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Current Opinion in Neurology Jun 2021Community-acquired bacterial meningitis is a continually changing disease. This review summarises both dynamic epidemiology and emerging data on pathogenesis. Updated... (Review)
Review
PURPOSE OF REVIEW
Community-acquired bacterial meningitis is a continually changing disease. This review summarises both dynamic epidemiology and emerging data on pathogenesis. Updated clinical guidelines are discussed, new agents undergoing clinical trials intended to reduce secondary brain damage are presented.
RECENT FINDINGS
Conjugate vaccines are effective against serotype/serogroup-specific meningitis but vaccine escape variants are rising in prevalence. Meningitis occurs when bacteria evade mucosal and circulating immune responses and invade the brain: directly, or across the blood-brain barrier. Tissue damage is caused when host genetic susceptibility is exploited by bacterial virulence. The classical clinical triad of fever, neck stiffness and headache has poor diagnostic sensitivity, all guidelines reflect the necessity for a low index of suspicion and early Lumbar puncture. Unnecessary cranial imaging causes diagnostic delays. cerebrospinal fluid (CSF) culture and PCR are diagnostic, direct next-generation sequencing of CSF may revolutionise diagnostics. Administration of early antibiotics is essential to improve survival. Dexamethasone partially mitigates central nervous system inflammation in high-income settings. New agents in clinical trials include C5 inhibitors and daptomycin, data are expected in 2025.
SUMMARY
Clinicians must remain vigilant for bacterial meningitis. Constantly changing epidemiology and emerging pathogenesis data are increasing the understanding of meningitis. Prospects for better treatments are forthcoming.
Topics: Anti-Bacterial Agents; Headache; Humans; Meningitis, Bacterial; Spinal Puncture
PubMed: 33767093
DOI: 10.1097/WCO.0000000000000934 -
JAMA Dec 2022Bacterial meningitis is a worldwide health problem, with incidence rates ranging from approximately 0.9 per 100 000 individuals per year in high-income countries to 80... (Review)
Review
IMPORTANCE
Bacterial meningitis is a worldwide health problem, with incidence rates ranging from approximately 0.9 per 100 000 individuals per year in high-income countries to 80 per 100 000 individuals per year in low-income countries. In low-income countries, bacterial meningitis has a mortality rate of up to 54%. Up to 24% of those who survive develop chronic neurological sequelae, such as hearing loss or focal neurological deficits.
OBSERVATIONS
Streptococcus pneumoniae causes about 72% and Neisseria meningitidis causes about 11% of cases of bacterial meningitis in people older than 16 years. Escherichia coli and Streptococcus agalactiae cause about 35% of cases of early-onset neonatal meningitis. In adults, risk factors for bacterial meningitis include older age and immunosuppressive conditions. The most common symptoms are headache (84%), fever (74%), stiff neck (74%), altered mental status (median [IQR] Glasgow Coma Scale score of 11 [9-14] on a scale ranging from 3-15), and nausea (62%). Brain imaging should be performed before lumbar puncture if patients present with altered mental status, focal neurological deficits, papilledema, or history of immunocompromising conditions or central nervous system disease. Bacterial meningitis should be suspected if any of the following are present on admission: serum leukocytes greater than 10.0 ×109/L, cerebrospinal fluid (CSF) leukocytes greater than 2000/μL, CSF granulocytes greater than 1180/μL, CSF protein greater than 2.2 g/L, CSF glucose less than 34.23 mg/dL, or fever. A positive Gram stain result for bacteria is diagnostic, but the sensitivity of a positive Gram stain result for bacterial meningitis ranges from 50% to 90%. In countries in which the prevalence of ceftriaxone-resistant Streptococcus pneumoniae exceeds 1%, vancomycin and ceftriaxone are the empirical antibiotics of choice, with the addition of ampicillin in neonates, older patients, and immunocompromised patients. Adjunctive dexamethasone should be used in patients with bacterial meningitis but stopped if Listeria monocytogenes is confirmed.
CONCLUSIONS AND RELEVANCE
Bacterial meningitis affects approximately 0.9 per 100 000 individuals to 80 per 100 000 individuals per year and has a mortality rate as high as 54%. First-line therapy is prompt empirical intravenous antibiotic therapy and adjunctive dexamethasone.
Topics: Humans; Dexamethasone; Meningitis, Bacterial; Glucocorticoids; Anti-Bacterial Agents; Administration, Intravenous
PubMed: 36472590
DOI: 10.1001/jama.2022.20521 -
Continuum (Minneapolis, Minn.) Oct 2018While acute bacterial meningitis is becoming less common in developed countries because of the widespread use of vaccines against Streptococcus pneumoniae, Neisseria... (Review)
Review
PURPOSE OF REVIEW
While acute bacterial meningitis is becoming less common in developed countries because of the widespread use of vaccines against Streptococcus pneumoniae, Neisseria meningitides, and Haemophilus influenzae, bacterial meningitis still occurs worldwide, with peak incidence in young children and the elderly. Bacterial meningitis is usually lethal unless appropriate antibiotics that cross the blood-brain barrier are given. Clinical suspicion of bacterial meningitis begins when patients present with the abrupt onset of fever, headache, and meningismus.
RECENT FINDINGS
New technologies are being developed for more rapid identification of the bacterial species causing meningitis. When appropriate, administration of adjunctive dexamethasone with the antibiotics often lessens neurologic sequelae in survivors, which may include aphasia, ataxia, paresis, hearing loss, and cognitive impairment.
SUMMARY
Confirmation of the diagnosis of bacterial meningitis comes mainly from examination and culture of CSF obtained from a lumbar puncture. Typically, the CSF shows an elevated neutrophil count, elevated protein, depressed glucose, positive Gram stain, and growth of the bacteria on appropriate culture media. Antibiotic sensitivities of the bacteria determine the appropriate antibiotics, although an educated guess of the best antibiotics to be given promptly must be made until the antibiotic sensitivities return, usually in a few days.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Female; Humans; Infant; Infant, Newborn; Male; Meningitis, Bacterial; Middle Aged; Young Adult
PubMed: 30273239
DOI: 10.1212/CON.0000000000000660 -
Handbook of Clinical Neurology 2014Bacterial meningitis is a neurologic emergency. Vaccination against common pathogens has decreased the burden of disease. Early diagnosis and rapid initiation of empiric... (Review)
Review
Bacterial meningitis is a neurologic emergency. Vaccination against common pathogens has decreased the burden of disease. Early diagnosis and rapid initiation of empiric antimicrobial and adjunctive therapy are vital. Therapy should be initiated as soon as blood cultures have been obtained, preceding any imaging studies. Clinical signs suggestive of bacterial meningitis include fever, headache, meningismus, and an altered level of consciousness but signs may be scarce in children, in the elderly, and in meningococcal disease. Host genetic factors are major determinants of susceptibility to meningococcal and pneumococcal disease. Dexamethasone therapy has been implemented as adjunctive treatment of adults with pneumococcal meningitis. Adequate and prompt treatment of bacterial meningitis is critical to outcome. In this chapter we review the epidemiology, pathophysiology, and management of bacterial meningitis.
Topics: Anti-Infective Agents; Anti-Inflammatory Agents; Dexamethasone; Glycerol; Humans; Meningitis, Bacterial; Spinal Puncture
PubMed: 24365425
DOI: 10.1016/B978-0-7020-4088-7.00093-6 -
Clinical Microbiology Reviews Jul 2010The epidemiology of bacterial meningitis has changed as a result of the widespread use of conjugate vaccines and preventive antimicrobial treatment of pregnant women.... (Review)
Review
The epidemiology of bacterial meningitis has changed as a result of the widespread use of conjugate vaccines and preventive antimicrobial treatment of pregnant women. Given the significant morbidity and mortality associated with bacterial meningitis, accurate information is necessary regarding the important etiological agents and populations at risk to ascertain public health measures and ensure appropriate management. In this review, we describe the changing epidemiology of bacterial meningitis in the United States and throughout the world by reviewing the global changes in etiological agents followed by specific microorganism data on the impact of the development and widespread use of conjugate vaccines. We provide recommendations for empirical antimicrobial and adjunctive treatments for clinical subgroups and review available laboratory methods in making the etiological diagnosis of bacterial meningitis. Finally, we summarize risk factors, clinical features, and microbiological diagnostics for the specific bacteria causing this disease.
Topics: Anti-Bacterial Agents; Bacteria; Bacterial Vaccines; Bacteriological Techniques; Cross Infection; Humans; Immunocompromised Host; Meningitis, Bacterial
PubMed: 20610819
DOI: 10.1128/CMR.00070-09 -
Clinical Infectious Diseases : An... Nov 2004
Topics: Adult; Algorithms; Anti-Bacterial Agents; Cerebrospinal Fluid Shunts; Child; Humans; Infant; Infant, Newborn; Meningitis, Bacterial
PubMed: 15494903
DOI: 10.1086/425368 -
Clinical Microbiology and Infection :... May 2016
Topics: Anti-Bacterial Agents; Community-Acquired Infections; Humans; Meningitis, Bacterial; Meningitis, Pneumococcal; Patient Participation; Practice Guidelines as Topic
PubMed: 27062097
DOI: 10.1016/j.cmi.2016.01.007 -
Lancet (London, England) Dec 2016Over the past several decades, the incidence of bacterial meningitis in children has decreased but there remains a significant burden of disease in adults, with a... (Review)
Review
Over the past several decades, the incidence of bacterial meningitis in children has decreased but there remains a significant burden of disease in adults, with a mortality of up to 30%. Although the pathogenesis of bacterial meningitis is not completely understood, knowledge of bacterial invasion and entry into the CNS is improving. Clinical features alone cannot determine whether meningitis is present and analysis of cerebrospinal fluid is essential for diagnosis. Newer technologies, such as multiplex PCR, and novel diagnostic platforms that incorporate proteomics and genetic sequencing, might help provide a quicker and more accurate diagnosis. Even with appropriate antimicrobial therapy, mortality is high and so attention has focused on adjunctive therapies; adjunctive corticosteroids are beneficial in certain circumstances. Any further improvements in outcome are likely to come from either modulation of the host response or novel approaches to therapy, rather than new antibiotics. Ultimately, the best hope to reduce the disease burden is with broadly protective vaccines.
Topics: Acute Disease; Adrenal Cortex Hormones; Anti-Bacterial Agents; Anti-Infective Agents; Humans; Meningitis, Bacterial; Pneumococcal Vaccines; Streptococcus pneumoniae
PubMed: 27265346
DOI: 10.1016/S0140-6736(16)30654-7 -
Seminars in Neurology 2000In the past 10 years the epidemiology of bacterial meningitis has changed, with a decreased incidence of meningitis caused by Haemophilus influenzae and an increasing... (Review)
Review
In the past 10 years the epidemiology of bacterial meningitis has changed, with a decreased incidence of meningitis caused by Haemophilus influenzae and an increasing incidence of meningitis caused by penicillin- and cephalosporin-resistant strains of Streptococcus pneumoniae. Meningococcal meningitis has become an increasing threat to college students. Successful outcome from meningitis requires not only eradication of the bacterial pathogen but also management of the neurological complications of raised intracranial pressure, stroke, and seizure activity. In this article, the pathophysiology, etiology, clinical presentation, differential diagnosis, and management of acute bacterial meningitis are reviewed. The present recommendations for the use of dexamethasone in the treatment of this infection, the use of chemoprophylaxis, and the indications for vaccinations are included.
Topics: Acute Disease; Anti-Bacterial Agents; Bacterial Physiological Phenomena; Diagnosis, Differential; Humans; Meninges; Meningitis, Bacterial; Neisseria meningitidis; Streptococcus pneumoniae; Vaccines
PubMed: 11051294
DOI: 10.1055/s-2000-9393 -
The Lancet. Infectious Diseases Jan 2010Bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein... (Review)
Review
Bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has changed the epidemiology of bacterial meningitis. Suspected bacterial meningitis is a medical emergency and needs empirical antimicrobial treatment without delay, but recognition of pathogens with increasing resistance to antimicrobial drugs is an important factor in the selection of empirical antimicrobial regimens. At present, strategies to prevent and treat bacterial meningitis are compromised by incomplete understanding of the pathogenesis. Further research on meningitis pathogenesis is thus needed. This Review summarises information on the epidemiology, pathogenesis, new diagnostic methods, empirical antimicrobial regimens, and adjunctive treatment of acute bacterial meningitis in infants and children.
Topics: Anti-Bacterial Agents; Child; Humans; Infant; Meningitis, Bacterial
PubMed: 20129147
DOI: 10.1016/S1473-3099(09)70306-8