Factors associated with treatment delay and outcome in community acquired bacterial meningitis

Sex differences in bacterial meningitis and associations with socioeconomic indicators: a systematic review and meta-analysis with metaregression

INTRODUCTION

We aimed to describe global sex-specific proportions and case fatality ratios of bacterial meningitis and to explore their associations with the Human Development Index (HDI) and Gender Inequality Index (GII).

METHODS

Google Scholar and MEDLINE (via PubMed.gov) were searched in January 2022 using the terms "bacterial meningitis" and "mortality". Studies with a mean observation period after the year 1940 and reporting ≥10 patients with community-acquired bacterial meningitis and their survival status were included, irrespective of the participants' age. Studies that selected participants by specific risk factors, reported specific pathogens only, or had >10% missing outcomes were disregarded. Data were extracted by one researcher and validated by a second researcher. The main outcomes, sex-specific proportions and case fatality ratios, were analysed using random-effects models. Associations with HDI and GII were explored using metaregression.

RESULTS

In this meta-analysis with metaregression, from 371 studies with 157 656 meningitis episodes, 217 (58%) reported the patients' sex and 41 (11%) reported sex-specific outcomes. Proportion of males was 58% (95% CI 57%-59%, prediction interval (PI) 45%-71%). Case fatality ratios were slightly higher in females (male-to-female fatality ratio, 0.89, 95% CI 0.78 to 1.01, PI 0.53-1.49). The size of the male proportion was strongly associated with HDI (per index point, -0.64, 95% CI -0.88 to -0.40; R2 16%; p<0.001) and GII (per index point, 0.61, 95% CI 0.39 to 0.83; R2 19%; p<0.001). Sex-specific case fatality ratios were weakly associated with HDI (per index point, 0.53, 95% CI -0.19 to 1.25; R2 2%; p=0.15) and GII (per index point, -0.58, 95% CI -1.55 to 0.39; R2 7%; p=0.24).

CONCLUSION

Based on worldwide reporting from the last 80 years, we show that indicators of human development and gender inequality are associated with sex-based disparities and case fatality ratios in bacterial meningitis.

Revealing the diagnostic value of cerebrospinal fluid presepsin (sCD14) as a new biomarker for postneurosurgical and nosocomial central nervous system infections: A systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

Central nervous system (CNS) infections represent life-threatening conditions. Emerging evidence suggests cerebrospinal fluid (CSF) presepsin (sCD14) as a promising biomarker for these infections. However, its diagnostic accuracy remains controversial. This study aimed to systematically evaluate the reliability of CSF presepsin in diagnosing CNS infections through a comprehensive meta-analysis.

METHODS

A systematic search of PubMed, Scopus, and Web of Science databases was conducted up to November 2024. Five prospective studies involving 384 participants were included. CSF presepsin levels were compared between infected and non-infected patients. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive predictive value (PPV), and negative predictive value (NPV) were calculated using a random-effects model. Publication bias and clinical utility were assessed through Deek's funnel plot and Fagan's nomogram, respectively.

RESULTS

Infected patients exhibited significantly higher CSF presepsin levels (mean difference: 760.16 pg/mL; 95 % confidence interval (CI): 426.26-1094.05, p < 0.01). Pooled sensitivity and specificity were 87 % (95 % CI: 82-91 %) and 67 % (95 % CI: 60-74 %), respectively, with a DOR of 13.04 (95 % CI: 7.51-22.64). The pooled PPV and NPV were 79 % (95 % CI: 73-84 %) and 79 % (95 % CI: 71-85 %), respectively. The area under the curve of the summary receiver operating characteristic curve was 86 %, emphasizing high diagnostic accuracy. No statistically significant publication bias was detected (P = 0.12).

CONCLUSION

CSF presepsin demonstrated potential as a diagnostic biomarker for CNS infections, demonstrating high sensitivity and moderate specificity. Further large-scale studies are needed to refine its clinical applicability and establish standardized thresholds.

Factors contributing to the non-identification of bacterial meningitis in febrile infants: A case series study

Non-identification of serious bacterial infection (SBI) in febrile infants is a common occurrence in clinical practice, culminating in catastrophic presentations. Six infants who initially presented to the clinician with fever without a focus, and were lately diagnosed with bacterial meningitis were analyzed for clinician-related factors contributing to the non-identification of meningitis. In a febrile neonate and a febrile young infant, lack of comprehensive evaluation was contributing to the non-identification of SBI; in four infants above the age of 3 months, meningitis was missed in spite of clinicians practicing treatment guidelines. Inadequate symptom characterization in two febrile infants and inappropriate interpretation of hemogram in three febrile infants also contributed to the non-identification of meningitis. Except for one, all infants developed complications. We conclude that the characterization of clinical features of SBI-like meningitis, interpretation of lab data, and adherence to the treatment guidelines are crucial in the management of an infant presenting as fever without a focus.

Computed Tomography of the Head Before Lumbar Puncture in Adults With Suspected Meningitis in High-HIV Prevalence Settings

Background

The role of computed tomography (CT) before lumbar puncture (LP) is unclear, with limited evidence for a causal link between LP and cerebral herniation or for the ability of CT to identify individuals at risk of herniation. The risks of LP delay or deferral are potentially greater in high-HIV prevalence, resource-limited settings; we analyzed data from such a setting to determine the impact of CT on time to LP and treatment, as well as mortality.

Methods

Adults with suspected central nervous system (CNS) infection were enrolled prospectively into the Botswana National Meningitis Survey between 2016 and 2019. Inpatient mortality and clinical data including time of treatment initiation and CT were captured from medical records. Associations between preceding CT and outcomes were assessed using logistic regression.

Results

LPs were performed in 711 patients with suspected CNS infection; 27% had a CT before LP, and 73% were HIV positive. Time from admission to LP and time from admission to appropriate treatment were significantly longer in patients who had a CT before LP compared with those who did not (2.8 hours and 13.2 hours, respectively). There was some evidence for treatment delays being associated with increased mortality; however, there was no significant difference in mortality between those who had or did not have CT.

Conclusions

Patients who had a CT had delays to diagnostic LP and initiation of appropriate treatment; although treatment delays were associated with increased mortality, our observational study could not demonstrate a causal association between delays in diagnosis and treatment introduced by CT and mortality.

An Emergency Department Quality Improvement Project to Decrease Lumbar Puncture Rates in Febrile Infants 22 to 28 Days Old

Introduction

Most providers have routinely performed universal lumbar puncture (LP) on well-appearing, febrile infants 22 to 28 days old. In 2021, the American Academy of Pediatrics recommended clinicians should perform an LP in this age group if inflammatory markers are abnormal. This quality improvement project aimed to decrease LP rates in febrile infants 22 to 28 days old in the emergency department (ED) within 1 year, regardless of race/ethnicity, from a baseline of 87%.

Methods

We used our institution's quality improvement framework to perform multiple Plan-Do-Study-Act cycles. A multidisciplinary team reviewed the febrile infant literature, local epidemiology, and identified key drivers. We provided departmental education, updated our clinical pathway, and used clinical decision support. We analyzed baseline (January 2017-March 2022) and intervention data (April 2022-March 2024) and tracked data using statistical process control charts. Our primary outcome measure was rates of LP in the ED for this cohort. Process measures included rates of infants with procalcitonin results. ED length of stay, rates of first LP attempt after hospitalization, and missed bacterial meningitis were balancing measures.

Results

The baseline LP rate of 87% decreased to 44% during the intervention period, resulting in a downward centerline shift. There were no significant differences when LP rates were analyzed by race/ethnicity. There was an upward centerline shift in the process measure of infants with procalcitonin results. There was no observed special cause variation in our balancing measures.

Conclusion

Quality improvement efforts, including education, clinical pathway updates, and clinical decision support, safely reduced rates of LPs in febrile infants 22 to 28 days old.

Evaluation of metagenomic and pathogen-targeted next-generation sequencing for diagnosis of meningitis and encephalitis in adults: A multicenter prospective observational cohort study in China

BACKGROUND

Next-generation sequencing (NGS) might aid in the identification of causal pathogens. However, the optimal approaches applied to cerebrospinal fluid (CSF) for detection are unclear, and studies evaluating the application of different NGS workflows for the diagnosis of intracranial infections are limited.

METHODS

In this multicenter, prospective observational cohort study, we described the diagnostic efficacy of pathogen-targeted NGS (ptNGS) and metagenomic NGS (mNGS) compared to that of composite microbiologic assays, for infectious meningitis/encephalitis (M/E).

RESULTS

In total, 152 patients diagnosed with clinically suspected M/E at four tertiary hospitals were enrolled; ptNGS and mNGS were used in parallel for pathogen detection in CSF. Among the 89 patients who were diagnosed with definite infectious M/E, 57 and 39 patients had causal microbial detection via ptNGS and mNGS, respectively. The overall accuracy of ptNGS was 65.1%, with a positive percent agreement (PPA) of 64% and a negative percent agreement (NPA) of 66.7%; and the overall accuracy of mNGS was 47.4%, with a PPA of 43.8% and an NPA of 52.4% after discrepancy analysis. There was a significant difference in the detection efficiency between these two methods both for PPA (sensitivity) and overall accuracy for pathogen detection (P < 0.05).

CONCLUSIONS

NGS tests have provided new information in addition to conventional microbiologic tests. ptNGS seems to have superior performance over mNGS for common causative pathogen detection in CSF for infectious M/E.

Pre-hospital symptoms associated with acute bacterial meningitis differs between children and adults

Community acquired bacterial meningitis (CABM) is a medical emergency requiring timely appropriate action. More knowledge about pre-hospital symptoms is needed. Retrospective observational study of pre-hospital management in patients with CABM between 2016 and 2021 admitted to a hospital in the Capital Region of Denmark. Reported symptoms were extracted from archived audio files of the initial phone call to emergency medical service. The majority of the 209 patients (82%) were adults. The most common symptoms were altered mental state (58%) and fever (57%), while neck stiffness was less common (9%). Children more often presented with fever, fatigue, rashes, and neck stiffness, while adults more often presented with altered mental state, and leg pain. Most patients (85%) reported at least 1 of the 3 symptoms in the classical triad of meningitis, while 3% reported all 3. Children more often presented at least 2 of 3 symptoms in the triad. One child (3%) and 7 adults (4%) received antibiotics pre-admission. Patients with CABM reported a variety of symptoms that differed significantly in children and adults. The classic triad was rare. Very few patients received antibiotics pre-admission. We suggest that questioning relevant symptoms should be done in febrile or mentally altered patients.