Meningitis - Empric Therapy 

8/07/02 (Smith)

Question: What is the efficacy of empiric therapy for suspected menigitis?

Link Directly to Fulltext Article at Science Direct

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Unique Identifier:11728765

Authors: Miner JR. Heegaard W. Mapes A. Biros M.

Institution: Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota 55441, USA.

Title: Presentation, time to antibiotics, and mortality of patients with bacterial meningitis at an urban county medical center.

Source: Journal of Emergency Medicine. 21(4):387-92, 2001 Nov.

Abstract: Our objective was to analyze the presentation, time to antibiotics, treatment, and mortality of patients with bacterial meningitis at a large urban county hospital over a 10-year period. A retrospective chart review of all patients with the diagnosis of bacterial meningitis was done. Information concerning presentation, etiologic organisms, treatment (including time to antibiotics), and outcomes were collected and analyzed. There were 165 charts reviewed with 171 total cases of bacterial meningitis. For adults with community-acquired meningitis, the mortality rate was 14%, for children it was 1.6%. Seventy-six percent of patients received antibiotics in the Emergency Department (ED) with a mean time to antibiotics of 1:08 h +/- 13 min. The rest received them as inpatients with a mean time to antibiotics of 6 +/- 9 h. The mortality rate for patients with community-acquired disease who received an Emergency Department antibiotic was 7.9%; for patients who received their antibiotics as inpatients the mortality rate was 29%. Our results indicate that the mortality rates from bacterial meningitis at our institution are lower than previously published results. Furthermore, our study supports the concept that the early administration of antibiotics in the ED may reduce mortality and may be an explanation of the lower mortality rates seen here. CAS Registry/EC Number 0 (Antibiotics).

 Link Directly to Fulltext Article at Publisher

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Unique Identifier:10401941

Authors: Thomas R. Le Tulzo Y. Bouget J. Camus C. Michelet C. Le Corre P. Bellissant E.

Institution: Clinique des Maladies Infectieuses et Reanimation Medicale, Hopital Pontchaillou-CHU Rennes, France. remi.thomas@univ-rennes1.fr

Title: Trial of dexamethasone treatment for severe bacterial meningitis in adults. Adult Meningitis Steroid Group.

Source: Intensive Care Medicine. 25(5):475-80, 1999 May.

Abstract: OBJECTIVE: To evaluate the clinical benefit of early adjunctive dexamethasone therapy for severe bacterial meningitis in adults. DESIGN: Multicenter, double-blind, randomized trial initiated in emergency or intensive care units in France and Switzerland. Within 3 h after initiation of an aminopenicillin therapy, patients received dexamethasone (10 mg q.i.d.) or placebo for 3 days. The primary end-point was the rate of patients cured without any neurologic sequelae on day 30. RESULTS: Sixty patients were enrolled, predominantly with a severe form since 85% required ICU stay and 43% mechanical ventilation. Streptococcus pneumoniae accounted for 31 cases and Neisseria meningitidis for 18 cases. The study had to be stopped prematurely because of a new national recommendation of experts to use third generation cephalosporin and vancomycin as a result of the increasing rate of penicillin-resistant S. pneumoniae in France. After the third sequential analysis by the triangular statistical test, the difference of rate of cured patients without any neurologic sequelae was not statistically significant (p = 0.0711) between the dexamethasone group (74.2%; n = 31) and the placebo group (51.7%; n = 29). Furthermore, the former group was younger and less sick at inclusion. CONCLUSION: Bacterial meningitis is still a severe disease in adults, since the overall observed rate of death or severe neurologic sequelae was 26.7%. The reported data are inconclusive regarding a systematic use of dexamethasone as an adjunctive therapy for bacterial meningitis in adults. Moreover this treatment impairs antibiotic penetration into the cerebrospinal fluid (CSF) that can lead to therapeutic failure, particularly in areas with high or increasing rates of penicillin-resistant S. pneumoniae. CAS Registry/EC Number 0 (Glucocorticoids, Synthetic). 0 (Penicillins). 50-02-2 (Dexamethasone).

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Unique Identifier:10091011

Authors: Hasbun R. Aronin SI. Quagliarello VJ.

Institution: Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn., USA.

Title: Treatment of bacterial meningitis. [Review] [62 refs]

Source: Comprehensive Therapy. 25(2):73-81, 1999 Feb.

Abstract: Major epidemiological changes have altered the empiric therapy of patients with bacterial meningitis, a disease with significant morbidity and mortality. We offer recommendations for empiric management decisions and specific antibiotic choices for patients with bacterial meningitis. [References: 62] CAS Registry/EC Number 0 (Anti-Inflammatory Agents, Steroidal). 0 (Antibiotics). 0 (Antibiotics, Combined).

 Link Directly to Fulltext article in Ovid

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Unique Identifier:9867727

Authors: Aronin SI. Peduzzi P. Quagliarello VJ.

Institution: Waterbury Hospital, Connecticut 06721, USA.

Title: Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing. [see comments.].

Source: Annals of Internal Medicine. 129(11):862-9, 1998 Dec 1.

Abstract: BACKGROUND: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults. OBJECTIVE: To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome. DESIGN: Retrospective cohort study; patients were divided into derivation and validation samples. SETTING: Four hospitals in Connecticut. PATIENTS: 269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department. MEASUREMENTS: Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge). RESULTS: For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21 %) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P=0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P=0.008) or intermediate risk (P=0.003) at arrival in the emergency department to high risk before administration of antibiotics. CONCLUSIONS: In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given. CAS Registry/EC Number 0 (Antibiotics).