Length of prediagnostic history related to the course and sequelae of childhood bacterial meningitis

Seizures, focal neurological signs, and pneumococcal aetiology associate with impaired consciousness in childhood bacterial meningitis

AIM

A low Glasgow Coma Scale Score (GCS) on admission is a known predictor of poor outcome from childhood bacterial meningitis. In turn, the factors associated with the admission GCS are less known. Our aim was to identify them, both for clinical alerts of reserved prognosis and to find potential targets for intervention.

METHODS

This study is a secondary analysis of data collected prospectively in Angola and in Latin America between 1996 and 2007. Children with bacterial meningitis were examined on hospital admission and their GCS was assessed using the age-adjusted scale. Associations between on-admission GCS and host clinical factors were examined.

RESULTS

A total of 1376 patients with confirmed bacterial meningitis were included in the analysis (609 from Latin America and 767 from Angola). The median GCS was 13 for all patients (12 in Angola and 13 in Latin America). In the multivariate analysis, in the areas combined, seizures, focal neurological signs, and pneumococcal aetiology associated with GCS <13, as did treatment delay in Latin America.

CONCLUSION

Besides pneumococcal aetiology, we identified characteristics, easily registrable on admission, which are associated with a low GCS in childhood bacterial meningitis. Of these, expanding pneumococcal vaccinations and treatment delays could be modified.

Risk Factors for Severe Outcomes in Bacterial Meningitis

Objectives: This study aimed to define risk factors associated with suppurative complications, short-term sequelae, and death in pediatric patients with bacterial meningitis. Methods: A retrospective cohort study was conducted on children with bacterial meningitis, aged 0 months to 18 years, who were admitted to the Hospital Infantil João Paulo II, reference in infectious diseases, from 2005 to 2018. Results: In 178 cases, meningococcal meningitis was the most prevalent disease form (51%), followed by pneumococcal meningitis (31%) and Haemophilus influenzae type B meningitis (10%). The main clinical findings at admission were fever (93.1%), vomiting (67.9%), drowsiness (47.8%), headache (36.5%), irritability (28.3%), and seizures (26.4%). Suppurative complications were recorded in 19% of the patients. The prevalence of neurological sequelae during hospital discharge was 12.4%. Hearing (41%; n = 9) and cognitive (9%) impairments were prominent among the diagnosed sequelae. Incidences of epileptic crises, vestibular disorders, or hydrocephalus were noted in one case each (4.5%), and 12.4% of the patients died. Conclusions: Streptococcus pneumoniae and H. influenzae type B were associated with the diagnosis of sequelae during hospital discharge, seizures were considered a risk factor for suppurative complications, and gastrointestinal symptoms or signs of clinical severity were associated with death.

The Impact and Burden of Neurological Sequelae Following Bacterial Meningitis: A Narrative Review

The burden, impact, and social and economic costs of neurological sequelae following meningitis can be devastating to patients, families and communities. An acute inflammation of the brain and spinal cord, meningitis results in high mortality rates, with over 2.5 million new cases of bacterial meningitis and over 236,000 deaths worldwide in 2019 alone. Up to 30% of survivors have some type of neurological or neuro-behavioural sequelae. These include seizures, hearing and vision loss, cognitive impairment, neuromotor disability and memory or behaviour changes. Few studies have documented the long-term (greater than five years) consequences or have parsed out whether the age at time of meningitis contributes to poor outcome. Knowledge of the socioeconomic impact and demand for medical follow-up services among these patients and their caregivers is also lacking, especially in low- and middle-income countries (LMICs). Within resource-limited settings, the costs incurred by patients and their families can be very high. This review summarises the available evidence to better understand the impact and burden of the neurological sequelae and disabling consequences of bacterial meningitis, with particular focus on identifying existing gaps in LMICs.

Risk factors associated with the outcomes of pediatric bacterial meningitis: a systematic review

OBJECTIVE

The aim of this study was to systematically review the literature and answer the following central question: "What are the risk factors associated with worse clinical outcomes of pediatric bacterial meningitis patients?"

METHODS

The articles were obtained through literary search using electronic bibliographic databases: Web of Science, Scopus, MEDLINE, and LILACS; they were selected using the international guideline outlined by the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols.

RESULTS

The literature search identified 1,244 articles. After methodological screening, 17 studies were eligible for this systematic review. A total of 9,581 patients aged between 0 days and 18 years were evaluated in the included studies, and several plausible and important prognostic factors are proposed for prediction of poor outcomes after bacterial meningitis in childhood. Late diagnosis reduces the chances for a better evolution and reinforces the importance of a high diagnostic suspicion of meningitis, especially in febrile pictures with nonspecific symptomatology. S. pneumoniae as a causative pathogen was demonstrated to be related to clinical severity.

CONCLUSIONS

Early prediction of an adverse outcome may help determine which children require more intensive or longer follow-up and may provide the physician with rationale for parental counseling about their child's prognosis in an early phase of the disease.

Interferon-γ-Induced Nitric Oxide Synthase-2 Contributes to Blood/Brain Barrier Dysfunction and Acute Mortality in Experimental Streptococcus pneumoniae Meningitis

The proinflammatory cytokine interferon-gamma (IFNγ) recently was shown to play a crucial role in experimental pneumococcal meningitis (PM) pathogenesis, and we aimed in this study to investigate IFNγ-driven nitric oxide synthase-2 (NOS2)-mediated pathogenesis of murine PM. We demonstrate that costimulation of toll-like receptors and IFNγ receptors was synergistic for NOS2 expression in cultured murine microglia. Using an experimental PM model, wild-type mice treated with anti-IFNγ antibody, as well as IFNγ and NOS2 gene knockout (GKO) mice, were inoculated intracerebroventricularly with 10(3) colony-forming units of Streptococcus pneumoniae (WU2 strain). Mice were monitored daily during a 200-h disease course to assess survival rate and blood-brain barrier (BBB) permeability measured at 48 h. IFNγ deficiency was protective in PM, with an approximate 3-fold increase in survival rates in both antibody-treated and IFNγ GKO mice compared to controls (P < 0.01). At 48 h postinoculation, brain NOS2 mRNA expression was significantly increased in an IFNγ-dependent manner. Mortality was significantly delayed in NOS2 GKO mice compared to controls (P < 0.01), and BBB dysfunction was reduced by 54% in IFNγ GKO mice and abolished in NOS2 GKO. These data suggest that IFNγ-dependent expression of NOS2 in the brain contributes to BBB breakdown and early mortality in murine PM.

Risk Factors for Hearing Loss in Children following Bacterial Meningitis in a Tertiary Referral Hospital

Objective. This study aimed to examine hearing function in children admitted with bacterial meningitis to determine the risk factors for sensorineural hearing loss. Setting. The study was conducted in the audiology unit and paediatric wards of Kenyatta National Hospital. Subjects and Methods. The study involved 83 children between the ages of six months and twelve years admitted with bacterial meningitis. The median age for the children examined was 14. On discharge they underwent hearing testing to evaluate for presence and degree of hearing loss. Results. Thirty six of the 83 children (44.4%) were found to have at least a unilateral mild sensorineural hearing loss during initial audiologic testing. Of the children with hearing loss, 22 (26.5%) had mild or moderate sensorineural hearing loss and 14 (16.9%) had severe or profound sensorineural hearing loss. Significant determinants identified for hearing loss included coma score below eight, seizures, cranial nerve neuropathy, positive CSF culture, and fever above 38.7 degrees Celsius. Conclusions. Sensorineural hearing loss was found to be highly prevalent in children treated for bacterial meningitis. There is need to educate healthcare providers on aggressive management of coma, fever, and seizures due to their poor prognostic value on hearing.

Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis

Few data sources are available to assess the global and regional risk of sequelae from bacterial meningitis. We aimed to estimate the risks of major and minor sequelae caused by bacterial meningitis, estimate the distribution of the different types of sequelae, and compare risk by region and income. We systematically reviewed published papers from 1980 to 2008. Standard global burden of disease categories (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) were labelled as major sequelae. Less severe, minor sequelae (behavioural problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia), and multiple impairments were also included. 132 papers were selected for inclusion. The median (IQR) risk of at least one major or minor sequela after hospital discharge was 19.9% (12.3-35.3%). The risk of at least one major sequela was 12.8% (7.2-21.1%) and of at least one minor sequela was 8.6% (4.4-15.3%). The median (IQR) risk of at least one major sequela was 24.7% (16.2-35.3%) in pneumococcal meningitis; 9.5% (7.1-15.3%) in Haemophilus influenzae type b (Hib), and 7.2% (4.3-11.2%) in meningococcal meningitis. The most common major sequela was hearing loss (33.9%), and 19.7% had multiple impairments. In the random-effects meta-analysis, all-cause risk of a major sequela was twice as high in the African (pooled risk estimate 25.1% [95% CI 18.9-32.0%]) and southeast Asian regions (21.6% [95% CI 13.1-31.5%]) as in the European region (9.4% [95% CI 7.0-12.3%]; overall I(2)=89.5%, p<0.0001). Risks of long-term disabling sequelae were highest in low-income countries, where the burden of bacterial meningitis is greatest. Most reported sequelae could have been averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.

Microbial genome count in cerebrospinal fluid compared with clinical characteristics in pneumococcal and Haemophilus influenzae type b meningitis in children

Cerebrospinal fluid genome counts were determined by quantitative real-time polymerase chain reaction from 121 children: 36 with Streptococcus pneumoniae and 85 with Haemophilus influenzae meningitis. To examine the interactions of genome count and to determine its prognostic importance, we projected the results against findings on admission and different outcomes. The genome count varied vastly in both meningitides ranging from 0 to 9,250,000/microL. The genome quantity was weakly associated with only some of the patient findings on admission. High counts predicted neurologic (odds ratio [OR]=1.36; 95% confidence interval [CI], 1.09-1.69; P=0.006 for 1 log increase) but not audiologic sequelae. They also predicted death in S .pneumoniae (OR=2.05; 95% CI, 1.08-3.87; P=0.03) but not in H. influenzae meningitis.

Do Corticosteroids Prevent Hearing Loss in Pediatric Bacterial Meningitis? An Analysis of the Evidence

We reviewed the MEDLINE database of articles published from January 1966 through December 2001 in search of data on the ability of the corticosteroid dexamethasone to protect against sensorineural hearing loss in children with meningitis. We found 1,034 articles that matched our keyword entries, and after various exclusions, we winnowed this number down to 16 articles that contained adequate data regarding audiometric evaluation and follow-up. The 16 articles included reports of 11 randomized controlled trials (only 10 are considered in this analysis), two meta-analyses, two retrospective case series, and two consensus statements. Of the 10 clinical trials (all of which contained level I evidence), four showed that dexamethasone had a protective effect and six showed that it did not. The authors of the two meta-analyses (both level I) concluded that there was a protective effect, and the authors of the two retrospective case series (both level IV) concluded that there was not. Both consensus statements (both level V) recommended the use of dexamethasone only in Haemophilus influenzae meningitis. We conclude that well-designed studies with level I evidence have shown that the benefit of dexamethasone in preventing hearing loss in children with meningitis remains unclear. Significant variables in treatment response include the specific pathogen, the type of antibiotic, and the timing of dexamethasone administration.

Acute bacterial meningitis in children presenting to the Royal Liverpool Children's Hospital, Liverpool, UK and the Queen Elizabeth Central Hospital in Blantyre, Malawi: a world of difference

BACKGROUND

Bacterial meningitis is a serious childhood illness worldwide. Children can now be immunised against meningitis with conjugate vaccines. The outcome of bacterial meningitis in British and Malawian children before the introduction of these vaccines was compared.

METHODS

All children with culture-positive bacterial meningitis treated in the Royal Liverpool Children's Hospital (RLCH), UK during 1984-1991 (n=197) and in the Children's Unit, Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi during 1996-1997 (n=175) were studied.

RESULTS

Children at QECH presented later and were more often comatose and malnourished. Mortality was 7% in RLCH compared with 41% in QECH. Three organisms caused most cases of meningitis: N. meningitidis 56% vs 4%, H. influenzae b 27% vs 25%, and S. pneumoniae 11% vs 35% in RLCH and QECH, respectively. Mortality was lower in RLCH for each organism: N. meningitidis 10% vs 28%, H. influenzae b 6% vs 43%, S. pneumoniae 0% vs 46%.

CONCLUSIONS

Mortality from bacterial meningitis in Malawian children is much higher than in British children, even when infected with the same organisms. This might be owing to delay in presentation, malnutrition and HIV infection. Immunisation of Malawian children with conjugate vaccines should continue to develop since their risk of dying from meningitis is five times greater than that of British children.

Decrease in serum procalcitonin levels over time during treatment of acute bacterial meningitis

Introduction

The aim of this study was to describe the change in serum procalcitonin levels during treatment for community-acquired acute bacterial meningitis.

Methods

Out of 50 consecutive patients presenting with bacterial meningitis and infection at no other site, and who had received no prior antibiotic treatment, 48 had a serum procalcitonin level above 0.5 ng/ml on admission and were enrolled in the study.

Results

The mean age of the patients was 55 years, and mean Glasgow Coma Scale score on admission was 13. The time from symptom onset to admission was less than 24 hours in 40% of the patients, 24–48 hours in 20%, and more than 48 hours in 40%. The median (interquartile) interval between admission and initial antibiotic treatment was 160 min (60–280 min). Bacterial infection was documented in 45 patients. Causative agents included Streptococcus pneumoniae (n = 21), Neisseria meningitidis (n = 9), Listeria monocytogenes (n = 6), other streptococci (n = 5), Haemophilus influenzae (n = 2) and other bacteria (n = 2). The initial antibiotic treatment was effective in all patients. A lumbar puncture performed 48–72 hours after admission in 34 patients showed sterilization of cerebrospinal fluid. Median (interquartile) serum procalcitonin levels on admission and at day 2 were 4.5 (2.8–10.8) mg/ml and 2 (0.9–5.0) mg/ml, respectively (P < 0.0001). The corresponding values for C-reactive protein were 120 (21–241) mg/ml and 156 (121–240) mg/ml, respectively. Five patients (10%) died from noninfectious causes during their hospitalization.

Conclusions

Serum procalcitonin levels decrease rapidly with appropriate antibiotic treatment, diminishing the value of lumbar puncture performed 48–72 hours after admission to assess treatment efficacy.

A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis

BACKGROUND

Despite an extensive literature, the impact of both adjunctive steroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis is controversial.

AIM

To determine the independent contribution of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis in a representative population with good access to medical services.

METHODS

Data were obtained from laboratories and hospital records to assemble a population register in Sydney, Australia, 1994-99. Follow up questionnaires were completed by attending physicians.

RESULTS

A total of 122 cases of pneumococcal meningitis aged 0-14 years were identified. Almost 50% of 120 children with available records either died (n = 15) or had permanent neurological impairment (n = 39). Early use (before or with parenteral antibiotics) of corticosteroids protected against death or severe morbidity (adjusted OR 0.21, 95% CI 0.05 to 0.77). Delayed diagnosis was associated with increased morbidity in survivors (OR 3.4, 95% CI 1.03 to 11.4) but not with increased mortality.

CONCLUSION

In a population with good access to health care and after adjusting for other known prognostic variables, early recognition of pneumococcal meningitis and treatment with adjunctive dexamethasone significantly improves outcomes. These data add to those from randomised controlled trials. Implementation requires development of protocols and guidelines for use in emergency departments.

Bacterial meningitis: Diagnosis and treatment

Bacterial meningitis, once almost universally fatal, remains a cause of serious neurologic illness and subsequent disability. The initial diagnosis, although sometimes clear-cut, can be subtle and difficult. Appropriate intervention may have a favorable influence on outcome. The advent of corticosteroids and brain imaging has improved management but created controversy concerning the sequence at which various interventions should be introduced. Empiric treatment with antibiotics is important in the initial stages. Complications can arise, such as seizures, increased intracranial pressure, and ischemia. The prognosis remains unfavorable for some affected individuals in spite of advances in antibiotic management and supportive care.

Sequelae after bacterial meningitis in childhood

The neurological outcome of bacterial meningitis in children was evaluated retrospectively. Data were obtained from a large study on children aged between 1 month and 15 y who initially visited the emergency department of Sophia Children's Hospital, Rotterdam, The Netherlands with meningeal signs. This study presents data from 103 patients in whom bacterial meningitis was diagnosed. Neisseria meningitidis was the dominant pathogen of meningitis. We found a 2% case-fatality rate in children with bacterial meningitis and a 13% rate of sequelae among survivors: 7% hearing impairment and 7% neurological sequelae. Children with bacterial meningitis caused by Streptococcus pneumoniae and those with acute focal neurological symptoms tended to have the worst prognosis.

Childhood bacterial meningitis in Pondicherry, South India

OBJECTIVE

To identify causative bacteria from cerebrospinal fluid (CSF) of children with meningitis and analyse various clinical and laboratory parameters.

METHODS

Over a 20 month period, September 1994 to April 1996, one hundred episodes of acute bacterial meningitis in children aged 1 month-12 years were studied in a tertiary urban hospital in South India. Organisms were isolated from the cerebrospinal fluid (CSF) in 35% of cases. Among infants and children, the two major pathogens were H. influenzae (17%) and S. pneumoniae (12%).

RESULTS

The illness at presentation was mild in 13% and severe in 36% of cases. The association of subdural effusion in children with Salmonella Gp B meningitis merits attention. The overall case fatality rate was 25%. S. pneumoniae had a higher case fatality rate than Salmonella Gp B and H. influenzae (50% vs 17% vs 12%). All the three infants below 3 months of age with S. pneumoniae meningitis died. On analysis of selected clinical and laboratory features by discriminant analysis, CSF culture was the significant (P = 0.02) variable in relation to outcome. In pneumococcal meningitis, CSF WBC count was a highly significant variable in relation to outcome (Wilk's Lambda 0.15, F = 24.64, P = 0.0002).

CONCLUSION

Prevention of infections due to H. influenzae and S. pneumoniae should be given higher priority.

Timing of Administration of Antimicrobial Therapy in Bacterial Meningitis

Bacterial meningitis is an important cause of morbidity and mortality in the United States and throughout the world. The diagnosis of bacterial meningitis is often delayed in patients as a result of numerous factors such as length of illness, use of radiologic imaging studies, and/or prior use of antimicrobial agents. Many textbooks emphasize the need for prompt initiation of antimicrobial therapy in a patient with suspected acute bacterial meningitis to prevent many of the long-term sequelae associated with this disorder. We have reviewed the literature to determine if there is a standard of care for timing of administration of antimicrobial therapy in patients with a diagnosis of acute bacterial meningitis. Although the clinical data are inconclusive, it makes intuitive sense to initiate antimicrobial therapy as soon as possible in any patient with suspected or proven bacterial meningitis before the patient's illness advances to a high level of clinical severity, beyond which antimicrobial therapy is less likely to be of benefit. However, clinical experiences suggest that patient outcome in bacterial meningitis is a result of multiple factors, since some patients treated within a few hours of symptoms develop an adverse outcome whereas others who are symptomatic for days prior to presentation suffer no adverse sequelae.

Fever interval before diagnosis, prior antibiotic treatment, and clinical outcome for young children with bacterial meningitis

In young children, meningitis due to Streptococcus pneumoniae is preceded by a long interval from onset of fever to diagnosis of bacterial meningitis (hereafter known as "fever interval"), during which time the patient frequently contacts a clinician. By means of retrospective chart review, we compared the fever interval that preceded diagnosis with the complication rate among 288 young children (age, 3--36 months) who had bacterial meningitis (1984--1996), as stratified by causative organism and prior antibiotic treatment. Pathogens included S. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Pneumococcus species were associated with the longest fever interval prior to diagnosis of meningitis, the highest frequency of contact with a clinician before hospitalization, and the highest rate of documented morbidity or mortality. For S. pneumoniae, there was an association between antibiotic treatment received at prior meetings with a clinician and a reduced rate of meningitis-related complications (odds ratio, 0.14; P=.02). Antibiotic treatment during such meetings is associated with a substantial reduction in disease-related sequelae.

Acute bacterial meningitis in adults. A 12-year review

One hundred three episodes of acute bacterial meningitis in adults hospitalized in Edmonton's 2 largest hospitals from 1985 to 1996 were reviewed. Cases complicating neurosurgery were excluded. Most cases were community-acquired (87%). Twenty-three cases remained culture-negative, and there was no statistical relation between culture negativity and antibiotic pretreatment. Streptococcus pneumoniae was the predominant pathogen (52.5%), but Listeria monocytogenes was the second most common isolate, accounting for 12.5% of culture-positive cases. Compared to non-listerial meningitis, those with listeriosis were more likely to have negative cerebrospinal fluid (CSF) Gram stains (p = 0.07), CSF leukocyte counts < 1,000 cells/mm3 (p < 0.003), and normal CSF glucose (p = 0.006). Bacterial antigen detection was found to be of low sensitivity: 33% in all patients, but only 9% in cases with negative CSF Gram stains. The overall mortality was 18%, with 15 deaths directly attributable to acute meningitis; the case-fatality rates for S. pneumoniae and L. monocytogenes were 24% and 40%, respectively. Mortality was significantly higher among those with seizures (34% versus 7%, respectively; p < 0.001; OR = 17.6). Despite the urgency of acute bacterial meningitis, there were considerable delays in the institution of empiric antibiotics; mortality rates were slightly higher in those who experienced such a delay (16% versus 7% respectively; p = 0.18).

Hypothermia as an adjunctive treatment for severe bacterial meningitis

Brain injury due to bacterial meningitis results in a high mortality rate and significant neurologic sequelae in survivors. The objective of this study was to determine if the application of moderate hypothermia shortly after the administration of antibiotics would attenuate the inflammatory response and increase in intracranial pressure that occurs in meningitis. For this study we used a rabbit model of severe Group B streptococcal meningitis. The first component of this study evaluated the effects of hypothermia on blood-brain barrier function and markers of inflammation in meningitic animals. The second part of the study evaluated the effects of hypothermia on intracranial pressure, cerebral perfusion pressure and brain edema. This study demonstrates that the use of hypothermia preserves CSF/serum glucose ratio, decreases CSF protein and nitric oxide and attenuates myeloperoxidase activity in brain tissue. In the second part of this study we show a decrease in intracranial pressure, an improvement in cerebral perfusion pressure and a decrease in cerebral edema in hypothermic meningitic animals. We conclude that in the treatment of severe bacterial meningitis, the application of moderate hypothermia initiated shortly after antibiotic therapy improves short-term physiologic measures associated with brain injury.

Hearing loss during bacterial meningitis

OBJECTIVE

To determine the natural history and pathogenesis of hearing loss in children with acute bacterial meningitis.

DESIGN

Multicentre prospective study.

SETTING

21 hospitals in the south and west of England and South Wales.

SUBJECTS

124 children between the ages of 4 weeks and 16 years with newly diagnosed bacterial meningitis.

METHODS

Children underwent repeated audiological assessment with the first tests being performed within six hours of diagnosis. By using a combination of otoacoustic emissions, auditory brainstem responses, and tympanometry the differences between cochlear, neural, and conductive defects were distinguished.

RESULTS

Ninety two children (74%) had meningococcal and 18 (15%) had pneumococcal meningitis. All cases of hearing loss were apparent at the time of the first assessment. Three children (2.4%, 95% confidence interval (CI) 0.5 to 6.9%) had permanent sensorineural hearing loss. Thirteen children (10.5%) had reversible hearing loss of whom nine had an impairment that resolved within 48 hours of diagnosis. It is believed that this "fleeting' hearing loss has not been reported previously. The cochlea was identified as the site of the lesion in both the permanent sensorineural and reversible impairments. Hearing loss was more common in children who had been ill for more than 24 hours (relative risk 2.72; 95% CI 0.93 to 7.98).

CONCLUSIONS

Sensorineural hearing loss developed during the earliest stages of meningitis. Permanent deafness was rare but 10% of the patients had a rapidly reversible cochlear dysfunction. This may have progressed to permanent deafness if the patients had not been treated promptly.

Risk factors for adverse outcomes of bacterial meningitis

OBJECTIVE

To identify risk factors for adverse outcomes from bacterial meningitis.

METHODOLOGY

From a cohort of 166 children with bacterial meningitis who were studied prospectively, 130/158 (82%) survivors underwent neurological, neuropsychological, audiological and behaviour assessments 5-9 years following their illness.

RESULTS

Major adverse outcomes included B/166 (4.8%) deaths and severe neurological, intellectual or audiological sequelae in 11/130 (8.5%) children followed. Another 24 (18.5%) had cognitive, auditory or behaviour disorders. Bivariate analysis found age < or = 12 months, tertiary referral, symptoms > 24 h before diagnosis, seizures, focal neurological signs, deteriorating conscious state in hospital, Streptococcus pneumoniae infection and serum sodium concentration < 130 mmol/L were associated with adverse outcomes. Multivariate analysis showed age < or = 12 months, symptoms > 24 h, seizures after 72 h in hospital and focal neurological signs as independent risk factors. These were present in 18/19 (95%) children with major sequelae, but absent in 9/24 (37.5%) children with minor disabilities.

CONCLUSIONS

As minor disabilities following meningitis cannot be predicted, all survivors require assessment during their early school years.

Long-term sequelae of pneumococcal meningitis in children

The purpose of this study was to assess the long-term effects of pneumococcal meningitis in children. From 1967 to 1988, a total of 90 children were admitted to the Hospital for Infectious Diseases, Thessaloniki, Greece, with the diagnosis of pneumococcal meningitis. Sixteen patients died in the hospital as a direct result of meningitis. Eleven others were excluded from the study (neurologic deficits prior to onset of meningitis, two; death subsequent to hospitalization, two; recurrent meningitis, seven). Of the remaining 63 survivors, we were able to evaluate 47 patients (75%). Evaluation was performed 4 to 23 years (mean 12.3 +/- 5.8 years) after discharge. Forty patients returned to hospital for evaluation, and seven were evaluated by their primary physicians, who sent information by a standardized questionnaire. The following examinations were carried out: history, physical and neurologic examination, ophthalmologic and hearing evaluation, and psychometric testing. Fourteen patients (30%) had at least one neurologic handicap; nine (19%) had mental retardation, eight (17%) hearing loss, seven (15%) seizure disorder, five (11%) motor defects, and one each (2%) behavioral problems and visual impairment. The presence of coma was the strongest predictor of increased morbidity. The high frequency of long-term sequelae observed in our study supports the need of an effective vaccine.

Prognostic factors in childhood bacterial meningitis

The purpose of this study was to identify possible risk factors associated with a poor prognosis in childhood bacterial meningitis. We also analysed the influence of duration of symptoms and prehospital antibiotic therapy on outcome. Ninety-two children aged 1 month to 13.8 years were included, of whom 4 died (4.3%) and 14 (15.2%) experienced permanent neurological sequelae. Hearing impairment was the most frequent sequela and was strongly associated with the length of history. Multiple logistic regression revealed duration of symptoms > 48 h, pre-hospital seizures, peripheral vasoconstriction, < 1000 x 10(6)/l leucocytes in cerebrospinal fluid and temperature < or = 38.0 degrees C on admission as risk factors independently associated with later death or sequelae. There was no association between pre-hospital oral or parenteral antibiotic therapy and outcome. These risk factors may be of value in selecting patients for more intensive therapy and in identifying possible candidates for new treatment strategies.

Clinical manifestations and outcome of Haemophilus influenzae type b disease

OBJECTIVE

To document clinical manifestations, laboratory findings and outcome of childhood Haemophilus influenzae type b (Hib) infections.

METHODOLOGY

Medical records of 235 children with Hib disease admitted to hospital during a 2 year period were reviewed; additional information was obtained by questionnaire and follow up 6 weeks after discharge.

RESULTS

Three-quarters of patients presented with either meningitis or epiglottitis. Children with epiglottitis were older, had shorter illnesses and were less likely to have had antibiotics before admission than those with meningitis; 38% of the latter had been given some antibiotic therapy, with no apparent effect on the outcome. Fever persisted for 7 days or more in 23% of patients with meningitis. Death from meningitis occurred in 3.8% of patients and was due to fulminating disease.

CONCLUSIONS

These data will assist in recognition and appropriate management of Hib disease as the clinical manifestations become less familiar following the introduction of immunization. Specific laboratory diagnosis is required for accurate surveillance, which should be maintained in order to ensure high immunization rates.