Artificial ventilation and prognostic factors in bacterial meningitis

Characteristics and immediate outcome of childhood meningitis treated in the pediatric intensive care unit

OBJECTIVE

To describe patient characteristics, use of technology and mortality in children with meningitis admitted to the pediatric intensive care unit (PICU).

DESIGN

Retrospective cohort study.

SETTING

Fifteen US PICUs.

PATIENTS

All admissions with a diagnosis of meningitis between 1995 and 2000 in the Pediatric Intensive Care Unit Evaluations (PICUEs) database.

MEASUREMENTS AND RESULTS

Of 559 patients with meningitis, 58% were male. The median age was 19 months and the median length of PICU stay was 2 days. The crude PICU mortality rate was 7%. Three hundred thirty-four (60%) patients had bacterial meningitis. Non-survivors had significantly higher Pediatric Risk of Mortality (PRISM) III scores and also constituted a larger proportion of the patients with bacterial meningitis, coma and shock upon PICU admission. The use of invasive devices was higher among non-survivors, patients with bacterial meningitis or those who were in coma or shock upon PICU admission. There was significant variation in the use of intracranial pressure (ICP) monitors by coma status and by institution. In multivariate analysis, patients had 1.26 higher odds of mortality for each unit increase in PRISM III score (odds ratio 1.26, 95% confidence interval: 1.19-1.34), while adjusting for other variables.

CONCLUSION

In a large cohort of children admitted to the PICU with meningitis, severity of illness, particularly the presence of shock or coma, was significantly associated with both the higher use of invasive medical devices and higher mortality. There was significant variation in the use of ICP monitors among the various PICUs without statistical association with survival.

Recognition, treatment and complications of meningococcal disease

Meningococcal disease remains a major cause of death in young children. A decrease in mortality requires recognition and treatment of the disease at a number of stages in the illness. Life-threatening meningococcal disease usually presents as septicaemia rather than meningitis. The cardinal feature of meningococcal septicaemia is the purpuric rash. Many parents recognise the rash and seek medical advice because of it. When primary care physicians recognise the rash, the administration of parenteral penicillin may decrease mortality. However, antibacterials are not given promptly if there is no rash or if the disease presents in an atypical form. In hospital, antibacterial therapy with a third-generation cephalosporin should be given. Disease severity needs to be assessed by a valid method, such as the Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS). This can identify those patients who need intensive care and/or might benefit from new therapies. The 2 life-threatening complications are septic shock and meningoencephalitis with raised intracranial pressure. Despite numerous case reports of success with potential new treatments, none has been proven safe and/or effective by controlled trials. Although it is tempting to focus on new treatments, the early recognition of severe meningococcal disease by parents, primary care physicians and junior hospital doctors is equally, if not more, important as a potential means of decreasing mortality.

Survival and functional outcome of children requiring mechanical ventilation during therapy for acute bacterial meningitis

OBJECTIVE

To determine predictors of survival and functional outcome of pediatric patients requiring mechanical ventilation during therapy for acute bacterial meningitis.

DESIGN

Retrospective case series.

SETTING

Pediatric intensive care unit (ICU) at a midwestern tertiary care children's hospital.

PATIENTS

Consecutive sample of 32 patients (median age 9.8 months; range 9 days to 12 yrs) from 1985 to 1990 with acute bacterial meningitis severe enough to require mechanical ventilation during therapy. Of these patients, 59% were female and 59% were white.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were analyzed to identify predictors of survival and functional status after hospital discharge. Variables included were vital signs, Pediatric Risk of Mortality (PRISM) score within the first 24 hrs of hospitalization, Glasgow Coma Score, and course of illness. Functional status was assessed at hospital discharge and at follow-up (median follow-up: 41.5 months, range 7 to 77) in the areas of locomotion, self-care, and communication. There were ten inhospital deaths. The 22 survivors formed three groups. At hospital discharge, seven children showed no functional disability. Seven patients were dependent in all three areas of function at discharge, with six still dependent at follow-up evaluation. Eight patients showed mild to moderate impairment in at least one area of function at hospital discharge. At follow-up, four of these eight patients demonstrated no functional disability, one had improved status, two were unchanged, and one was lost to follow-up. The best predictor of death and functional status at follow-up was the admission PRISM score. Hypotension and tachycardia within the first 24 hrs after pediatric ICU admission were strongly associated with poor outcome.

CONCLUSIONS

After bacterial meningitis in children whose care included mechanical ventilation, half of the patients died or survived with severe functional deficits. Patients with mild or moderate functional deficits at hospital discharge improved with time.

Staphylococcus aureus meningitis: a review of 28 consecutive community-acquired cases

From 1966 to 1989 a total of 1,830 cases of bacterial meningitis were recorded at the Department of Infectious Diseases, Rigshospitalet, Denmark. Staphylococcus aureus meningitis accounted for 44 (2.4%) of these cases. Among these, 28 cases were classified as community-acquired S. aureus meningitis. The mortality rate for these cases was 43%. A retrospective study of clinical features and parameters in these community-acquired cases showed the following conditions to be associated with a high mortality risk: advanced age, an underlying condition requiring artificial ventilation, cardiovascular disease and immune deficiencies. At admission, more than 75% of the patients had fever, nuchal rigidity and decreased consciousness. In 57% of cases the focus for the S. aureus infection was endocarditis, pneumonia or skin infections. All the patients had complications due to the meningitis, the major one being insufficient respiration. Autopsy performed in 9 of the 12 fatalities showed endocarditis in 5, pneumonia in 4, and pyelonephritis in 2. All of the brains examined at autopsy showed cerebral and subarachnoid hemorrhage.