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Mbakwe PL, Roine I, Cruzeiro ML, Kallio M, Peltola H, Pelkonen T. Clinical Picture and Risk Factors for Poor Outcome in Streptococcus pneumoniae Meningitis of Childhood on Three Continents. Pediatr Infect Dis J 2024; 43:415-419. [PMID: 38359336 PMCID: PMC11003404 DOI: 10.1097/inf.0000000000004265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
| | - Irmeli Roine
- Faculty of Medicine, University Diego Portales, Santiago, Chile
| | | | - Markku Kallio
- Department of Pediatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heikki Peltola
- Department of Pediatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuula Pelkonen
- Serviço de Neuroinfecciologia, Hospital Pediátrico David Bernardino, Luanda, Angola
- Department of Pediatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- New Children’s Hospital, Pediatric Research Center, Helsinki, Finland
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Yang Y, Hu Y, Yang C, Shi W, Jin S, Hua C, Jiang K. Development and validation of a novel multiplex digital PCR assay for identification of pathogens in cerebrospinal fluid of children with bacterial meningitis. Clin Chim Acta 2024; 554:117787. [PMID: 38246212 DOI: 10.1016/j.cca.2024.117787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND AIMS Identifying the pathogens of bacterial meningitis (BM) is crucial for its diagnosis and treatment. The aim of this study is to develop and validate a novel method for detecting pathogens in cerebrospinal fluid (CSF) of children with BM using a digital polymerase chain reaction (dPCR) assay. MATERIALS AND METHODS A novel multiplex dPCR assay method has been developed and validated. The diagnostic performance of the dPCR assay was compared with that of synchronous CSF culture, and the factors affecting its performance were analyzed. RESULTS A total of 69 children with BM were enrolled prospectively. The sensitivity of the dPCR assay was 94.44 %, specificity was 100 %, coincidence rate was 98.55 %, Kappa value was 0.959, and net reclassification improvement was 61.11 %. Compared with the CSF culture assay, the dPCR assay had higher sensitivity in different bacterial groups. Multiple factors affected its performance, including previous use of antibiotics, sampling time, BM complications, and levels of inflammatory biomarkers in CSF and blood (all P < 0.05). Patients who required intensive care and died had a higher bacterial DNA loads identified by dPCR assay (both P < 0.05). CONCLUSION This novel assay has better pathogen detection ability than CSF culture. Its performance was influenced by sampling time, previous use of antibiotics, and disease severity.
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Affiliation(s)
- Ying Yang
- Department of Infectious Diseases, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Yiting Hu
- Department of Child Psychology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Cheng Yang
- Clinical Laboratory Center, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Wen Shi
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China.
| | - Sufeng Jin
- Clinical Laboratory Center, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Chunzhen Hua
- Department of Infectious Diseases, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
| | - Kewen Jiang
- Department of Child Psychology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, China.
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Importance of underweight in childhood bacterial meningitis in Finland, Latin America and Angola. Sci Rep 2022; 12:10929. [PMID: 35768574 PMCID: PMC9243085 DOI: 10.1038/s41598-022-15131-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 06/20/2022] [Indexed: 11/08/2022] Open
Abstract
Our objective was to explore the importance of underweight on the course of childhood bacterial meningitis (BM) at different study sites, because prior studies showed discrepant results. Using directly comparable, prospective data from three continents, weight-for-age z-scores (WAZ) were determined by WHO Anthro programs in children with BM in Finland (N = 318), LatAm (N = 580), and Angola (N = 780) and compared with data describing the admission, course, and outcome of BM. WAZ < –1 indicates underweight; either mild (< –1 to –2), moderate (< –2 to –3), or severe (< –3). The mean WAZ (SD) was 0.17 (1.17), –0.42 (1.53), and –1.36 (1.44), and the prevalence of moderate-severe underweight 2.8%, 12.6%, and 31.3%, in Finland, LatAm, and Angola, respectively. In univariate analysis, LatAm and Angola showed an association between lower WAZ and poorer condition on admission, slower recovery, and more deaths. In Finland, infrequent underweight limited meaningful analysis. In multivariate analysis of different variables for increasing the odds of death, severe underweight had lower odds compared to disease severity in Angola, but highest in LatAm. Thus, the apparent discrepancy in underweights´ importance for increasing deaths varied from primary to more secondary according to locally more prominent risks.
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Pelkonen T, Roine I, Kallio M, Jahnukainen K, Peltola H. Prevalence and significance of anaemia in childhood bacterial meningitis: a secondary analysis of prospectively collected data from clinical trials in Finland, Latin America and Angola. BMJ Open 2022; 12:e057285. [PMID: 35288394 PMCID: PMC8921951 DOI: 10.1136/bmjopen-2021-057285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To describe the prevalence and severity of anaemia and to examine its associations with outcome in children with bacterial meningitis (BM). DESIGN Secondary analysis of descriptive data from five randomised BM treatment trials. SETTING Hospitals in Finland, Latin America and Angola. PARTICIPANTS Consecutive children from 2 months to 15 years of age admitted with BM and who had haemoglobin (Hb) measured on admission. OUTCOME MEASURES Prevalence and degree of anaemia using the WHO criteria, and their associations with recovery with sequelae or death. RESULTS The median Hb was 11.8 g/dL in Finland (N=341), 9.2 g/dL in Latin America (N=597) and 7.6 g/dL in Angola (N=1085). Of the children, 79% had anaemia, which was severe in 29%, moderate in 58% and mild in 13% of cases. Besides study area, having anaemia was independently associated with age <1 year, treatment delay >3 days, weight-for-age z-score <-3 and other than meningococcal aetiology. Irrespective of the study area, anaemia correlated with the markers of disease severity. In children with severe to moderate anaemia (vs mild or no anaemia), the risk ratio for death was 3.38 and for death or severe sequelae was 3.07. CONCLUSION Anaemia, mostly moderate, was common in children with BM, especially in Angola, in underweight children, among those with treatment delay, and in pneumococcal meningitis. Poor outcome was associated with anaemia in all three continents. TRIAL REGISTRATION NUMBER The registration numbers of Angolan trials were ISRCTN62824827 and NCT01540838.
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Affiliation(s)
- Tuula Pelkonen
- New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Pediatric Research Center, Helsinki, Finland
- Hospital Pediátrico David Bernardino, Luanda, Angola
| | - Irmeli Roine
- Faculty of Medicine, University Diego Portales, Santiago, Chile
| | - Markku Kallio
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kirsi Jahnukainen
- New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Pediatric Research Center, Helsinki, Finland
| | - Heikki Peltola
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Outcome of childhood bacterial meningitis on three continents. Sci Rep 2021; 11:21593. [PMID: 34732790 PMCID: PMC8566566 DOI: 10.1038/s41598-021-01085-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022] Open
Abstract
Our objective was to quantify the differences in the outcomes from childhood bacterial meningitis (BM) and to describe the factors associated with them in different parts of the world. This study is a secondary analysis of prospectively collected data from five clinical BM trials conducted in Finland, Latin America (LatAm), and Angola between 1984 and 2017. As all data were collected uniformly, direct comparison of the series was possible. Associations between patient characteristics and death or dismal outcome—the triad of death, severe neurological sequelae, or deafness—were explored. In all, data on 2123 children with BM were analyzed. Etiology was confirmed in 95%, 83%, and 64%, in Finland, LatAm and Angola, respectively. The leading agents were Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis. Dismal outcome was the end result for 54%, 31%, and 5% of children in Angola, LatAm, and Finland, respectively. Although underweight, anemia, and tardy arrival worsened prognoses in Angola and LatAm, it was the presenting condition that was central in terms of outcome. In multivariate analysis, the factors independently associated with dismal outcome were the study site (Angola vs. Finland, OR 11.91, 95% CI 5.54–25.63, p < 0.0001 or LatAm vs. Finland, OR 9.46, 95% CI 4.35–20.61, p < 0.0001), Glasgow Coma Score < 13 (OR 4.58, 95% CI 3.31–6.32, p < 0.0001), seizures (OR 1.96, 95% CI 1.43–2.69), age < 1 year (OR 1.55, 95% CI 1.13–2.14, p = 0.007), and pneumococcal etiology (OR 1.49, 95% CI 1.08–2.06, p = 0.015). Greatly dissimilar outcomes from BM reflected the findings on admission on all three continents. Optimizing growth, preventing anemia, and prompt treatment may improve outcomes in resource poor areas.
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Wang G, Fu Y, Ma K, Liu J, Liu X. NOD2 regulates microglial inflammation through the TAK1-NF-κB pathway and autophagy activation in murine pneumococcal meningitis. Brain Res Bull 2020; 158:20-30. [PMID: 32109527 DOI: 10.1016/j.brainresbull.2020.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/16/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
Streptococcus pneumoniae is responsible for pneumococcal meningitis, with significant mortality and morbidity worldwide. Microglial inflammation plays a vital role in meningitis. The peptidoglycan sensor NOD2 (nucleotide-binding oligomerization domain 2) has been identified to promote microglia activation, but the role in autophagy following pneumococcal meningitis remains unclear. In the present study, we investigated the role of NOD2 in microglial inflammation and autophagy, as well as related signaling pathways, during S. pneumonia infection. NOD2 expression was knocked down by the injection of lentivirus-mediated short-hairpin RNA (shRNA). Our results revealed that NOD2 promotes microglial inflammation by increasing inflammatory mediators. We also showed that the TAK1-NF-κB pathway is involved in this process. In addition, NOD2 increased the expression of autophagy-related proteins and induced autophagosome formation. Rapamycin and 3-MA were utilized to assess the role of autophagy in microglial inflammation induced by S. pneumonia. We demonstrated that autophagy serves as a cellular defense mechanism to reduce inflammatory mediators. Similar to the in vitro results, NOD2 induced inflammation and autophagy in the brain in a mouse meningitis model. Moreover, NOD2 silencing significantly reduced brain edema and improved the neurological function of pneumococcal meningitis mice. Taken together, these data demonstrate that NOD2 promotes microglial inflammation and autophagy in murine pneumococcal meningitis, and the TAK1-NF-κB pathway is involved in microglial activation.
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Affiliation(s)
- Guan Wang
- Department of Pediatrics, Qilu Hospital, Shandong University, 107#, Wen Hua Xi Road, Jinan, Shandong, 250012, PR China
| | - Yanan Fu
- Qilu Hospital, Shandong University, 107#, Wen Hua Xi Road, Jinan, Shandong, 250012, PR China
| | - Kun Ma
- Department of Pediatrics, Shandong Provincial Qianfoshan Hospital, The Frist Hospital Affiliated with Shandong First Medical University, 16766#, Jing Shi Road, Jinan, Shandong, 250014, PR China
| | - Junli Liu
- Department of Pediatrics, Taian Central Hospital, 29#, Long Tan Road, Taian, Shandong, 271000, PR China
| | - Xinjie Liu
- Department of Pediatrics, Qilu Hospital, Shandong University, 107#, Wen Hua Xi Road, Jinan, Shandong, 250012, PR China.
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Wall ECB, Ajdukiewicz KMB, Bergman H, Heyderman RS, Garner P. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev 2018; 2:CD008806. [PMID: 29405037 PMCID: PMC5815491 DOI: 10.1002/14651858.cd008806.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Emma CB Wall
- University College LondonDivision of Infection and ImmunityGower StreetLondonUKWC1E 6BT
| | - Katherine MB Ajdukiewicz
- Pennine Acute Hospitals NHS TrustDepartment of Infectious DiseasesNorth Manchester General HospitalDelaunays Road, CrumpsallManchesterUKMB 5RB
| | - Hanna Bergman
- CochraneCochrane ResponseSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Robert S Heyderman
- University of Malawi College of MedicineMalawi‐Liverpool‐Wellcome Clinical Research ProgrammeP. O Box 30096BlantyreChichiriMalawi
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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Hou C, Zhu X, Chang X. Correlation of vitamin D receptor with bronchial asthma in children. Exp Ther Med 2018; 15:2773-2776. [PMID: 29456680 PMCID: PMC5795668 DOI: 10.3892/etm.2018.5739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/11/2017] [Indexed: 12/21/2022] Open
Abstract
This study was designed to investigate the correlation of vitamin D receptor (VDR) gene polymorphism with bronchial asthma in children. Seventy patients admitted to Daqing Longnan Hospital and diagnosed as bronchial asthma for the first time from April 2015 to May 2017 were selected as observation group. Patients received routine treatment and intervention. Seventy healthy subjects admitted to hospital during the same period were enrolled as the control group. Vitamin D gene polymorphism was detected by polymerase chain reaction-restriction fragment length polymorphism assay; the levels of total serum immunoglobulin E (IgE) in the two groups were determined by electrochemiluminescence immunoassay; lung function levels in patients were measured using PowerCube (Germany) pulmonary function instrument before and after treatment, and the relationship between VDR gene polymorphism and lung function in children with bronchial asthma was analyzed. The difference in comparison of base frequency of rs1544410 locus of VDR gene had no statistical significance between the two groups (P>0.05). The locus CC frequency of rs7975232 of VDR gene in observation group was lower in the observation group than that in the control group (P<0.05); the locus AC and AA frequencies of rs7975232 of VDR gene were higher in the observation group than those in the control group (P<0.05). The level of vitamin D was lower in the observation group than that in the control group (P<0.05); the level of total serum IgE was higher in the observation group than that in the control group (P<0.05). The forced expiratory volume in 1 sec (FEV1), peak expiratory flow (PEF) and the ratio of FEV1 to forced vital capacity (FVC) in children with bronchial asthma in the observation group were higher after treatment than those before treatment (P<0.05). The correlation research displayed that VDR gene polymorphism was negatively correlated with lung function levels in children with bronchial asthma (P<0.05). The results showed that children with bronchial asthma are often accompanied by different degrees of changes in VDR gene polymorphism, which is negatively correlated with the severity of asthma, so vitamin D should be strengthened to ameliorate the prognosis of children.
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Affiliation(s)
- Chunlei Hou
- Department of Pediatrics, Daqing Longnan Hospital, Daqing, Heilongjiang 163453, P.R. China
| | - Xiaoli Zhu
- Department of Pediatrics, Daqing Longnan Hospital, Daqing, Heilongjiang 163453, P.R. China
| | - Xiangyun Chang
- Department of Pediatrics, Daqing Longnan Hospital, Daqing, Heilongjiang 163453, P.R. China
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Abstract
PURPOSE OF REVIEW The purpose of this review is to give an overview of viral meningitis and then focus in on some of the areas of uncertainty in diagnostics, treatment and outcome. RECENT FINDINGS Bacterial meningitis has been declining in incidence over recent years. Over a similar time period molecular diagnostics have increasingly been used. Because of both of these developments viral meningitis is becoming relatively more important. However, there are still many unanswered questions. Despite improvements in diagnostics many laboratories do not use molecular methods and even when they are used many cases still remain without a proven viral aetiology identified. There are also no established treatments for viral meningitis and the one potential treatment, aciclovir, which is effective in vitro for herpes simplex virus, has never been subjected to a clinical trial. SUMMARY Viruses are in increasingly important cause of meningitis in the era of declining bacterial disease. The exact viral aetiology varies according to age and country. Molecular diagnostics can not only improve the rate of pathogen detection but also reduce unnecessary antibiotics use and length of hospitalization. Further research is required into treatments for viral meningitis and the impact in terms of longer term sequelae.
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Clinical and pathogenic analysis of 507 children with bacterial meningitis in Beijing, 2010-2014. Int J Infect Dis 2016; 50:38-43. [PMID: 27452172 DOI: 10.1016/j.ijid.2016.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To explore the clinical characteristics and analyze the pathogens of bacterial meningitis in children. METHODS Bacterial meningitis cases occurring from January 2010 through December 2014 at Beijing Children's Hospital were reviewed retrospectively. The records of all patients, including data on clinical features and laboratory information, were obtained and analyzed. RESULTS In total, the cases of 507 pediatric patients seen over a 5-year period were analyzed; 220 of these cases were etiologically confirmed. These patients were classified into four age groups: 29 days to 1 year (n=373, 73.6%), 1-3 years (n=61, 12.0%), 3-6 years (n=41, 8.1%), and >6 years (n=32, 6.3%). The main pathogens identified in this study were Streptococcus pneumoniae (n=73, 33.2%), Escherichia coli (n=24, 10.9%), Enterococcus (n=22, 10.0%), and group B Streptococcus (n=18, 8.2%). All Gram-positive bacteria were sensitive to vancomycin and linezolid. All Gram-negative bacteria were sensitive to meropenem. The total non-susceptibility rate of S. pneumoniae to penicillin was 47.6% (20/42). The resistance rates to ceftriaxone, cefepime, and ceftazidime were 75% (9/12), 55.6% (5/9), and 40% (4/10), respectively. CONCLUSIONS The main pathogen of bacterial meningitis in this study was S. pneumoniae. The antibiotic resistance rates among children with bacterial meningitis are of serious concern.
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Abstract
BACKGROUND In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response. OBJECTIVES To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis. SEARCH METHODS We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015), EMBASE (1974 to February 2015), Web of Science (2010 to February 2015), CINAHL (2010 to February 2015) and LILACS (2010 to February 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality. MAIN RESULTS We included 25 studies involving 4121 participants (2511 children and 1517 adults; 93 mixed population). Four studies were of high quality with no risk of bias, 14 of medium quality and seven of low quality, indicating a moderate risk of bias for the total analysis. Nine studies were performed in low-income countries and 16 in high-income countries.Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P value = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P value = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events. AUTHORS' CONCLUSIONS Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
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Affiliation(s)
- Matthijs C Brouwer
- Academic Medical Center University of AmsterdamDepartment of Neurology, Center for Infection and Immunity Amsterdam (CINIMA)P.O. Box 22660AmsterdamNetherlands1100 DE
| | - Peter McIntyre
- Children's Hospital at Westmead and University of SydneyNational Centre for Immunisation Research and Surveillance of Vaccine Preventable DiseasesLocked Bag 4001WestmeadSydneyNSWAustralia2145
| | - Kameshwar Prasad
- All India Institute of Medical Sciences (AIIMS)Department of NeurologyAnsarinagarNew DelhiIndia110029
| | - Diederik van de Beek
- University of AmsterdamDepartment of Neurology, Academic Medical CentreP.O. Box 22660AmsterdamNetherlands1100 DE
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Li Y, Yin Z, Shao Z, Li M, Liang X, Sandhu HS, Hadler SC, Li J, Sun Y, Li J, Zou W, Lin M, Zuo S, Mayer LW, Novak RT, Zhu B, Xu L, Luo H. Population-based surveillance for bacterial meningitis in China, September 2006-December 2009. Emerg Infect Dis 2014; 20:61-9. [PMID: 24377388 PMCID: PMC3884703 DOI: 10.3201/eid2001.120375] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
During September 2006-December 2009, we conducted active population and sentinel laboratory-based surveillance for bacterial meningitis pathogens, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b, in 4 China prefectures. We identified 7,876 acute meningitis and encephalitis syndrome cases, including 6,388 among prefecture residents. A total of 833 resident cases from sentinel hospitals met the World Health Organization case definition for probable bacterial meningitis; 339 of these cases were among children <5 years of age. Laboratory testing confirmed bacterial meningitis in 74 of 3,391 tested cases. The estimated annual incidence (per 100,000 population) of probable bacterial meningitis ranged from 1.84 to 2.93 for the entire population and from 6.95 to 22.30 for children <5 years old. Active surveillance with laboratory confirmation has provided a population-based estimate of the number of probable bacterial meningitis cases in China, but more complete laboratory testing is needed to better define the epidemiology of the disease in this country.
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Abstract
BACKGROUND In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response. OBJECTIVES To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis. SEARCH METHODS We searched CENTRAL 2012, Issue 12, MEDLINE (1966 to January week 2, 2013), EMBASE (1974 to January 2013), Web of Science (2010 to January 2013), CINAHL (2010 to January 2013) and LILACS (2010 to January 2013). SELECTION CRITERIA Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality. MAIN RESULTS Twenty-five studies involving 4121 participants were included. Corticosteroids were associated with a non-significant reduction in mortality (17.8% versus 19.9%; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.80 to 1.01, P = 0.07). A similar non-significant reduction in mortality was observed in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.74, 95% CI 0.63 to 0.87) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S. pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98), but not in Haemophilus influenzae (H. influenzae) orNeisseria meningitidis (N. meningitidis) meningitis. Corticosteroids reduced severe hearing loss in children with H. influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) but not in children with meningitis due to non-Haemophilus species.In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high-quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events. AUTHORS' CONCLUSIONS Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
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Affiliation(s)
- Matthijs C Brouwer
- Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center University ofAmsterdam, Amsterdam, Netherlands
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Namani S, Milenković Z, Koci B. A prospective study of risk factors for neurological complications in childhood bacterial meningitis. J Pediatr (Rio J) 2013; 89:256-62. [PMID: 23664199 DOI: 10.1016/j.jped.2012.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 10/31/2012] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To prospectively analyze the prognostic factors for neurological complications of childhood bacterial meningitis. METHODS This prospective study enrolled 77 children from 1 month until 16 years of age, treated for bacterial meningitis during the period of January 1, 2009 through December 31, 2010. 16 relevant predictors were chosen to analyze their association with the incidence of neurological complications. p-values < 0.05 were considered statistically significant. RESULTS Of the 77 children treated for bacterial meningitis, 33 patients developed neurological complications (43%), and two children died (2.6%). The etiology of bacterial meningitis cases was proven in 57/77 (74%) cases: 32 meningococci, eight pneumococci, six Gram-negative bacilli, five H. influenzae, five staphylococci, and one S. viridans isolates were found. Factors found to be associated with increased risk of development of neurological complications were age < 12 months, altered mental status, seizures prior to admission, initial therapy with two antibiotics, dexamethasone use, presence of focal neurological deficit on admission and increased proteins in cerebrospinal fluid (CSF) (p < 0.05). Initial pleocytosis > 5,000 cells/mm(3), pleocytosis > 5,000 cells/mm(3) after 48 hours, CSF/blood glucose ratio < 0.20, female gender, previous treatment with antibiotics, community-acquired infection, duration of illness > 48 hours, presence of comorbidity, and primary focus of infection were not associated with increased risk for the development of neurological complications. CONCLUSION Age < 12 months and severity of clinical presentation at admission were identified as the strongest predictors of neurological complications and may be of value in selecting patients for more intensive care and treatment.
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Affiliation(s)
- Sadie Namani
- Infectious Diseases Clinic, University Clinical Center of Kosovo, Medical Faculty, University of Prishtina, Kosovo.
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Wall ECB, Ajdukiewicz KMB, Heyderman RS, Garner P. Osmotic therapies added to antibiotics for acute bacterial meningitis. Cochrane Database Syst Rev 2013; 3:CD008806. [PMID: 23543568 PMCID: PMC3996551 DOI: 10.1002/14651858.cd008806.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Emma C B Wall
- International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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McCormick DW, Wilson ML, Mankhambo L, Phiri A, Chimalizeni Y, Kawaza K, Denis B, Carrol ED, Molyneux EM. Risk factors for death and severe sequelae in Malawian children with bacterial meningitis, 1997-2010. Pediatr Infect Dis J 2013; 32:e54-61. [PMID: 22914560 PMCID: PMC3671939 DOI: 10.1097/inf.0b013e31826faf5a] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute bacterial meningitis (ABM) causes significant death and disability in children worldwide, with HIV recognized as an established risk factor for infection and negative outcomes. However, additional major risk factors for death and disability in pediatric ABM remain unclear. METHODS We conducted a retrospective analysis of case data from 3 departmental studies of ABM involving 1784 children <15 years old who attended Queen Elizabeth Central Hospital in Blantyre, Malawi during 1997 to 2010. Univariate and multivariate logistic regression models were used to estimate the effects of HIV seropositivity, impaired consciousness and causative organism on death and severe sequelae. RESULTS Impaired consciousness or coma at the time of admission was strongly associated with death (coma: odds ratio [OR] = 14.4, 95% confidence interval [CI]: 9.42, 22.1) and severe sequelae (Coma: OR = 3.27, 95% CI: 2.02, 5.29) in multivariate logistic regression models. HIV seropositivity was significantly associated with increased odds of death (OR = 1.65, 95% CI: 1.20, 2.26) but not with developing severe sequelae (OR = 0.88, 95% CI: 0.56, 1.38). After adjustment, infection with Salmonella spp. was associated with increased odds of death (OR = 2.11, 95% CI: 1.06, 4.08) and pneumococcal meningitis was associated with increased odds of severe sequelae (OR = 1.84, 95% CI: 1.03, 3.29). CONCLUSIONS Impaired consciousness and HIV infection increased the odds of death from ABM in Malawian children. Use of pneumococcal conjugate vaccine could greatly reduce the burden of ABM in Malawi.
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Affiliation(s)
- David W McCormick
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
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Prats JAGG, Gaspar AJ, Ribeiro ABG, Paula GDD, Boas LVDSPV, Sá FPD. Revisão sistemática do uso da dexametasona como terapia adjuvante na meningite bacteriana em crianças. REVISTA PAULISTA DE PEDIATRIA 2012. [DOI: 10.1590/s0103-05822012000400018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Analisar a melhor evidência disponível nos últimos 15 anos com relação aos benefícios da terapia adjuvante com dexametasona na meningite bacteriana em população pediátrica. FONTES DE DADOS: Das bases de dados Medline, Lilacs e SciELO, foram analisados ensaios clínicos randomizados de 1996 a 2011, os quais comparavam a dexametasona ao placebo e/ou a outra terapia adjuvante em pacientes com meningite bacteriana diagnosticada laboratorialmente por critérios quimiocitológicos e/ou bacteriológicos, na faixa etária de 29 dias aos 18 anos. Os desfechos avaliados foram mortalidade e ocorrência de sequelas neurológicas e/ou auditivas. Foram excluídos estudos relacionados à meningite tuberculosa. SÍNTESE DOS DADOS: Com os critérios utilizados, foram identificadas cinco publicações correspondentes a quatro protocolos de estudo. Nenhum dos estudos mostrou diferenças entre a dexametasona e o placebo para os desfechos avaliados. Os estudos analisados tiveram alta qualidade (escore de Jadad et al=5). CONCLUSÕES: As evidências encontradas na literatura são insuficientes para indicar de forma rotineira o uso da dexametasona como terapia adjuvante para redução de mortalidade, perda auditiva e sequelas neurológicas em pacientes pediátricos com meningite bacteriana não tuberculosa.
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Wolzak NK, Cooke ML, Orth H, van Toorn R. The changing profile of pediatric meningitis at a referral centre in Cape Town, South Africa. J Trop Pediatr 2012; 58:491-5. [PMID: 22791086 DOI: 10.1093/tropej/fms031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Pediatric meningitis remains a common cause of childhood morbidity and mortality in developing countries. Knowledge of the causative organisms in a region is of importance in guiding empiric antibiotic regimes and immunization schedules assisting decisions on primary health-care interventions. METHODS This retrospective review of 557 meningitis cases represents a third pediatric survey conducted over a 3-year period (January 2007 to December 2009) at the same institution and after an interval of 14 years. Cases were identified using cerebrospinal fluid results. Demographic and laboratory variables were collected and meningitis was classified as aseptic/viral, bacterial, septic, tuberculous meningitis (TBM) or fungal. RESULTS The commonest form of bacterial meningitis was TBM diagnosed in 22% (n = 126) of children. Streptococcus pneumoniae 4% (n = 23) and Klebsiella pneumoniae 3% (n = 17) were the next commonest causes of bacterial meningitis diagnosed. Haemophilus influenzae meningitis occurred in <1% (n = 3) of cases with a median age of 3 months. Aseptic meningitis remains the commonest category. Human immunodeficiency virus (HIV) testing was requested in 43% (n = 241) of cases; 8% (n = 46) were positive. CONCLUSION TBM remains the commonest cause of pediatric bacterial meningitis in the Western Cape. It is concerning that the percentage of TBM cases out of the total study population has more than doubled compared with that in previous surveys. The low prevalence and young age of H. influenzae meningitis cases confirm the benefits derived from H. influenzae type b (Hib) vaccination.
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Affiliation(s)
- Nena Katrina Wolzak
- Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
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Pace D, Pollard AJ. Meningococcal disease: clinical presentation and sequelae. Vaccine 2012; 30 Suppl 2:B3-9. [PMID: 22607896 DOI: 10.1016/j.vaccine.2011.12.062] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 12/10/2011] [Accepted: 12/13/2011] [Indexed: 10/28/2022]
Abstract
The clinical spectrum of invasive meningococcal disease is diverse with meningitis and/or septicaemia being the commonest modes of presentation. The severity of manifestations of meningococcal infection ranges from bacteraemia, associated with mild non-specific symptoms, to fulminant sepsis with multiorgan failure and death in approximately 10-15% of cases. Localised infections (such as conjunctivitis or septic arthritis) as well as chronic disease may be the sole clinical manifestations but can also lead to disseminated fulminant disease. Among survivors, disabling long-term sequelae can complicate meningococcal disease and result in potentially devastating effects on the quality of life of survivors, most of whom are infants, children and adolescents. The only rational approach to the prevention of meningococcal disease and the associated human suffering is through vaccination.
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Affiliation(s)
- David Pace
- Department of Paediatrics, Mater Dei Hospital, Tal-Qroqq, Msida, MSD 2090, Malta.
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Factors influencing neurological outcome of children with bacterial meningitis at the emergency department. Eur J Pediatr 2012; 171:1365-71. [PMID: 22527566 DOI: 10.1007/s00431-012-1733-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 03/28/2012] [Indexed: 10/28/2022]
Abstract
We performed a cohort study of children who survived bacterial meningitis after the neonatal period at a single pediatric center in France over a 10-year period (1995-2004) to identify predictors of death and long-term neurological deficits in children with bacterial meningitis. We performed multivariate regression to determine independent predictors of death and neurologic deficits. We identified 101 children with bacterial meningitis of which 19 died during initial hospitalization. Need for mechanical ventilation [hazard ratio (HR) 11.5, 95 % confidence interval (CI) 2.4-55.5)] and thrombocytopenia defined as a platelet count <150 × 10(9) per liter (HR 0.6, 95 % CI 0.4-0.9) at presentation were associated with death during initial hospitalization. At final assessment, 42 of the 70 survivors had no neurologic deficits identified; 20 had a single deficit, and eight had multiple deficits. A delay in initiation of antibiotics (HR 1.3, 95 % CI 1.1-1.7) and hydrocephalus on computed tomographic scan (HR 2.6, 95 % CI 1.1-6.0) were associated with having one or more long-term neurologic deficits. Identification of children at risk of death or long-term neurologic sequelae may allow therapeutic interventions to be directed to children at the highest risk.
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Ho Dang Trung N, Le Thi Phuong T, Wolbers M, Nguyen Van Minh H, Nguyen Thanh V, Van MP, Thieu NTV, Le Van T, Song DT, Le Thi P, Thi Phuong TN, Van CB, Tang V, Ngoc Anh TH, Nguyen D, Trung TP, Thi Nam LN, Kiem HT, Thi Thanh TN, Campbell J, Caws M, Day J, de Jong MD, Van Vinh CN, Van Doorn HR, Tinh HT, Farrar J, Schultsz C. Aetiologies of central nervous system infection in Viet Nam: a prospective provincial hospital-based descriptive surveillance study. PLoS One 2012; 7:e37825. [PMID: 22662232 PMCID: PMC3360608 DOI: 10.1371/journal.pone.0037825] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 04/24/2012] [Indexed: 11/19/2022] Open
Abstract
Background Infectious diseases of the central nervous system (CNS) remain common and life-threatening, especially in developing countries. Knowledge of the aetiological agents responsible for these infections is essential to guide empiric therapy and develop a rational public health policy. To date most data has come from patients admitted to tertiary referral hospitals in Asia and there is limited aetiological data at the provincial hospital level where most patients are seen. Methods We conducted a prospective Provincial Hospital-based descriptive surveillance study in adults and children at thirteen hospitals in central and southern Viet Nam between August 2007– April 2010. The pathogens of CNS infection were confirmed in CSF and blood samples by using classical microbiology, molecular diagnostics and serology. Results We recruited 1241 patients with clinically suspected infection of the CNS. An aetiological agent was identified in 640/1241 (52%) of the patients. The most common pathogens were Streptococcus suis serotype 2 in patients older than 14 years of age (147/617, 24%) and Japanese encephalitis virus in patients less than 14 years old (142/624, 23%). Mycobacterium tuberculosis was confirmed in 34/617 (6%) adult patients and 11/624 (2%) paediatric patients. The acute case fatality rate (CFR) during hospital admission was 73/617 (12%) in adults and to 42/624 (7%) in children. Conclusions Zoonotic bacterial and viral pathogens are the most common causes of CNS infection in adults and children in Viet Nam.
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Affiliation(s)
- Nghia Ho Dang Trung
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
- * E-mail:
| | - Tu Le Thi Phuong
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Marcel Wolbers
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Hoang Nguyen Van Minh
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Vinh Nguyen Thanh
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Minh Pham Van
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Nga Tran Vu Thieu
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Tan Le Van
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Diep To Song
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Phuong Le Thi
- Dong Thap Provincial Hospital, Dong Thap Province, Viet Nam
| | | | - Cong Bui Van
- Kien Giang Provincial Hospital, Kien Giang Province, Viet Nam
| | - Vu Tang
- Soc Trang Provincial Hospital, Soc Trang Province, Viet Nam
| | | | - Dong Nguyen
- Khanh Hoa Provincial Hospital, Khanh Hoa Province, Viet Nam
| | | | | | - Hao Tran Kiem
- Hue Central Hospital, Thua Thien – Hue Province, Viet Nam
| | | | - James Campbell
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Maxine Caws
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Jeremy Day
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Menno D. de Jong
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
- Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - H. Rogier Van Doorn
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Hien Tran Tinh
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Jeremy Farrar
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
| | - Constance Schultsz
- Centre for Tropical Medicine, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine, Oxford University, Oxford, United Kingdom
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Kihara M, de Haan M, Were EO, Garrashi HH, Neville BGR, Newton CRJC. Cognitive deficits following exposure to pneumococcal meningitis: an event-related potential study. BMC Infect Dis 2012; 12:79. [PMID: 22462525 PMCID: PMC3347992 DOI: 10.1186/1471-2334-12-79] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 03/31/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumococcal meningitis (PM) is a severe and life-threatening disease that is associated with cognitive impairment including learning difficulties, cognitive slowness, short-term memory deficits and poor academic performance. There are limited data on cognitive outcomes following exposure to PM from Africa mainly due to lack of culturally appropriate tools. We report cognitive processes of exposed children as measured by auditory and visual event-related potentials. METHODS Sixty-five children (32 male, mean 8.4 years, SD 3.0 years) aged between 4-15 years with a history of PM and an age-matched control group of 93 children (46 male; mean 8.4 years, SD 2.7 years) were recruited from a well-demarcated study area in Kilifi. In the present study, both baseline to peak and peak-to-peak amplitude differences are reported. RESULTS Children with a history of pneumococcal meningitis had significantly longer auditory P1 and P3a latencies and smaller P1 amplitudes compared to unexposed children. In the visual paradigm, children with PM seemingly lacked a novelty P3a component around 350 ms where control children had a maximum, and showed a lack of stimulus differentiation at Nc. Further, children with exposure to PM had smaller peak to peak amplitude (N2-P1) compared to unexposed children. CONCLUSION The results suggest that children with a history of PM process novelty differently than do unexposed children, with slower latencies and reduced or absent components. This pattern suggests poorer auditory attention and/or cognitive slowness and poorer visual attention orienting, possibly due to disruption in the functions of the lateral prefrontal and superior temporal cortices. ERPs may be useful for assessment of the development of perceptual-cognitive functions in post brain-injury in African children by providing an alternate way of assessing cognitive development in patient groups for whom more typical standardized neuropsychological assessments are unavailable.
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Affiliation(s)
- Michael Kihara
- The Centre for Geographical Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
| | - Michelle de Haan
- Developmental Cognitive Neuroscience Unit, University College London Institute of Child Health, London, UK
| | - Eugene O Were
- The Centre for Geographical Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
- Department of Paediatrics, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Harrun H Garrashi
- The Centre for Geographical Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
| | - Brian GR Neville
- Neurosciences Unit, University College London Institute of Child Health, The Wolfson Centre, London, UK
| | - Charles RJC Newton
- The Centre for Geographical Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
- Neurosciences Unit, University College London Institute of Child Health, The Wolfson Centre, London, UK
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Sadarangani M, Pollard AJ. Bacterial meningitis in childhood. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 719:185-99. [PMID: 22125045 DOI: 10.1007/978-1-4614-0204-6_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Pelkonen T, Roine I, Monteiro L, Cruzeiro ML, Pitkäranta A, Kataja M, Peltola H. Prognostic accuracy of five simple scales in childhood bacterial meningitis. ACTA ACUST UNITED AC 2012; 44:557-65. [PMID: 22292706 DOI: 10.3109/00365548.2011.652666] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Clinical outcome of pneumococcal meningitis during the emergence of pencillin-resistant Streptococcus pneumoniae: an observational study. BMC Infect Dis 2011; 11:323. [PMID: 22103652 PMCID: PMC3276609 DOI: 10.1186/1471-2334-11-323] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 11/21/2011] [Indexed: 12/04/2022] Open
Abstract
Background Prior to the availability of generic third-generation cephalosporins, penicillins were widely used for treatment of pneumococcal meningitis in developing countries despite concerns about rising levels of penicillin resistance among pneumococcal isolates. We examined the impact of penicillin resistance on outcomes of pneumococcal meningitis over a ten year period in an infectious diseases hospital in Brazil. Methods Clinical presentation, antimicrobial therapy and outcomes were reviewed for 548 patients with culture-confirmed pneumococcal meningitis from December, 1995, to November, 2005. Pneumococcal isolates from meningitis patients were defined as penicillin-resistant if Minimum Inhibitory Concentrations for penicillin were greater than 0.06 μg/ml. Proportional hazards regression was used to identify risk factors for fatal outcomes. Results During the ten-year period, ceftriaxone replaced ampicillin as first-line therapy for suspected bacterial meningitis. In hospital case-fatality for pneumococcal meningitis was 37%. Of 548 pneumococcal isolates from meningitis cases, 92 (17%) were resistant to penicillin. After controlling for age and severity of disease at admission, penicillin resistance was associated with higher case-fatality (Hazard Ratio [HR], 1.62; 95% Confidence Interval [CI], 1.08-2.43). Penicillin-resistance remained associated with higher case-fatality when initial therapy included ceftriaxone (HR, 1.68; 95% CI 1.02-2.76). Conclusions Findings support the use of third generation cephalosporin antibiotics for treatment of suspected pneumococcal meningitis even at low prevalence of pneumococcal resistance to penicillins.
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Pelkonen T, Roine I, Cruzeiro ML, Pitkäranta A, Kataja M, Peltola H. Slow initial β-lactam infusion and oral paracetamol to treat childhood bacterial meningitis: a randomised, controlled trial. THE LANCET. INFECTIOUS DISEASES 2011; 11:613-21. [DOI: 10.1016/s1473-3099(11)70055-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Furyk JS, Swann O, Molyneux E. Systematic review: neonatal meningitis in the developing world. Trop Med Int Health 2011; 16:672-9. [PMID: 21395927 DOI: 10.1111/j.1365-3156.2011.02750.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Meningitis is more common in the neonatal period than any other time in life and is an important cause of morbidity and mortality globally. Despite the majority of the burden occurring in the developing world, the majority of the existing literature originates from wealthy countries. Mortality from neonatal meningitis in developing countries is estimated to be 40-58%, against 10% in developed countries. Important differences exist in the spectrum of pathogens isolated from cerebrospinal fluid cultures in developed versus developing countries. Briefly, while studies in developed countries have generally found Group B streptococcus (GBS), Escherichia coli and Listeria monocytogenes as important organisms, we describe how in the developing world results have varied; particularly regarding GBS, other Gram negatives (excluding E. coli), Listeria and Gram-positive organisms. The choice of empiric antibiotics should take into consideration local epidemiology if known, early versus late disease, resistance patterns and availability within resource constraints. Gaps in knowledge, the role of adjuvant therapies and future directions for research are explored.
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Affiliation(s)
- J S Furyk
- James Cook University, School of Public Health, Tropical Medicine and rehabilitation sciences, Townsville, Australia.
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Wall ECB, Ajdukiewicz KMB, Heyderman RS, Garner P. Osmotic therapies as adjuncts to antibiotics for acute bacterial meningitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Yin Z, Wang H, Yang J, Luo H, Li Y, Hadler SC, Sandhu HS, Fischer M, Jiang Y, Zhang Z, Liu G, Li L, Johnson BW, Liang X. Japanese encephalitis disease burden and clinical features of Japanese encephalitis in four cities in the People's Republic of China. Am J Trop Med Hyg 2010; 83:766-73. [PMID: 20889863 DOI: 10.4269/ajtmh.2010.09-0748] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The incidence rate of Japanese encephalitis (JE) in the People's Republic of China has decreased substantially with the wide use of JE vaccine, but the accuracy of JE reporting is uncertain. We established active surveillance for acute meningitis and encephalitis syndrome (AMES) in four prefectures in China during 2006-2008 and performed JE laboratory testing on AMES cases identified from six sentinel hospitals in each prefecture. We estimated JE incidence for each prefecture by applying age-adjusted and season-adjusted JE positivity rates from sentinel hospitals to the total AMES resident cases. We identified 4,513 AMES cases, including 3,561 (79%) among residents of four prefectures. Among 2,294 AMES cases from sentinel hospitals, we identified 213 (9.2%) laboratory-confirmed JE cases. Adjusted estimates of JE incidence per 100,000 persons ranged from 0.08 in Shijiazhuang to 1.58 in Guigang. Active surveillance and laboratory confirmation provides a better estimate of the actual JE disease burden and should be used to further refine JE prevention strategies.
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Affiliation(s)
- Zundong Yin
- National Immunization Programme, and State Key Laboratory for Infectious Disease Control and Prevention, Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China.
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Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2010:CD004405. [PMID: 20824838 DOI: 10.1002/14651858.cd004405.pub3] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In experimental studies, the outcome of bacterial meningitis has been related to the severity of inflammation in the subarachnoid space. Corticosteroids reduce this inflammatory response. OBJECTIVES To examine the effect of adjuvant corticosteroid therapy versus placebo on mortality, hearing loss and neurological sequelae in people of all ages with acute bacterial meningitis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 1), MEDLINE (1966 to February 2010), EMBASE (1974 to February 2010) and Current Contents (2001 to February 2010). SELECTION CRITERIA Randomised controlled trials (RCTs) of corticosteroids for acute bacterial meningitis. DATA COLLECTION AND ANALYSIS We scored RCTs for methodological quality. We collected outcomes and adverse effects. We performed subgroup analyses for children and adults, causative organisms, low-income versus high-income countries, time of steroid administration and study quality. MAIN RESULTS Twenty-four studies involving 4041 participants were included. Similar numbers of participants died in the corticosteroid and placebo groups (18.0% versus 20.0%; risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.04, P = 0.18). There was a trend towards lower mortality in adults receiving corticosteroids (RR 0.74, 95% CI 0.53 to 1.05, P = 0.09). Corticosteroids were associated with lower rates of severe hearing loss (RR 0.67, 95% CI 0.51 to 0.88), any hearing loss (RR 0.76, 95% CI 0.64 to 0.89) and neurological sequelae (RR 0.83, 95% CI 0.69 to 1.00).Subgroup analyses for causative organisms showed that corticosteroids reduced severe hearing loss in Haemophilus influenzae meningitis (RR 0.34, 95% CI 0.20 to 0.59) and reduced mortality in Streptococcus pneumoniae meningitis (RR 0.84, 95% CI 0.72 to 0.98).In high-income countries, corticosteroids reduced severe hearing loss (RR 0.51, 95% CI 0.35 to 0.73), any hearing loss (RR 0.58, 95% CI 0.45 to 0.73) and short-term neurological sequelae (RR 0.64, 95% CI 0.48 to 0.85). There was no beneficial effect of corticosteroid therapy in low-income countries.Subgroup analysis for study quality showed no effect of corticosteroids on severe hearing loss in high quality studies.Corticosteroid treatment was associated with an increase in recurrent fever (RR 1.27, 95% CI 1.09 to 1.47), but not with other adverse events. AUTHORS' CONCLUSIONS Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries. We found no beneficial effect in low-income countries.
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Affiliation(s)
- Matthijs C Brouwer
- Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center University of Amsterdam, P.O. Box 22700, Amsterdam, Netherlands, 1100 DE
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de Jonge RCJ, van Furth AM, Wassenaar M, Gemke RJBJ, Terwee CB. Predicting sequelae and death after bacterial meningitis in childhood: a systematic review of prognostic studies. BMC Infect Dis 2010; 10:232. [PMID: 20684796 PMCID: PMC2921388 DOI: 10.1186/1471-2334-10-232] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 08/05/2010] [Indexed: 11/10/2022] Open
Abstract
Background Bacterial meningitis (BM) is a severe infection responsible for high mortality and disabling sequelae. Early identification of patients at high risk of these outcomes is necessary to prevent their occurrence by adequate treatment as much as possible. For this reason, several prognostic models have been developed. The objective of this study is to summarize the evidence regarding prognostic factors predicting death or sequelae due to BM in children 0-18 years of age. Methods A search in MEDLINE and EMBASE was conducted to identify prognostic studies on risk factors for mortality and sequelae after BM in children. Selection of abstracts, full-text articles and assessment of methodological quality using the QUIPS checklist was performed by two reviewers independently. Data on prognostic factors per outcome were summarized. Results Of the 31 studies identified, 15 were of moderate to high quality. Due to substantial heterogeneity in study characteristics and evaluated prognostic factors, no quantitative analysis was performed. Prognostic factors found to be statistically significant in more than one study of moderate or high quality are: complaints >48 hours before admission, coma/impaired consciousness, (prolonged duration of) seizures, (prolonged) fever, shock, peripheral circulatory failure, respiratory distress, absence of petechiae, causative pathogen Streptococcus pneumoniae, young age, male gender, several cerebrospinal fluid (CSF) parameters and white blood cell (WBC) count. Conclusions Although several important prognostic factors for the prediction of mortality or sequelae after BM were identified, the inability to perform a pooled analysis makes the exact (independent) predictive value of these factors uncertain. This emphasizes the need for additional well-conducted prognostic studies.
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Affiliation(s)
- Rogier C J de Jonge
- VU University Medical Center, Department of Pediatrics and Infectious Diseases, Amsterdam, The Netherlands.
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Abstract
BACKGROUND Malnutrition may be an important cofactor explaining poor outcome of childhood bacterial meningitis (BM) in developing countries. We examined its effect in Latin American children. METHODS The weight-for-age z score was determined for 482 children with BM aged 2 months to 5 years. Normal weight (z score from >-1 to <+1), underweight (z score <-1) and overweight (z score >+1) children were compared on admission, in-hospital and at discharge. Using uni- and multivariate analysis, we sought for associations between malnutrition and 3 different outcomes. RESULTS The mean z score was -0.41 +/- 1.54, with a normal distribution. Overall, 260 (54%) patients were of normal weight, 151 (31%) underweight, and 71 (15%) overweight. Compared with others, underweight patients had on admission a lower Glasgow coma score (P = 0.0006) and cerebrospinal fluid glucose concentration (P = 0.03), and a slower capillary filling time (P = 0.02). Their death rate was higher (P = 0.0004) and they survived with more neurological sequelae (P = 0.04), but a similar frequency of hearing impairment (P > 0.05). The odds for death increased 1.98 times by mild (95% confidence interval [CI], 1.03-3.83; P = 0.04), 2.55 times by moderate (95% CI, 1.05-6.17; P = 0.04), and 5.85 times (95% CI, 2.53-13.50; P < 0.0001) by severe underweight. Overweight was not associated with adverse outcomes (P > 0.05). CONCLUSIONS Children who are underweight at the time of onset of BM have a substantially increased probability of neurological sequelae and death.
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Fitch MT, van de Beek D. Drug Insight: steroids in CNS infectious diseases--new indications for an old therapy. ACTA ACUST UNITED AC 2008; 4:97-104. [PMID: 18256681 DOI: 10.1038/ncpneuro0713] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 11/08/2007] [Indexed: 01/15/2023]
Abstract
Infectious diseases of the CNS lead to overwhelming inflammatory processes within the brain and spinal cord that contribute substantially to patient morbidity and mortality. Pharmacological strategies to modulate inflammation have been investigated, although the resulting guidelines have sometimes been contradictory. Steroids have been proposed as adjunctive treatments for bacterial meningitis, tuberculous meningitis and herpes simplex virus encephalitis. Well-designed randomized controlled trials have established dexamethasone as an adjunctive therapy for adult patients receiving antibiotics for bacterial meningitis, and physicians prescribing the initial antibiotics need to be aware of current guidelines. Morbidity and mortality in patients with tuberculous meningitis exceeds 50%. Steroid treatments reduce mortality through an as yet unknown mechanism, although their effects on morbidity are less clear. Herpes simplex virus encephalitis is also associated with considerable morbidity and mortality. Despite a lack of randomized trials, there is some evidence that steroids used alongside antiviral therapy might be beneficial in this condition. As we discuss in this Review, systemic steroid treatment is an important aspect of treatment regimens for CNS infectious diseases, and the recent literature provides guidelines for the use of steroids in combination with appropriate antimicrobial therapy.
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Affiliation(s)
- Michael T Fitch
- Department of Neurology, Center of Infection and Immunity Amsterdam, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
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Beek D, Gans J, McIntyre P, Prasad K. Cochrane review: Corticosteroids for acute bacterial meningitis. ACTA ACUST UNITED AC 2008. [DOI: 10.1002/ebch.240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND In experimental studies, the clinical outcome of acute bacterial meningitis has been related to the severity of the inflammatory process in the subarachnoidal space. Treatment with corticosteroids can reduce this inflammatory response and thereby may improve outcome. We conducted a meta-analysis of randomised controlled trials (RCTs) of adjuvant corticosteroids in the treatment of acute bacterial meningitis. OBJECTIVES We conducted a systematic review examining the efficacy and safety of adjuvant corticosteroid therapy in acute bacterial meningitis. SEARCH STRATEGY In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (1966 to July 2006); EMBASE (1974 to June 2006); Current Contents (2001 to June 2006); and reference lists of all articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA Eligible published and non-published RCTs on corticosteroids as adjuvant therapy in acute bacterial meningitis. Patients of any age and in any clinical condition, treated with antibacterial agents and randomised to corticosteroid therapy (or placebo) of any type, could be included. At least case fatality rate or hearing loss had to be recorded for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Adverse effects were collected from the trials. Additional analyses were performed for children and adults, causative organisms, and low-income and developed countries. MAIN RESULTS Eighteen studies involving 2750 people were included. Overall, adjuvant corticosteroids were associated with lower case fatality (relative risk (RR) 0.83, 95% CI 0.71 to 0.99), lower rates of severe hearing loss (RR 0.65, 95% CI 0.47 to 0.91) and long-term neurological sequelae (RR 0.67, 95% CI 0.45 to 1.00). In children, corticosteroids reduced severe hearing loss (RR 0.61, 95% CI 0.44 to 0.86). In adults, corticosteroids gave significant protection against death (RR 0.57, 95% CI 0.40 to 0.81) and short-term neurological sequelae (RR 0.42, 95% CI 0.22 to 0.87). Subgroup analysis for causative organisms showed that corticosteroids reduced mortality in patients with meningitis due to Streptococcus pneumoniae (RR 0.59, 95% CI 0.45 to 0.77) and reduced severe hearing loss in children with meningitis due to Haemophilus influenzae (RR 0.37, 95% CI 0.20 to 0.68); subgroup analysis for patients with meningococcal showed a nonsignificant favourable trend in mortality (RR 0.71, 95% CI 0.31 to 1.62). Sub analyses for high-income and low-income countries of the effect of corticosteroids on mortality showed RRs of 0.83 (95% CI 0.52 to 1.05) and 0.87 (95% CI 0.72 to 1.05), respectively. Corticosteroids were protective against short-term neurological sequelae in patients with bacterial meningitis high-income countries (RR 0.56, 95% CI 0.3 to 0.84); in low-income countries this RR was 1.09 (95% CI 0.83 to 1.45). For children with bacterial meningitis admitted in high-income countries, corticosteroids showed a protective effect of on severe hearing loss (RR 0.61, 95% CI 0.41 to 0.90) and favourable point estimates for severe hearing loss associated with non-Haemophilus influenzae meningitis (RR 0.51, 95% CI 0.23 to 1.13) and short-term neurological sequelae (RR 0.72, 95% CI 0.39 to 1.33). For children in low-income countries, the use of corticosteroids was neither associated with benefit nor with harmful effects. Overall, adverse events were not increased significantly with the use of corticosteroids. AUTHORS' CONCLUSIONS Overall, corticosteroids significantly reduced rates of mortality, severe hearing loss and neurological sequelae. In adults with community-acquired bacterial meningitis, corticosteroid therapy should be administered in conjunction with the first antibiotic dose. In children, data support the use of adjunctive corticosteroids in children in high-income countries. We found no beneficial effect of corticosteroids for children in low-income countries.
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Affiliation(s)
- D van de Beek
- Academic Medical Center University of Amsterdam, Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), P.O. Box 22700, 1100 DE, Amsterdam, Netherlands.
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