A revised clinical method for assessment of severity of acute bacterial meningitis

Risk Factors for Death and Severe Neurological Sequelae in Childhood Bacterial Meningitis

INTRODUCTION

Acute bacterial meningitis (ABM) continues to be a challenge from a diagnostic and therapeutic point of view. Identifying severity risk factors and predictive scores may guide interventions to reduce poor outcome.

METHODS

Data from a retrospective study for ABM in children admitted to the Institute of Tropical Medicine in Paraguay was analyzed. ABM was defined as positive cerebrospinal fluid culture, positive latex agglutination, or identification of microorganism by real time-polymerase chain reaction. Univariate and multivariate analyses of risk factors at hospital admission that predicted major morbidity or death during hospitalization were performed. A point-based scoring system that included variables, which were clearly different among those who passed away, was constructed.

RESULTS

One hundred fourteen children hospitalized with ABM were eligible for the study. The mean age was 46 ± 57 months (range, 1-192 months). The observed mortality was 33% (38/114 patients). When a point-based scoring system was used, for score of 0 (n = 29) and 1 (n = 12), no death was observed. Among patients with a score of 2 (n = 14), 3 (n = 10 patients), 4 (n = 12 patients), and 5 (n = 13 patients), the mortality rate was 14.3%, 40%, 50%, and 53.8%, respectively. When the score was 6 or higher, the mortality rate was at least 63.6%.

CONCLUSIONS

The present score accurately discriminated the probability of death in children hospitalized with ABM, and it could be a useful tool to select candidates for admission to the intensive care unit and for adjunctive therapy in clinical trials.

Risk Factors for Death and Major Morbidity in Guatemalan Children with Acute Bacterial Meningitis

BACKGROUND

Acute bacterial meningitis (ABM) remains a significant cause of pediatric illness and death in low and middle income countries. Identifying severity risk factors and predictive scores may guide interventions to reduce poor outcomes.

METHODS

Data from a prospective surveillance study for ABM in children aged 0-59 months admitted to 3 referral hospitals in Guatemala City from 2000 to 2007 were analyzed. ABM was defined as positive cerebrospinal fluid (CSF) culture, positive latex agglutination or CSF white blood cell greater than 100 cells/mL. Univariate and multivariate analyses of risk factors at hospital admission that predicted major morbidity or death during hospitalization were performed, along with validation of the predictive Herson-Todd score (HTS).

RESULTS

Of 809 children with ABM episodes, 221 (27.3%) survived with major morbidity and 192 (23.7%) died. Among 383 children with nonmissing data, the most significant multivariate predictors for death or major morbidity were seizure [odds ratio (OR), 101.5; P < 0.001], CSF glucose less than 20 mg/dL (OR, 5.3; P = 0.0004), symptom duration more than 3 days (OR, 3.7; P = 0.003) and coma (OR, 6.3; P = 0.004). Of 221 children with a HTS greater than 5, 204 (92%) died or suffered major morbidity (OR, 10.3; P < 0.0001).

CONCLUSION

ABM is a cause of considerable morbidity and mortality in Guatemala. Several clinical risk factors and the composite HTS predicted death or major morbidity. These predictors could help clinicians in low and middle income country guide medical care for ABM and could contribute to the public health impact assessment in preventing meningitis with vaccines.

Prognostic accuracy of five simple scales in childhood bacterial meningitis

BACKGROUND

In childhood acute bacterial meningitis, the level of consciousness, measured with the Glasgow coma scale (GCS) or the Blantyre coma scale (BCS), is the most important predictor of outcome. The Herson-Todd scale (HTS) was developed for Haemophilus influenzae meningitis. Our objective was to identify prognostic factors, to form a simple scale, and to compare the predictive accuracy of these scales.

METHODS

Seven hundred and twenty-three children with bacterial meningitis in Luanda were scored by GCS, BCS, and HTS. The simple Luanda scale (SLS), based on our entire database, comprised domestic electricity, days of illness, convulsions, consciousness, and dyspnoea at presentation. The Bayesian Luanda scale (BLS) added blood glucose concentration. The accuracy of the 5 scales was determined for 491 children without an underlying condition, against the outcomes of death, severe neurological sequelae or death, or a poor outcome (severe neurological sequelae, death, or deafness), at hospital discharge.

RESULTS

The highest accuracy was achieved with the BLS, whose area under the curve (AUC) for death was 0.83, for severe neurological sequelae or death was 0.84, and for poor outcome was 0.82. Overall, the AUCs for SLS were ≥0.79, for GCS were ≥0.76, for BCS were ≥0.74, and for HTS were ≥0.68.

CONCLUSIONS

Adding laboratory parameters to a simple scoring system, such as the SLS, improves the prognostic accuracy only little in bacterial meningitis.

Referral and previous care of children with meningitis in Nigeria: implications for the presentation and outcome of meningitis in developing countries

There is a paucity of data on the referral of children with meningitis in developing countries, and on the relationship of presentation and outcome to previous care. Referral and previous care were investigated in 281 post-neonatal children treated in two tertiary centres. Data were obtained through the review of referral notes from orthodox health facilities, interview of parents/guardians and review of admission notes. Forty-four (16%) children were facility-referred and 81 (29%) self-referred from orthodox facilities while 156 (55%) were self-referred without previous care in these facilities. The facility-referrals (n=44) included 19 (43%) with meningitis on treatment, 13 (30%) with suspected meningitis and 12 (27%) with unsuspected meningitis. Twenty-two (50%) were referred because of deterioration, partial response or non-response to treatment, 5 (11%) on request by the parents, 9 (21%) on the suspicion of meningitis or other neurological disorder and 7 (16%) for mixed reasons. No reason was given in 1 case of meningitis on treatment. Among the 19 children referred with meningitis on treatment, only 1 was referred within 24 h of diagnosis, a confirmatory lumbar puncture was done only in 7, and only 10 of 18 (no data in 1 case) were on reasonably appropriate antibiotic regimens. Previous care in orthodox facilities was significantly associated with delayed presentation (>3 days of illness, p<0.001), partial treatment (p<0.001), lack of typical signs (p<0.05), severe illness (p<0.01), and adverse outcome (death or recovery with neurological sequelae, p<0.05). Limited recognition of the possibility of meningitis in acutely ill children and an inadequate referral practice may account for these effects. A clear delineation of referral needs might reduce the magnitude of these problems.