendations to parents by HCPs, the use of technology, and disease-awareness initiatives that engage parents through physical and digital channels. Further studies are warranted to assess the impact of the COVID-19 pandemic on IMD vaccination.

Public health impact and cost-effectiveness of 15-valent pneumococcal conjugate vaccine use among the pediatric population of the United States

BACKGROUND

Although use of the 13-valent pneumococcal conjugate vaccine (PCV13) among children has reduced incidence of pneumococcal disease, a considerable burden of disease remains. PCV15 is a new vaccine that contains pneumococcal serotypes 22F and 33F in addition to serotypes contained in PCV13. To inform deliberations by the Advisory Committee on Immunization Practices on recommendations for PCV15 use among U.S. children, we estimated the health impact and cost-effectiveness of replacing PCV13 with PCV15 within the routine infant immunization program in the United States. We also assessed the impact and cost-effectiveness of a supplementary PCV15 dose among children aged 2-5 years who have already received a full PCV13 series.

METHODS

We estimated the incremental number of pneumococcal disease events and deaths averted, costs per quality adjusted life-year (QALY) gained, and costs per life-year gained under different vaccination strategies using a probabilistic model following a single birth cohort of 3.9 million individuals (based on 2020 U.S. birth cohort). We assumed that vaccine effectiveness (VE) of PCV15 against the two additional serotypes was the same as the VE of PCV13. The cost of PCV15 use among children was informed from costs of PCV15 use among adults and from discussions with the manufacturer.

RESULTS

Our base case results found that replacing PCV13 with PCV15 prevented 92,290 additional pneumococcal disease events and 22 associated deaths, while also saving $147 million in costs. A supplementary PCV15 dose among children aged 2-5 years who were fully vaccinated with PCV13 prevented further pneumococcal disease events and associated deaths but at a cost of more than $2.5 million per QALY gained.

CONCLUSIONS

A further decrease in pneumococcal disease in conjunction with considerable societal cost savings could be expected from replacing PCV13 with PCV15 within the routine infant immunization program in the United States.

Auditory Steady-State Response and Hearing Impairment in Survivors of Childhood Bacterial Meningitis in Luanda, Angola

Survivors of childhood bacterial meningitis (BM) often develop hearing impairment (HI). In low- and middle-income countries (LMICs), BM continues to be a significant cause of hearing disability. We assessed hearing among BM survivors using auditory steady-state responses (ASSR), providing frequency-specific estimated audiograms, and examined whether ASSR would provide a greater understanding of BM-induced HI. Survivors from two prospective BM trials (ISRCTN62824827; NCT01540838) from Luanda Children's Hospital were examined in a follow-up visit with a median duration of 26 months after BM. The hearing of 50 BM survivors and 19 control children was evaluated using ASSR and auditory brainstem response (ABR) after interview and neurological and otorhinolaryngological examinations. The median age of survivors was 80 (IQR 86) months. We diagnosed HI (better ear hearing ≥ 26 dB) in 9/50 (18%) children. Five of the fifty survivors (10%) and 14/100 ears (14%) had profound HI (>80 dB). Severe-to-profound HI affected all frequencies steadily, affecting only the ears of BM survivors (18/100 vs. 0/38, p = 0.003). When looking only at the severely or profoundly affected ears, young age, low Glascow coma score, pneumococcal aetiology, and ataxia were associated with a worse hearing outcome.

Estimating national, regional and provincial cost-effectiveness of introducing childhood 13-valent pneumococcal conjugate vaccination in China: a modelling analysis

Background

Although 13-valent pneumococcal conjugate vaccine (PCV13) is available in China's private market, it has yet to be introduced into the National Immunization Programme (NIP) and is therefore not available to large parts of the population. This study aimed to estimate the cost-effectiveness of including PCV13 in China's NIP at national and provincial levels.

Methods

We adopted a decision-tree Markov model to estimate the cost-effectiveness of adding 3-dose PCV13 in the NIP compared to the status quo in the private market from a societal perspective. The model hypothesized a birth cohort for five years after vaccine introduction. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Disease burden data, incidence rate ratios, and other parameters were derived from published and grey literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were estimated at the provincial, regional, and national levels. One-way, scenario and probabilistic sensitivity analyses were conducted to explore model uncertainty.

Findings

At the national level, introducing PCV13 in the NIP was predicted to prevent approximately 4807 pneumococcal deaths (66% reduction) and 1,057,650 pneumococcal cases (17% reduction) in the first five years of the 2019 birth cohort. Under the assumed base case price of US$ 25 per dose in the NIP, PCV13 in the NIP was cost-effective nationally with ICER of US$ 5.222 per QALY gained, and was cost-effective in 17 and cost-saving in 4 of the 31 provinces compared to the status quo. One-way and scenario sensitivity analyses indicated robust results when varying all model parameters, and probabilistic sensitivity analysis showed a 98% probability of cost-effectiveness nationally.

Interpretation

Our findings highlight the cost-effectiveness of introducing PCV13 in China's NIP. Provincial results supported subnational introduction of PCV13, and priority should be given to less socioeconomically developed provinces. Since vaccination cost is the most influential model parameter, efforts to improve PCV affordability after pooled procurement will benefit public health in a cost-effective manner.

Funding

The Bill & Melinda Gates Foundation.

Bacterial meningitis in Africa

Bacterial meningitis differs globally, and the incidence and case fatality rates vary by region, country, pathogen, and age group; being a life-threatening disease with a high case fatality rate and long-term complications in low-income countries. Africa has the most significant prevalence of bacterial meningitis illness, and the outbreaks typically vary with the season and the geographic location, with a high incidence in the meningitis belt of the sub-Saharan area from Senegal to Ethiopia. Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus) are the main etiological agents of bacterial meningitis in adults and children above the age of one. Streptococcus agalactiae (group B Streptococcus), Escherichia coli, and Staphylococcus aureus are neonatal meningitis's most common causal agents. Despite efforts to vaccinate against the most common causes of bacterial neuro-infections, bacterial meningitis remains a significant cause of mortality and morbidity in Africa, with children below 5 years bearing the heaviest disease burden. The factors attributed to this continued high disease burden include poor infrastructure, continued war, instability, and difficulty in diagnosis of bacterial neuro-infections leading to delay in treatment and hence high morbidity. Despite having the highest disease burden, there is a paucity of African data on bacterial meningitis. In this article, we discuss the common etiologies of bacterial neuroinfectious diseases, diagnosis and the interplay between microorganisms and the immune system, and the value of neuroimmune changes in diagnostics and therapeutics.

The Contribution of Multiplex Polymerase Chain Reaction in the Diagnosis of Central Nervous System Infections in Intensive Care Units

Introduction The aim of this study was to evaluate the contribution and limits of BioFire® FilmArray® meningitis/encephalitis panel (FA MEP) polymerase chain reaction (PCR) (bioMérieux, Marcy-l'Étoile, France) (product references: LLC RFIT-ASY-0118) coupled with bacterial and fungal culture in the diagnosis of central nervous system infections (CNSIs). Methods This was a retrospective observational study including all patients (adults and children) hospitalized in the intensive care units (ICUs) of a Moroccan university hospital, who benefited from multiplex PCR on a cerebrospinal fluid (CSF) sample. Results A total of 112 PCRs were performed, with a positivity rate of 18%. Bacterial etiology was the most frequent (70%), represented mainly by Streptococcus pneumoniae (45%), followed by viruses (25%), with four isolates of Herpes simplex virus (HSV) 1. On 94 samples, there was an agreement between the culture and PCR results. Their discordance was found in 18 cases, including 16 suspected CNSIs recovered only by PCR and two diagnoses confirmed only by bacterial culture. Conclusion This study revealed the significant impact of multiplex PCR on the early and targeted diagnostic and therapeutic management of infectious meningitis and meningoencephalitis in intensive care unit patients.