Intensive care needs of children with acute bacterial meningitis: a developing country perspective

Global Case Fatality of Bacterial Meningitis During an 80-Year Period: A Systematic Review and Meta-Analysis

Importance

The impact of vaccination, antibiotics, and anti-inflammatory treatment on pathogen distribution and outcome of bacterial meningitis over the past century is uncertain.

Objective

To describe worldwide pathogen distribution and case fatality ratios of community-acquired bacterial meningitis.

Data Sources

Google Scholar and MEDLINE were searched in January 2022 using the search terms bacterial meningitis and mortality.

Study Selection

Included studies reported at least 10 patients with bacterial meningitis and survival status. Studies that selected participants by a specific risk factor, had a mean observation period before 1940, or had more than 10% of patients with health care-associated meningitis, tuberculous meningitis, or missing outcome were excluded.

Data Extraction and Synthesis

Data were extracted by 1 author and verified by a second author. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Random-effects models stratified by age (ie, neonates, children, adults), Human Development Index (ie, low-income or high-income countries), and decade and meta-regression using the study period's year as an estimator variable were used.

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

This review included 371 studies performed in 108 countries from January 1, 1935, to December 31, 2019, describing 157 656 episodes. Of the 33 295 episodes for which the patients' sex was reported, 13 452 (40%) occurred in females. Causative pathogens were reported in 104 598 episodes with Neisseria meningitidis in 26 344 (25%) episodes, Streptococcus pneumoniae in 26 035 (25%) episodes, Haemophilus influenzae in 22 722 (22%), other bacteria in 19 161 (18%) episodes, and unidentified pathogen in 10 336 (10%) episodes. The overall case fatality ratio was 18% (95% CI, 16%-19%), decreasing from 32% (95% CI, 24%-40%) before 1961 to 15% (95% CI, 12%-19%) after 2010. It was highest in meningitis caused by Listeria monocytogenes at 27% (95% CI, 24%-31%) and pneumococci at 24% (95% CI, 22%-26%), compared with meningitis caused by meningococci at 9% (95% CI, 8%-10%) or H influenzae at 11% (95% CI, 10%-13%). Meta-regression showed decreasing case fatality ratios overall and stratified by S pneumoniae, Escherichia coli, or Streptococcus agalactiae (P < .001).

Conclusions and Relevance

In this meta-analysis with meta-regression, declining case fatality ratios of community-acquired bacterial meningitis throughout the last century were observed, but a high burden of disease remained.

Meningococcal Disease Burden in India: A Systematic Review and Meta-Analysis

Objective

To perform systematic review and meta-analysis of meningococcal disease burden in India.

Methods

We searched publications on meningococcal disease in India between 1996 and 2020 using PubMed and Google Scholar. Prevalence (proportion) of Meningococcal meningitis and Case-fatality ratio (CFR) were pooled using random effects model. Other outcomes were pooled qualitatively.

Results

The prevalence of Meningococcal meningitis in epidemic and endemic conditions was 12.1% (95% CI: 5.2-21.4) and 0.76% (95% CI: 0.3-1.4), respectively, with a CFR of 12.8% (95% CI: 6.8-20.4) in epidemic settings; N. meningitis caused 3.2% (95% CI: 1.6-5.3) of Acute Bacterial Meningitis (ABM) cases in endemic settings. The disease appeared in infants, adolescents, and adults with Serogroup A prevalence. Treatment and prophylaxis were limited to antibiotics despite increased resistance.

Conclusion

The study reveals epidemic and endemic presence of the disease in India with high fatality and serogroup A prevalence. Further monitoring and immunization are required to prevent outbreaks.

Randomized Clinical Trial of 20% Mannitol Versus 3% Hypertonic Saline in Children With Raised Intracranial Pressure Due to Acute CNS Infections

OBJECTIVES

Mannitol is a commonly used osmotherapy agent in raised intracranial pressure. However, the side effects of mannitol are significant. In traumatic brain injury (adult and pediatric), hypertonic saline (3%) shows varied results in comparison with 20% mannitol. We compared the effect of 3% hypertonic saline versus 20% mannitol (using common dosing strategies) on raised intracranial pressure in pediatric acute CNS infections.

DESIGN

Open-label randomized controlled trial.

SETTING

PICU of a quaternary care academic institute.

PATIENTS

Children 1-12 years old, with raised intracranial pressure and modified-Glasgow Coma Scale scores less than or equal to 8, were enrolled.

INTERVENTIONS

Patients were randomly assigned to 20%-mannitol (n = 28), 0.5 gram/kg/dose versus 3%-hypertonic saline (n = 29), 10 mL/kg loading followed by 0.5-1 mL/kg/hr infusion. An intraparenchymal catheter was used to monitor the intracranial pressure. The primary outcome was the proportion of patients achieved target average intracranial pressure less than 20 mm Hg during 72 hours. Secondary outcomes were interventions, morbidity, and mortality.

MEASUREMENTS AND MAIN RESULTS

The proportion of patients with target average intracranial pressure (< 20 mm Hg) was higher in hypertonic saline-group as compared to mannitol-group (79.3% vs 53.6%; adjusted hazard ratio 2.63; 95% CI: 1.23-5.61). Mean (± SE) reduction of intracranial pressure (-14.3 ± 1.7 vs -5.4 ± 1.7 mm Hg; p ≤ 0.001) and elevation of cerebral perfusion pressure (15.4 ± 2.4 vs 6 ± 2.4 mm Hg; p = 0.007) from baseline were significant in hypertonic saline-group. Mean (± SE) intracranial pressure over 72 hours was lower (14 ± 2 vs 22 ± 2 mm Hg; p = 0.009), and cerebral perfusion pressure was higher (65 ± 2.2 vs 58 ± 2.2; p = 0.032) in hypertonic saline-group. Hypertonic saline-group had higher modified-Glasgow Coma Scale score at 72 hours (median, interquartile range 10; 7-11 vs 7; 3-9; p = 0.003), lower mortality (20.7% vs 35.7%; p = 0.21), shorter duration of mechanical ventilation (5 vs 15 d; p = 0.002), and PICU stay (11 vs 19 d; p = 0.016) and less severe neurodisability at discharge (31% vs 61%; p = 0.049).

CONCLUSIONS

In pediatric acute CNS infections, 3%-hypertonic saline was associated with a greater reduction of intracranial pressure as compared to 20% mannitol.

A Comprehensive Review of Meningococcal Disease Burden in India

INTRODUCTION

Meningococcal disease caused by Neisseria meningitidis has a high case fatality rate. Of 12 distinct serogroups, A, B, C, W-135 (W) and Y cause the majority of infections. The meningococcal disease burden and epidemiology in India are not reliably known. Hence, we performed a narrative review with a systematically conducted search to summarize information on meningococcal disease burden and epidemiology and vaccination recommendations for meningococcal disease in India.

METHODS

A search of Medline and Embase databases was undertaken to identify relevant publications published in the last 25 years.

RESULTS

Results from 32 original publications, 11 of which were case reports, suggest a significant burden of meningococcal disease and related complications. Meningococcal disease is increasingly reported among adolescents and adults, and large outbreaks have been reported in this population. Meningococcal disease in India is caused almost exclusively by serogroup A; serogroups B, C, W and Y have also been documented. Meningococcal disease burden data remain unreliable because of limited disease surveillance, insufficient laboratory capacity, misdiagnosis and prevalence of extensive antibiotic use in India. Lack of access to healthcare also increases under-reporting, thus bringing the reliability of the data into question. Conjugate meningococcal vaccines are being used for disease prevention by national governments and immunization programs globally. In India, meningococcal vaccination is recommended only for certain high-risk groups, during outbreaks and for international travelers such as Hajj pilgrims and students pursuing studies abroad.

CONCLUSION

Meningococcal disease is prevalent in India but remains grossly underestimated and under-reported. Available literature largely presents outbreak data related to serogroup A disease; however, non-A serogroup disease cases have been reported. Reliable epidemiologic data are urgently needed to inform the true burden of endemic disease. Further research into the significance of meningococcal disease burden can be used to improve public health policy in India. Fig. 1 Plain language summary.

Principles of Management of Central Nervous System Infections

CNS infections in children are medical emergency and are associated with high mortality and morbidity. For diagnosis, a high index of suspicion is required. Clinical assessment should be supplemented by laboratory investigations including CSF Gram stain and cultures, blood culture, PCR on CSF, serological tests, and imaging. Commonly associated life threatening complications include coma, seizure, raised intracranial pressure (ICP), focal deficits, shock, respiratory failure, and fluid and electrolyte abnormalities. Immediate management should first address control of airway, breathing and circulation; protocolized management of raised ICP and status epilepticus; maintaining adequate intravascular volume; and close monitoring for early detection of complications. Appropriate antimicrobial agents should be administered promptly according to the suspected pathogen. Clinical evaluation, laboratory workup, specific antimicrobial therapy, supportive treatment, and management of associated complications should go hand in hand in a protocolized way for better outcome.

Osmotic therapies added to antibiotics for acute bacterial meningitis

BACKGROUND

Every day children and adults die from acute community-acquired bacterial meningitis, particularly in low-income countries, and survivors risk deafness, epilepsy and neurological disabilities. Osmotic therapies may attract extra-vascular fluid and reduce cerebral oedema, and thus reduce death and improve neurological outcomes.This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To evaluate the effects of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults on mortality, deafness and neurological disability.

SEARCH METHODS

We searched CENTRAL (2017, Issue 1), MEDLINE (1950 to 17 February 2017), Embase (1974 to 17 February 2017), CINAHL (1981 to 17 February 2017), LILACS (1982 to 17 February 2017) and registers of ongoing clinical trials (ClinicalTrials.com, WHO ICTRP) (21 February 2017). We also searched conference abstracts and contacted researchers in the field (up to 12 December 2015).

SELECTION CRITERIA

Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results and selected trials for inclusion. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included five trials with 1451 participants. Four trials evaluated glycerol against placebo, and one evaluated glycerol against 50% dextrose; in addition three trials evaluated dexamethasone and one trial evaluated acetaminophen (paracetamol) in a factorial design. Stratified analysis shows no effect modification with steroids; we present aggregate effect estimates.Compared to placebo, glycerol probably has little or no effect on death in people with bacterial meningitis (RR 1.08, 95% CI 0.90 to 1.30; 5 studies, 1272 participants; moderate-certainty evidence), but may reduce neurological disability (RR 0.73, 95% CI 0.53 to 1.00; 5 studies, 1270 participants; low-certainty evidence).Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30; 4 studies, 1090 participants; low-certainty evidence).Glycerol may reduce the risk of subsequent deafness (RR 0.64, 95% CI 0.44 to 0.93; 5 studies, 922 participants; low to moderate-certainty evidence).Glycerol probably has little or no effect on gastrointestinal bleeding (RR 0.93, 95% CI 0.39 to 2.19; 3 studies, 607 participants; moderate-certainty evidence). The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness.

Osmotic therapies added to antibiotics for acute bacterial meningitis

BACKGROUND

Every day children and adults throughout the world die from acute community-acquired bacterial meningitis, particularly in low-income countries. Survivors are at risk of deafness, epilepsy and neurological disabilities. Osmotic therapies have been proposed as an adjunct to improve mortality and morbidity from bacterial meningitis. The theory is that they will attract extra-vascular fluid by osmosis and thus reduce cerebral oedema by moving excess water from the brain into the blood. The intention is to thus reduce death and improve neurological outcomes.

OBJECTIVES

To evaluate the effects on mortality, deafness and neurological disability of osmotic therapies added to antibiotics for acute bacterial meningitis in children and adults.

SEARCH METHODS

We searched CENTRAL 2012, Issue 11, MEDLINE (1950 to November week 3, 2012), EMBASE (1974 to November 2012), CINAHL (1981 to November 2012), LILACS (1982 to November 2012) and registers of ongoing clinical trials (April 2012). We also searched conference abstracts and contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials testing any osmotic therapy in adults or children with acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results and selected trials for inclusion. We collected data from each study for mortality, deafness, seizures and neurological disabilities. Results are presented using risk ratios (RR) and 95% confidence intervals (CI) and grouped according to whether the participants received steroids or not.

MAIN RESULTS

Four trials were included comprising 1091 participants. All compared glycerol (a water-soluble sugar alcohol) with a control; in three trials this was a placebo, and in one a small amount of 50% dextrose. Three trials included comparators of dexamethasone alone or in combination with glycerol. As dexamethasone appeared to have no modifying effect, we aggregated results across arms where both treatment and control groups received corticosteroids and where both treatment and control groups did not.Compared to placebo, glycerol may have little or no effect on death in people with bacterial meningitis (RR 1.09, 95% confidence interval (CI) 0.89 to 1.33, 1091 participants, four trials, low-quality evidence); or on death and neurological disability combined (RR 1.04, 95% CI 0.86 to 1.25).Glycerol may have little or no effect on seizures during treatment for meningitis (RR 1.08, 95% CI 0.90 to 1.30, 909 participants, three trials, low-quality evidence).Glycerol may reduce the risk of subsequent deafness (RR 0.60, 95% CI 0.38 to 0.93, 741 participants, four trials, low-quality evidence).

AUTHORS' CONCLUSIONS

The only osmotic diuretic to have undergone randomised evaluation is glycerol. Data from trials to date have not demonstrated benefit on death, but it may reduce deafness. Osmotic diuretics, including glycerol, should not be given to adults and children with bacterial meningitis unless as part of carefully conducted randomised controlled trial.

Recovery of consciousness following acute symptomatic seizures due to central nervous system infections in children

AIM

The aim of this study was to assess whether acute symptomatic epileptic seizures associated with central nervous system infections (AS(inf) ) have a different ictal and postictal course to seizures of other aetiologies.

METHOD

A case note analysis of 81 children (47 males; 34 females; age range 1mo-15y 6mo; median age 12mo) with central nervous system infections was undertaken. Seizure type, duration, aetiology, and timing were recorded. Recovery time to full consciousness in those not intubated was determined. Intubation rates and recovery times were compared with those from previous studies.

RESULTS

Of the 81 children, 40 (49.4%) had one or more AS(inf) . The different aetiologies were bacterial meningitis, aseptic meningitis, abscess/empyema, encephalitis, and postoperative infection. Twenty-two had status epilepticus. The intubation rate in children with AS(inf) was higher than that in children with seizures of other aetiologies (21/40 [52.5%] vs 4/124 [3.23%]; p < 0.0001). Median postictal recovery time was 4.33 hours (0-207h). Children with AS(inf) took 4.3 (p<0.01), 3.0 (p=0.004), and 8.8 (p<0.001) times longer to recover than children who had seizures from all causes, remote symptomatic seizures, and febrile seizures respectively.

INTERPRETATION

AS(inf) in children are often longer, more likely to be associated with status epilepticus, more likely to necessitate intubation, and take longer to recover from than seizures of other aetiologies. This may help in the early diagnosis of central nervous system infection in children presenting with seizures.

Infectious causes of seizures and epilepsy in the developing world

Central nervous system (CNS) infections are the main cause of seizures and acquired epilepsy in the developing world. Geographical variations determine the common causes in a particular region. Acute seizures are common in severe meningitis, viral encephalitis, malaria, and neurocysticercosis, and in most cases are associated with increased mortality and morbidity, including subsequent epilepsy. Neuronal excitability secondary to proinflammatory signals induced by CNS infections are an important common mechanism for the generation of seizures, in addition to various other specific mechanisms. Newer insights into the neurobiology of these infections and the associated epilepsy could help in developing neuroprotective interventions. Management issues include prompt treatment of acute seizures and the underlying CNS infection, correction of associated predisposing factors, and decisions regarding the appropriate choice and duration of antiepileptic therapy. Strategies for the prevention of epilepsy in CNS infections such as early anti-infective and anti-inflammatory therapy need scientific exploration. Prevention of CNS infections is the only definitive way forward to reduce the burden of epilepsy in developing countries.

The epidemiology of meningococcal disease in India

OBJECTIVE

To undertake a review of the literature on the epidemiology of meningococcal disease in India, with a view to informing future control policies.

METHODS

We searched the PUBMED, EMBASE, Global Health, IMSEAR and MedIND databases for observational studies relating to the burden of endemic meningococcal disease in India, the occurrence and epidemiological characteristics of epidemics, and the prevalence of individual meningococcal serogroups.

RESULTS

The relatively few reports identified suggest that the incidence of endemic meningococcal disease in India is low, but that occasional epidemics of meningococcal disease have been recorded for at least 100 years. The larger epidemics have affected mainly the cities of northern India and have almost universally been caused by meningococci belonging to serogroup A. These epidemics have showed a few characteristics, including a marked seasonality, which are similar to those of epidemic meningococcal A disease in Africa.

CONCLUSIONS

New serogroup A-containing meningococcal conjugate vaccines are now being developed and reaching the market, including an affordable monovalent serogroup A vaccine manufactured in India, but intended primarily for use in Africa. These new tools may have a role in containing future Indian epidemics, but their usefulness is dependent on early identification of epidemics. This will require a functional disease surveillance system with adequate laboratory support throughout India.

Central nervous system infection is an important cause of death in underfives hospitalised with World Health Organization (WHO) defined severe and very severe pneumonia

Over 6 years, 1667 children aged 2-59 months admitted for pneumonia [1287 severe and 380 very severe] were studied. The case fatality rate (CFR) in children with severe pneumonia was 2.1% and 14.3% with CNS infection, with very severe pneumonia the CFR was 18.9%, 10.4% in those with hypoxemia and 43.6% with CNS infection. High CFRs were associated with CNS infection and inability to drink/cyanosis. The appropriate management of children with very severe pneumonia should include cerebrospinal fluid examination, oxygen monitoring and possibly ventilated support, suggesting that these are minimal standards of care at the district hospital.

Serum cortisol levels in children with acute bacterial and aseptic meningitis

OBJECTIVE

To study serum cortisol levels in acute childhood meningitis with respect to the severity of illness and the outcome.

DESIGN

Prospective observational study.

SETTING

Pediatric services of a tertiary care teaching and referral hospital.

SUBJECTS

A total of 30 consecutive children, 2 months to 12 yrs of age, with suspected bacterial meningitis.

METHODS

Serum cortisol levels (by enzyme-linked immunosorbent assay) obtained at admission were correlated with clinical characteristics (including Glasgow Coma Scale and Pediatric Risk of Mortality scores) recorded at admission and with neurologic and hearing status 2 months after discharge using SPSS 10.0.

RESULTS

Mean +/- sd serum cortisol was 467 +/- 251 ng/dL in patients with bacterial (n = 16) and 319 +/- 159 ng/dL in aseptic meningitis (n = 14, p = .068). Glasgow coma scale score, systolic blood pressure, age, Pediatric Risk of Mortality, and cerebrospinal fluid protein were significant independent predictors of serum cortisol on stepwise multivariate regression analysis (each had an R change of >5%). Patients with neurologic or hearing sequelae had significantly higher median serum cortisol (450 ng/mL, n = 12) than those without sequelae (300 ng/mL, n = 17; p = .043 by Mann-Whitney U test). On multivariate logistic regression analysis, a serum cortisol of >/=420 ng/mL (odds ratio, 0.022; 95% confidence interval, 0.01-0.43) and systolic blood pressure (odds ratio, 1.35; 95% confidence interval, 1.04-1.74) were significant independent predictors of neurologic and hearing sequelae.

CONCLUSION

Low serum cortisol is uncommon in acute bacterial meningitis of nonmeningococcal pathogenesis. Very high levels are likely to be associated with sequelae.