Clinical management of community-acquired meningitis in adults in the UK and Ireland in 2017: a retrospective cohort study on behalf of the National Infection Trainees Collaborative for Audit and Research (NITCAR)

Corticosteroids for viral central nervous system infections

PURPOSE OF REVIEW

Viruses are frequent causes of central nervous system (CNS) infection. Lacking specific antiviral treatment or inadequate clinical response may lead to treatment with corticosteroids. This review describes the rationale for and clinical experience with the use of adjunctive corticosteroids for viral CNS infections.

RECENT FINDINGS

Corticosteroids display anti-inflammatory, immunosuppressive, antiproliferative, and vasoconstrictive effects by genomic and nongenomic regulation of human cells. Recent population-based studies consistently show that empiric dexamethasone during diagnostic work-up for meningitis has neither been associated with improved outcome nor adverse effects in viral meningitis. Myelitis is most often due to noninfectious causes and standard empiric treatment includes high-dose methylprednisolone. There are no convincing data on viral myelitis to support a change of this approach. Corticosteroids have occasionally been employed in different types of viral encephalitis. Observational data and a few randomized clinical trials have not documented any substantial beneficial effects of adjunctive corticosteroids in viral encephalitis. Risks of harm with current treatment regimens remained low in published studies.

SUMMARY

Except for myelitis, there are no data to support routine use of corticosteroids for viral CNS infections. Large, multidisciplinary syndromic platform trials of all-cause encephalitis may be a viable way to inform treatment guidelines.

A multifaceted intervention to improve diagnosis and early management of hospitalised patients with suspected acute brain infections in Brazil, India, and Malawi: an international multicentre intervention study

BACKGROUND

Brain infections pose substantial challenges in diagnosis and management and carry high mortality and morbidity, especially in low-income and middle-income countries. We aimed to improve the diagnosis and early management of patients admitted to hospital (adults aged 16 years and older and children aged >28 days) with suspected acute brain infections at 13 hospitals in Brazil, India, and Malawi.

METHODS

With hospital stakeholders, policy makers, and patient and public representatives, we co-designed a multifaceted clinical and laboratory intervention, informed by an evaluation of routine practice. The intervention, tailored for each setting, included a diagnostic and management algorithm, a lumbar puncture pack, a testing panel, and staff training. We used multivariable logistic regression and interrupted time series analysis to compare the coprimary outcomes-the percentage of patients achieving a syndromic diagnosis and the percentage achieving a microbiological diagnosis before and after the intervention. The study was registered at ClinicalTrials.gov (NCT04190303) and is complete.

FINDINGS

Between Jan 5, 2021, and Nov 30, 2022, we screened 10 462 patients and enrolled a total of 2233 patients at 13 hospital sites connected to the four study centres in Brazil, India, and Malawi. 1376 (62%) were recruited before the intervention and 857 (38%) were recruited after the intervention. 2154 patients (96%) had assessment of the primary outcome (1330 [62%] patients recruited pre-intervention and 824 [38%] recruited post-intervention). The median age across centres was 23 years (IQR 6-44), with 1276 (59%) being adults aged 16 years or older and 888 (41%) children aged between 29 days and 15 years; 1264 (59%) patients were male and 890 (41%) were female. Data on race and ethnicity were not recorded. 1020 (77%) of 1320 patients received a syndromic diagnosis before the intervention, rising to 701 (86%) of 813 after the intervention (adjusted odds ratio [aOR] 1·81 [95% CI 1·40-2·34]; p<0·0001). A microbiological diagnosis was made in 294 (22%) of 1330 patients pre-intervention, increasing to 250 (30%) of 824 patients post-intervention (aOR 1·46 [95% CI 1·18-1·79]; p=0·00040). Interrupted time series analysis confirmed that these increases exceeded a modest underlying trend of improvement over time. The percentage receiving a lumbar puncture, time to appropriate therapy, and functional outcome also improved.

INTERPRETATION

Diagnosis and management of patients with suspected acute brain infections improved following introduction of a simple intervention package across a diverse range of hospitals on three continents. The intervention is now being implemented in other settings as part of the WHO Meningitis Roadmap and encephalitis control initiatives.

FUNDING

UK National Institute for Health and Care Research.

Dexamethasone in adults with viral meningitis: an observational cohort study

OBJECTIVES

To investigate whether there is a dose-dependent association between empiric dexamethasone and outcome in viral meningitis.

METHODS

Observational cohort study of adults hospitalized for viral meningitis, both with and without a microbiologically confirmed diagnosis, in Denmark between 2015 and 2020. Dose-dependent associations between dexamethasone (one dose = 10 mg) and an unfavourable outcome (Glasgow Outcome Scale score 1-4) at 30 days after discharge were assessed using weighted logistic regression. Entropy balancing was used to compute weights.

RESULTS

Of 1025 included patients, 658 (64%) did not receive dexamethasone, 115 (11%) received 1-2 doses, 131 (13%) received 3-4 doses, and 121 (12%) received ≥5 doses. Among patients treated with dexamethasone, the median number of doses was higher for those without an identified pathogen than for those with a microbiologically confirmed viral aetiology (5 [interquartile range (IQR) 3-8] vs. 3 [IQR 2-5]; p < 0.001). Using no doses of dexamethasone as a reference, the weighted OR for an unfavourable outcome were 0.55 (95% CI, 0.29-1.07) for 1-2 doses, 1.13 (95% CI, 0.67-1.89) for 3-4 doses, and 1.43 (95% CI, 0.77-2.64) for ≥5 doses. In the subgroup of enteroviral meningitis, the weighted OR was 3.08 (95% CI, 1.36-6.94) for ≥5 doses, but decreased to 2.35 (95% CI, 0.65-8.40) when the reference group was restricted to patients treated with antibiotics for suspected bacterial meningitis.

DISCUSSION

This study showed no dose-dependent association between dexamethasone and an unfavourable outcome in patients with viral meningitis. In enteroviral meningitis, ≥5 doses were associated with an increased risk of an unfavourable outcome. However, sensitivity analysis indicated that the association was affected by unmeasured or residual confounding by severity.

Intracranial complications in adult patients with severe pneumococcal meningitis: a retrospective multicenter cohort study

BACKGROUND

We aimed to investigate the association of intracranial complications diagnosed on neuroimaging with neurological outcomes of adults with severe pneumococcal meningitis.

METHODS

We performed a retrospective multicenter study on consecutive adults diagnosed with pneumococcal meningitis requiring at least 48 h of stay in the intensive care unit (ICU) and undergoing neuroimaging, between 2005 and 2021. All neuroimaging were reanalyzed to look for intracranial complications which were categorized as (1) ischemic lesion, (2) intracranial hemorrhage (3) abscess/empyema, (4) ventriculitis, (5) cerebral venous thrombosis, (6) hydrocephalus, (7) diffuse cerebral oedema. The primary outcome was unfavorable outcome at 90 days after ICU admission, defined by a modified Rankin Scale (mRS) score > 2.

RESULTS

Among the 237 patients included, intracranial complications were diagnosed in 68/220 patients (31%, 95%CI 0.25-0.37) who underwent neuroimaging at ICU admission and in 75/110 patients (68%, 95%CI 0.59-0.77) who underwent neuroimaging during ICU stay. At 90 days, 103 patients (44%, 95%CI 37-50) had unfavorable outcome, including 71 (30%) deaths. The most frequent intracranial complications were ischemic lesion (69/237 patients, 29%), diffuse cerebral oedema (43/237, 18%) and ventriculitis (36/237, 15%). Through multivariable analysis, we found that intracranial complications (adjusted odds ratio (aOR) 2.88, 95%CI 1.37-6.21) were associated with unfavorable outcome, along with chronic alcohol consumption (aOR 3.10, 95%CI 1.27-7.90), chronic vascular disease (aOR 4.41, 95%CI 1.58-13.63), focal neurological sign(s) (aOR 2.38, 95%CI 1.11-5.23), and cerebrospinal fluid leukocyte count < 1000 cell/microL (aOR 4.24, 95%CI 2.11-8.83). Competing risk analysis, with persistent disability (mRS score 3-5) as the primary risk and ICU-death as the competing risk, revealed that chronic alcohol consumption was the sole significant variable associated with persistent disability at 90 days (cause-specific hazard ratio 4.26, 95%CI 1.83-9.91), whereas the remaining variables were associated with mortality.

CONCLUSIONS

In adults with severe pneumococcal meninigitis, intracranial complications were independently associated with a higher risk of poor functional outcome, in the form of persistent disability or death. This study highlights the value of neuroimaging studies in this population, and provides relevant information for prognostication.

Computed Tomography of the Head Before Lumbar Puncture in Adults With Suspected Meningitis in High-HIV Prevalence Settings

Background

The role of computed tomography (CT) before lumbar puncture (LP) is unclear, with limited evidence for a causal link between LP and cerebral herniation or for the ability of CT to identify individuals at risk of herniation. The risks of LP delay or deferral are potentially greater in high-HIV prevalence, resource-limited settings; we analyzed data from such a setting to determine the impact of CT on time to LP and treatment, as well as mortality.

Methods

Adults with suspected central nervous system (CNS) infection were enrolled prospectively into the Botswana National Meningitis Survey between 2016 and 2019. Inpatient mortality and clinical data including time of treatment initiation and CT were captured from medical records. Associations between preceding CT and outcomes were assessed using logistic regression.

Results

LPs were performed in 711 patients with suspected CNS infection; 27% had a CT before LP, and 73% were HIV positive. Time from admission to LP and time from admission to appropriate treatment were significantly longer in patients who had a CT before LP compared with those who did not (2.8 hours and 13.2 hours, respectively). There was some evidence for treatment delays being associated with increased mortality; however, there was no significant difference in mortality between those who had or did not have CT.

Conclusions

Patients who had a CT had delays to diagnostic LP and initiation of appropriate treatment; although treatment delays were associated with increased mortality, our observational study could not demonstrate a causal association between delays in diagnosis and treatment introduced by CT and mortality.

Management of Adults With Bacterial Meningitis in the Emergency Department

INTRODUCTION

 The Leicester Royal Infirmary Emergency Department is one of the largest single-site Emergency Departments in the UK. We evaluated the department's management of bacterial meningitis. The current national guideline recommends that all patients presenting with suspected bacterial meningitis receive antibiotics within one hour.

METHODS

A survey of 100 clinicians (Consultants, Registrars, House Officers, and Advanced Clinical Practitioners) working in the Emergency Department was performed to determine the awareness of the guidelines and a retrospective examination of case notes for patients who presented at the Leicester Royal Infirmary Emergency Department with suspected meningitis was carried out between May 1, 2022, and May 1, 2023. A random sample of 30 patients was drawn from the department's database of 190 patients, identified through discharge coding summaries.

RESULTS

Nine (25%) of the prescribers knew of the guidelines for managing meningitis, and six (16.7%) had utilised the hospital guidelines. Thirty-three (91.7%) prescribers acknowledged the importance of administering steroids to patients suspected of having bacterial meningitis (excluding those displaying signs of meningococcal sepsis, such as a rash). However, only seven (23%) of patients received this treatment. Additionally, only one (3.3%) patient was documented as having received a dose within the first hour of presentation.

CONCLUSION

The timely diagnosis and administration of appropriate antibiotic therapy are pivotal elements in managing bacterial meningitis. As a result, we designed a checklist to facilitate the effective management of meningitis within the department by increasing awareness of the guidelines and making the critical principles of suspected meningitis management more accessible.

Comparison of international guidelines for CT prior to lumbar puncture in patients with suspected meningitis

PURPOSE

To compare the performance of multiple international guidelines in selecting patients for head CT prior to lumbar puncture (LP) in suspected meningitis, focusing on identification of potential contraindications to immediate LP.

METHODS

Retrospective study of 196 patients with suspected meningitis presenting to an emergency department between March 2013 and March 2023 and undergoing head CT prior to LP. UK Joint Specialist Society Guidelines (UK), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) guidelines were evaluated by cross-referencing imaging criteria with clinical characteristics present at time of presentation. Sensitivity of each guideline for recommending neuroimaging in cases with brain shift on CT was evaluated, along with the number of normal studies and incidental or spurious findings.

RESULTS

2/196 (1%) patients had abnormal CTs with evidence of brain shift, while 14/196 (7%) had other abnormalities on CT without brain shift. UK, ESCMID and IDSA guidelines recommended imaging in 10%, 14% and 33% of cases respectively. All three guidelines recommended imaging pre-LP in 2/2 (100%) cases with brain shift. IDSA guidelines recommended more CT studies with normal findings (59 vs 16 and 24 for UK and ESCMID guidelines respectively) and CT abnormalities without brain shift (4 vs 1 and 2 respectively) than the other guidelines.

CONCLUSION

UK, ESCMID and IDSA guidelines are all effective at identifying the small cohort of patients who benefit from a head CT prior to LP. Following the more selective UK/ESCMID guidelines limits the number of normal studies and incidental or spurious CT findings.

A retrospective analysis of 20,178 adult neurological infection admissions to United Kingdom critical care units from 2001 to 2020

BACKGROUND

Neurological infection is an important cause of critical illness, yet little is known on the epidemiology of neurological infections requiring critical care.

METHODS

We analysed data on all adults with proven or probable neurological infection admitted to UK (NHS) critical care units between 2001 and 2020 reported to the Intensive Care National Audit and Research Centre. Diagnoses, physiological variables, organ support and clinical outcomes were analysed over the whole period, and for consecutive 5-year intervals within it. Predictors of in-hospital mortality were identified using a backward stepwise regression model.

RESULTS

We identified 20,178 critical care admissions for neurological infection. Encephalitis was the most frequent presentation to critical care, comprising 6725 (33.3%) of 20,178 cases. Meningitis- bacterial, viral or unspecified cases - accounted for 10,056 (49.8%) of cases. In-hospital mortality was high, at 3945/19,765 (20.0%) overall. Over the four consecutive 5-year periods, there were trends towards higher Glasgow Coma Scale scores on admission, longer critical care admissions (from median 4 [IQR 2-8] to 5 days [IQR 2-10]), and reduced in-hospital mortality (from 24.9 to 18.1%). We identified 12 independent predictors of in-hospital death which when used together showed good discrimination between patients who die and those who survive (AUC = 0.79).

CONCLUSIONS

Admissions with neurological infection to UK critical care services are increasing and the mortality, although improving, remains high. To further improve outcomes from severe neurological infection, novel approaches to the evaluation of risk stratification, monitoring and management strategies are required.

Characteristics and prognostic factors of bacterial meningitis in the intensive care unit: a prospective nationwide cohort study

BACKGROUND

Patients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study.

METHODS

We prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1-4) by multivariable logistic regression.

RESULTS

A total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49-69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high.

CONCLUSIONS

The majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome.

Adjunctive dexamethasone treatment in adults with listeria monocytogenes meningitis: a prospective nationwide cohort study

Background

A French cohort study described a detrimental effect of adjunctive dexamethasone treatment in listeria meningitis. Based on these results guidelines recommend not to use dexamethasone if L. monocytogenes is suspected or stop dexamethasone when the pathogen is detected. We studied clinical characteristics, treatment regimens and outcome of adults with Listeria monocytogenes meningitis in a nationwide cohort study on bacterial meningitis.

Methods

We prospectively assessed adults with community-acquired L. monocytogenes meningitis in the Netherlands between Jan 1, 2006, and July 1, 2022. We identified independent predictors for an unfavourable outcome (Glasgow Outcome Scale score 1 to 4) and mortality by logistic regression.

Findings

162 out of 2664 episodes (6%) of community-acquired bacterial meningitis episode were caused by L. monocytogenes in 162 patients. Adjunctive dexamethasone 10 mg QID was started with the first dose of antibiotics in 93 of 161 patients (58%) and continued for the full four days in 83 (52%) patients. Different doses, duration or timing of dexamethasone were recorded in 11 patients (7%) and 57 patients (35%) did not receive dexamethasone. The case fatality rate was 51 of 162 (31%) and an unfavourable outcome occurred in 91 of 162 patients (56%). Age and the standard regimen of adjunctive dexamethasone were independent predictors for an unfavourable outcome and mortality. The adjusted odds ratio of dexamethasone treatment for unfavourable outcome was 0.40 (95% confidence interval 0.19-0.81).

Interpretation

Adjunctive dexamethasone is associated with an improved outcome in patients with L. monocytogenes meningitis and should not be withheld if L. monocytogenes is suspected or detected as causative pathogen.

Funding

European Research Council and Netherlands Organisation for Health Research and Development.

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition.

The management of acute meningitis: an update

Meningitis remains an important cause of mortality and morbidity. Clinicians should be alert to this diagnosis and have a low threshold for investigation and treatment of meningitis. This article provides an update of current evidence and existing guidelines for the management of suspected acute meningitis in adults in the UK.