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Abstract
Outbreaks of vaccine-preventable diseases are becoming more common in the United States. Outbreaks of some diseases, such as measles, can be attributed to decreasing vaccination rates. Clinicians need to be aware of the vulnerabilities in their communities. Detection of an outbreak requires familiarity with signs, symptoms, and laboratory findings for these now unusual diseases. Clinicians also need to work with public health officials to identify, treat, and limit the spread of these infections. This article describes the populations most at risk from illnesses associated with sporadic outbreaks, with information on diagnosis, treatment, and ways to limit the spread of infection.
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Affiliation(s)
- Jennifer L Hamilton
- Department of Family, Community, and Preventive Medicine, Drexel University College of Medicine, 10 Shurs Lane, Suite 301, Philadelphia, PA 19127, USA.
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2
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Pearce J, Peters M, May N, Marshall H, Hein C, Grantham H. Care of the patient with invasive meningococcal disease by prehospital emergency medical service clinicians: a scoping review. BMJ Open 2020; 10:e033447. [PMID: 32114468 PMCID: PMC7050377 DOI: 10.1136/bmjopen-2019-033447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/12/2019] [Accepted: 02/12/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The objective of this scoping review is to systematically map the literature to identify the scope, depth, key concepts and gaps in the evidence regarding care of the patient with invasive meningococcal disease by emergency medical service (EMS) clinicians. DESIGN Scoping review. This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guideline. ELIGIBILITY CRITERIA Sources which focused on patients with invasive meningococcal disease (population), where the care of EMS clinicians was the focus (concept), in EMS systems worldwide (context) were eligible for inclusion. SEARCH STRATEGY This review utilised a comprehensive search strategy including MEDLINE, Embase, Emcare, CINAHL, Scopus, Web of Science, Google Scholar and 'grey' literature databases from 1992 to January 2019. The search also included a Google search, a hand-search of relevant journals, screening of reference lists, contact with authors of included sources and use of social media in an attempt to locate all sources of evidence which fit the inclusion criteria of the review. Two reviewers independently screened sources for inclusion. RESULTS The search yielded 1803 unique records, of which 10 were included in the synthesis. No original research papers were identified, with all sources classed as either clinical audit or text and opinion literature. The dominant concept throughout the literature is that early antibiotic therapy is critical in the treatment of invasive meningococcal disease. CONCLUSIONS Overall, there is a very narrow scope and shallow depth of literature on the topic of interest. There are gaps in the evidence regarding the care of the patient with invasive meningococcal disease by EMS clinicians. Despite these shortfalls, current consensus-based guidelines should direct clinical practice. Further research is planned to bridge the gaps in knowledge to support best practice.
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Affiliation(s)
- James Pearce
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Micah Peters
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia
| | - Nikki May
- SA Health Library Service, Bedford Park, South Australia, Australia
| | - Helen Marshall
- School of Medicine and Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Vaccinology and Immunology Research Trials Unit, Discipline of Paediatrics, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
| | - Cindy Hein
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Hugh Grantham
- South Australian Ambulance Service, Adelaide, South Australia, Australia
- Faculty of Health Sciences, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
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Bannister SA, Kidd SP, Kirby E, Shah S, Thomas A, Vipond R, Elmore MJ, Telfer Brunton A, Marsh P, Green S, Silman NJ, Kempsell KE. Development and Assessment of a Diagnostic DNA Oligonucleotide Microarray for Detection and Typing of Meningitis-Associated Bacterial Species. High Throughput 2018; 7:ht7040032. [PMID: 30332776 PMCID: PMC6306750 DOI: 10.3390/ht7040032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/11/2018] [Accepted: 09/21/2018] [Indexed: 02/03/2023] Open
Abstract
Meningitis is commonly caused by infection with a variety of bacterial or viral pathogens. Acute bacterial meningitis (ABM) can cause severe disease, which can progress rapidly to a critical life-threatening condition. Rapid diagnosis of ABM is critical, as this is most commonly associated with severe sequelae with associated high mortality and morbidity rates compared to viral meningitis, which is less severe and self-limiting. We have designed a microarray for detection and diagnosis of ABM. This has been validated using randomly amplified DNA targets (RADT), comparing buffers with or without formamide, in glass slide format or on the Alere ArrayTubeTM (Alere Technologies GmbH) microarray platform. Pathogen-specific signals were observed using purified bacterial nucleic acids and to a lesser extent using patient cerebral spinal fluid (CSF) samples, with some technical issues observed using RADT and glass slides. Repurposing the array onto the Alere ArrayTubeTM platform and using a targeted amplification system increased specific and reduced nonspecific hybridization signals using both pathogen nucleic and patient CSF DNA targets, better revealing pathogen-specific signals although sensitivity was still reduced in the latter. This diagnostic microarray is useful as a laboratory diagnostic tool for species and strain designation for ABM, rather than for primary diagnosis.
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Affiliation(s)
| | - Stephen P Kidd
- Public Health England, Porton Down, Salisbury SP4 0JG, UK.
| | | | - Sonal Shah
- Public Health England, Porton Down, Salisbury SP4 0JG, UK.
| | - Anvy Thomas
- Public Health England, Porton Down, Salisbury SP4 0JG, UK.
| | - Richard Vipond
- Public Health England, Porton Down, Salisbury SP4 0JG, UK.
| | | | - Andrew Telfer Brunton
- Department of Clinical Microbiology, Royal Cornwall Hospitals NHS Trust, Penventinnie Lane, Treliske, Truro, Cornwall TR1 3LQ, UK.
| | - Peter Marsh
- Public Health England Laboratory Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
| | - Steve Green
- Public Health England Laboratory Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
| | - Nigel J Silman
- Public Health England, Porton Down, Salisbury SP4 0JG, UK.
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Vardakas KZ, Matthaiou DK, Falagas ME. Adjunctive dexamethasone therapy for bacterial meningitis in adults: a meta-analysis of randomized controlled trials. Eur J Neurol 2009; 16:662-73. [PMID: 19475753 DOI: 10.1111/j.1468-1331.2009.02615.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The objective of this review was to study the effectiveness of dexamethasone for the treatment of adult patients with bacterial meningitis. Data was extracted from randomized controlled trials (RCTs) comparing dexamethasone with placebo or no treatment and pooled using meta-analysis techniques. Treatment with dexamethasone was associated with a non-significant lower mortality than placebo or no treatment [odds ratio (OR) = 0.68, 95% confidence interval (CI) 0.45-1.04]. If a RCT conducted in Malawi was excluded from the analysis, dexamethasone was associated with lower mortality than placebo or no treatment (OR = 0.58, 95% CI 0.40-0.83). Dexamethasone was associated with lower mortality in patients with definite meningitis (OR = 0.55, 95% CI 0.31-0.96), short duration of symptoms (OR = 0.61, 95% CI 0.38-1.00), Streptococcus pneumoniae meningitis (OR = 0.26, 95% CI 0.08-0.78), patients in countries with high (OR = 0.45, 95% CI 0.23-0.87) and medium Human Development Index (OR = 0.65, 95% CI 0.42-1.00). No benefit was seen in patients with longer duration of symptoms (OR = 0.80, 95% CI 0.47-1.36) or no antibiotic use (OR = 0.68, 95% CI 0.36-1.28). Dexamethasone was associated with fewer episodes of hearing impairment in high quality RCTs (OR = 0.64, 95% CI 0.43-0.94). The currently available evidence suggests that dexamethasone should be administered to all adult patients with bacterial meningitis. Large studies are needed to clarify the role of the duration of symptoms, disease severity, and antibiotic administration before the initiation of treatment with dexamethasone on modifying the outcomes.
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Affiliation(s)
- K Z Vardakas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
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Fitch MT, van de Beek D. Emergency diagnosis and treatment of adult meningitis. THE LANCET. INFECTIOUS DISEASES 2007; 7:191-200. [PMID: 17317600 DOI: 10.1016/s1473-3099(07)70050-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Despite the existence of antibiotic therapies against acute bacterial meningitis, patients with the disease continue to suffer significant morbidity and mortality in both high and low-income countries. Dilemmas exist for emergency medicine and primary-care providers who need to accurately diagnose patients with bacterial meningitis and then rapidly administer antibiotics and adjunctive therapies for this life-threatening disease. Physical examination may not perform well enough to accurately identify patients with meningitis, and traditionally described lumbar puncture results for viral and bacterial disease cannot always predict bacterial meningitis. Results from recent studies have implications for current treatment guidelines for adults with suspected bacterial meningitis, and it is important that physicians who prescribe the initial doses of antibiotics in an emergency setting are aware of guidelines for antibiotics and adjunctive steroids. We present an overview and discussion of key diagnostic and therapeutic decisions in the emergency evaluation and treatment of adults with suspected bacterial meningitis.
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Affiliation(s)
- Michael T Fitch
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Van den Bruel A, Bartholomeeusen S, Aertgeerts B, Truyers C, Buntinx F. Serious infections in children: an incidence study in family practice. BMC FAMILY PRACTICE 2006; 7:23. [PMID: 16569232 PMCID: PMC1435901 DOI: 10.1186/1471-2296-7-23] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Accepted: 03/28/2006] [Indexed: 11/22/2022]
Abstract
Background Information on the incidence of serious infections in children in general practice is scarce. However, estimates on the incidence of disease are important for several reasons, for example to assess the burden of disease or as a basis of diagnostic research. We therefore estimated the incidence of serious infections in general practice in Belgium. Methods Intego is a morbidity registration network, in which 51 general practitioners continuously register all diagnoses and additional data in their electronic medical records. Serious infections were defined as pneumonia, sepsis, meningitis, pyelonephritis and osteomyelitis. Incidences are calculated for the period of 1998 to 2002, per 1000 patients in the yearly contact group, which is the group of patients that consulted their GP at least once that year, and in the practice population, which is the estimated true population of that practice. Results The incidence of all infectious diseases peaks in children between 0 and 4 years, with 1731 infections per 1000 children per year in the yearly contact group. Incidence drops with increasing age: 972 infections per 1000 children per year in children between 5 and 9 years old, and 732 in children between 10 and 14 years old. The same decline in incidence is observed in the subgroup of serious infections: 21 infections per 1000 children per year in children between 0 and 4 years, 12 in children between 5 and 9 years and 5 in children between 10 and 14 years. The results for the estimated practice population are respectively 17, 9 and 4 serious infections per 1000 children per year. Conclusion In contrast to the total incidence of acute infections, serious infections are rare, around 1% per year. Children younger than 4 years old have the highest risk for serious infections, and incidences of some infections are different for boys and girls.
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Affiliation(s)
- Ann Van den Bruel
- Academisch Centrum voor Huisartsgeneeskunde, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stefaan Bartholomeeusen
- Academisch Centrum voor Huisartsgeneeskunde, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Academisch Centrum voor Huisartsgeneeskunde, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Carla Truyers
- Academisch Centrum voor Huisartsgeneeskunde, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Frank Buntinx
- Academisch Centrum voor Huisartsgeneeskunde, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of General Practice, Universiteit Maastricht, Maastricht, The Netherlands
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Van den Bruel A, Bruyninckx R, Vermeire E, Aerssens P, Aertgeerts B, Buntinx F. Signs and symptoms in children with a serious infection: a qualitative study. BMC FAMILY PRACTICE 2005; 6:36. [PMID: 16124874 PMCID: PMC1215482 DOI: 10.1186/1471-2296-6-36] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Accepted: 08/26/2005] [Indexed: 11/17/2022]
Abstract
Background Early diagnosis of serious infections in children is difficult in general practice, as incidence is low, patients present themselves at an early stage of the disease and diagnostic tools are limited to signs and symptoms from observation, clinical history and physical examination. Little is known which signs and symptoms are important in general practice. With this qualitative study, we aimed to identify possible new important diagnostic variables. Methods Semi-structured interviews with parents and physicians of children with a serious infection. We investigated all signs and symptoms that were related to or preceded the diagnosis. The analysis was done according to the grounded theory approach. Participants were recruited in general practice and at the hospital. Results 18 children who were hospitalised because of a serious infection were included. On average, parents and paediatricians were interviewed 3 days after admittance of the child to hospital, general practitioners between 5 and 8 days after the initial contact. The most prominent diagnostic signs in seriously ill children were changed behaviour, crying characteristics and the parents' opinion. Children either behaved drowsy or irritable and cried differently, either moaning or an inconsolable, loud crying. The parents found this illness different from previous illnesses, because of the seriousness or duration of the symptoms, or the occurrence of a critical incident. Classical signs, like high fever, petechiae or abnormalities at auscultation were helpful for the diagnosis when they were present, but not helpful when they were absent. Conclusion behavioural signs and symptoms were very prominent in children with a serious infection. They will be further assessed for diagnostic accuracy in a subsequent, quantitative diagnostic study.
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Affiliation(s)
- Ann Van den Bruel
- Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 Blok J, 3000 Leuven, Belgium
| | - Rudi Bruyninckx
- Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 Blok J, 3000 Leuven, Belgium
| | - Etienne Vermeire
- Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 Blok J, 3000 Leuven, Belgium
- Department of General Practice, Universtaire Instelling Antwerpen, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Peter Aerssens
- Department of Pediatrics, Virga Jesseziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Bert Aertgeerts
- Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 Blok J, 3000 Leuven, Belgium
| | - Frank Buntinx
- Department of General Practice, Katholieke Universiteit Leuven, Kapucijnenvoer 33 Blok J, 3000 Leuven, Belgium
- Department of General Practice, Universiteit Maastricht, Postbus 616, 6200 MD Maastricht, The Netherlands
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van de Beek D, de Gans J. Adjunctive Corticosteroids in Adults with Bacterial Meningitis. Curr Infect Dis Rep 2005; 7:285-291. [PMID: 15963330 DOI: 10.1007/s11908-005-0061-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bacterial meningitis is a complex disorder in which neurologic injury is caused, in part, by the causative organism and, in part, by the host's own inflammatory response. In studies of experimental bacterial meningitis, adjuvant treatment with corticosteroids, specifically dexamethasone, has beneficial effects. On the basis of these experimental studies, several clinical trials were undertaken to determine the effects of adjunctive corticosteroids in patients with bacterial meningitis. On the basis of overall benefit without detrimental effects by subgroup analysis, dexamethasone therapy should be initiated before or with the first dose of antibiotic and should be continued in most patients with community-acquired acute bacterial meningitis. For patients with a low suspicion of meningitis but an urgent need for antibiotics before cerebrospinal fluid can be obtained, we recommend initiation of treatment with dexamethasone, with discontinuation of dexamethasone therapy as soon as the diagnosis has been excluded.
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Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE, Amsterdam, The Netherlands.
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van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. THE LANCET. INFECTIOUS DISEASES 2004; 4:139-43. [PMID: 14998499 DOI: 10.1016/s1473-3099(04)00937-5] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bacterial meningitis is uncommon but causes significant mortality and morbidity, despite optimum antibiotic therapy. A clinical trial in 301 patients showed a beneficial effect of adjunctive steroid treatment in adults with acute community-acquired pneumococcal meningitis, but data on other organisms or adverse events are sparse. This led us to do a quantitative systematic review of adjunctive steroid therapy in adults with acute bacterial meningitis. Five trials involving 623 patients were included (pneumococcal meningitis=234, meningococcal meningitis=232, others=127, unknown=30). Overall, treatment with steroids was associated with a significant reduction in mortality (relative risk 0.6, 95% CI 0.4-0.8, p=0.002) and in neurological sequelae (0.6, 0.4-1, p=0.05), and with a reduction of case-fatality in pneumococcal meningitis of 21% (0.5, 0.3-0.8, p=0.001). In meningococcal meningitis, mortality (0.9, 0.3-2.1) and neurological sequelae (0.5, 0.1-1.7) were both reduced, but not significantly. Adverse events, recorded in 391 cases, were equally divided between the treatment and placebo groups (1, 0.5-2), with gastrointestinal bleeding in 1% of steroid-treated and 4% of other patients. Since treatment with steroids reduces both mortality and neurological sequelae in adults with bacterial meningitis, without detectable adverse effects, routine steroid therapy with the first dose of antibiotics is justified in most adult patients in whom acute community-acquired bacterial meningitis is suspected.
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MESH Headings
- Acute Disease
- Adult
- Anti-Infective Agents/therapeutic use
- Chemotherapy, Adjuvant
- Community-Acquired Infections/complications
- Community-Acquired Infections/drug therapy
- Community-Acquired Infections/mortality
- Drug Therapy, Combination
- Female
- Humans
- Male
- Meningitis, Bacterial/complications
- Meningitis, Bacterial/drug therapy
- Meningitis, Bacterial/mortality
- Meningitis, Meningococcal/complications
- Meningitis, Meningococcal/drug therapy
- Meningitis, Meningococcal/mortality
- Meningitis, Pneumococcal/complications
- Meningitis, Pneumococcal/drug therapy
- Meningitis, Pneumococcal/mortality
- Meta-Analysis as Topic
- Randomized Controlled Trials as Topic
- Steroids/adverse effects
- Steroids/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Diederik van de Beek
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Netherlands.
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Ellis-Pegler R, Galler L, Roberts S, Thomas M, Woodhouse A. Three days of intravenous benzyl penicillin treatment of meningococcal disease in adults. Clin Infect Dis 2003; 37:658-62. [PMID: 12942396 DOI: 10.1086/377203] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2003] [Accepted: 04/18/2003] [Indexed: 11/03/2022] Open
Abstract
New Zealand has experienced an epidemic of predominantly serogroup B meningococcal disease during the past decade. In a prospective study, we treated adults (age, >15 years) with meningococcal disease with intravenous benzyl penicillin (12 MU [7.2 g] per day) for 3 days. Sixty-one adults with suspected meningococcal disease were consecutively admitted during the 33-month period; 3 patients were excluded. The 58 patients had a mean age (+/- standard deviation [SD]) of 27.9+/-14.5 years (median, 21 years; range, 15-70 years). Forty-four patients had confirmed and 14 patients had probable meningococcal disease. Fifty-seven patients received 12 MU (7.2 g) and 1 received 8 MU (4.8 g) of benzyl penicillin per day. Thirteen patients received additional antibiotics within the first 24 h because of diagnostic uncertainties. Patients received a mean (+/-SD) of 3.0+/-0.5 days of treatment. No patients relapsed. Five patients died. All but 1 death occurred during benzyl penicillin treatment, and the only posttreatment death was not due to meningococcal disease. Three days of intravenous benzyl penicillin is sufficient treatment for adults with meningococcal disease. The usual recommendations for duration of treatment are excessive.
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Affiliation(s)
- Rod Ellis-Pegler
- Department of Infectious Diseases, Auckland Hospital, Auckland, New Zealand.
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van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2003. [DOI: 10.1002/14651858.cd004405] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Senneville E, Baclet V. [Physiopathology and curative treatment of meningococcal diseases: current aspects]. PATHOLOGIE-BIOLOGIE 2002; 50:613-9. [PMID: 12504371 DOI: 10.1016/s0369-8114(02)00362-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early administration of antibiotics as soon as the diagnosis of meningococcemia has been evoked is a significant therapeutic advance. However, the poor outcome of these diseases whose mortality remains high despite the current techniques of reanimation shows that improving the vaccination against meningococci is still of actuality. Diagnosing rapidly severe meningococcal disease is also a means for acting against the pathological activation of the inflammatory and coagulation pathways. Significant advances have been made in understanding the physiopathology of the meningococcal purpura fulminans especially about the deleterious role of the deficiency of the protein C and the antithrombin III. It is too soon to advance that the prognosis of these diseases has been improved by these new therapeutic approaches but the results of preliminary clinical studies are encouraging. However, informing parents about the first skin abnormalities seen in infants with purpura fulminans is essential in attempt to improve the efficiency of these new therapeutic strategies.
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Affiliation(s)
- E Senneville
- Service universitaire régional des maladies infectieuses et du voyageur (Pr. Y. Mouton), hôpital Dron, 135, rue du Président-Coty BP 619, 59200 Tourcoing, France.
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15
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Affiliation(s)
- R Munro
- Department of Microbiology and Infectious Diseases, South Western Area Pathology Service, Sydney, New South Wales, Australia.
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Abstract
Many countries have been experiencing a significant increase in meningococcal disease. With the strains currently circulating, septicaemia is now a more frequent manifestation than meningitis and early recognition of disease manifestations by patient, parent or physician as well as early recognition of disease severity are the most important factors in attempting to reduce mortality and morbidity. Ceftriaxone is the treatment of choice but must be accompanied by aggressive supportive therapy in those with severe disease. The role of steroids is unknown. The evidence to support their use in both meningitis and severe systemic sepsis is discussed. The purified polysaccharide vaccines that have been available for some years may play a limited role in disease prevention. The recently introduced conjugate vaccine for preventing serogroup C disease represents a major advance but no vaccine is currently available to prevent serogroup B disease, cases of which will continue to challenge clinical practice.
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Affiliation(s)
- Robert A Wall
- Department of Microbiology, Northwick Park Hospital, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex, England HA1 3UJ.
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Holdgate A, Cuthbert K. Perils and pitfalls of lumbar puncture in the emergency department. EMERGENCY MEDICINE (FREMANTLE, W.A.) 2001; 13:351-8. [PMID: 11554868 DOI: 10.1046/j.1035-6851.2001.00239.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Lumbar Puncture is a procedure commonly performed in the emergency department. It provides important diagnostic information but has a significant number of limitations and complications. This article reviews the role of lumbar puncture in the emergency department based on an extensive review of the current literature, focusing on the recognized contraindications and complications of the procedure and how they can be minimized. The interpretation of diagnostic tests performed on cerebrospinal fluid is also examined, highlighting those tests most commonly ordered from the emergency department.
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Affiliation(s)
- A Holdgate
- Department of Emergency Medicine, St George Hospital, Sydney, New South Wales, Australia.
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Piscopo T, Mallia-Azzopordi C, Grech V, Muscat M, Attard-Montalto S, Mallia C. Epidemiology and prognostic factors in meningococcal disease in a small island population: Malta 1994-1998. Eur J Epidemiol 2001; 16:1051-6. [PMID: 11421475 DOI: 10.1023/a:1010865315425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVE To review the epidemiology of meningococcal disease in Malta over the period 1994-1998, and to identify factors at presentation and in the management of meningococcal disease which may influence mortality. DESIGN All admissions with meningococcal disease to a national hospital in a population-based study over the period 1994-1998 were studied retrospectively. MAIN RESULTS Fifty-six cases were diagnosed over 1994-1998, the incidence rising from 0.8/100,000 to 7.2/100,000 total population (p < 0.0001). The median time interval from arrival at hospital to administration of parenteral antibiotic decreased over the 5-year period from 4.4 to 1.2 hours (p = 0.025), with no significant change in the case-fatality rate. There was no association between the time interval from arrival at hospital to parenteral antibiotic administration, and mortality. The following features at presentation were associated with increased mortality: older age (p = 0.03), meningococcaemia compared with meningitis (p = 0.05), shock (p < 0.0001), disseminated intravascular coagulation (p = 0.0001), a normal/low white blood cell count (p = 0.0003), a low platelet count (p = 0.0001) and a high serum creatinine (p = 0.003). CONCLUSIONS The upsurge of cases in the population was accompanied by a decrease in intervention time in the general hospital, probably due to increased awareness of the disease. This study did not show a positive relationship between early in-hospital administration of antibiotics and improved survival, probably because antibiotics were given earlier to those with fulminant disease and, with therefore, an inherently worse outcome. Stratification of cases by severity on admission is recommended in future studies.
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Affiliation(s)
- T Piscopo
- Medical Department, St. Luke's Hospital, Guardamangia, Malta.
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Affiliation(s)
- D Lennon
- Community Paediatrics, South Auckland Clinical School, University of Auckland, Auckland, New Zealand.
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Affiliation(s)
- R A Wall
- Department of Microbiology, Northwick Park Hospital, North West London NHS Trust, UK
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Leclerc F, Leteurtre S, Cremer R, Fourier C, Sadik A. Do new strategies in meningococcemia produce better outcomes? Crit Care Med 2000; 28:S60-3. [PMID: 11007200 DOI: 10.1097/00003246-200009001-00013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Meningococcal septic shock (MSS) has high mortality and morbidity rates. In addition to the traditional prompt antibiotics and respiratory and circulatory support, new treatment strategies have been proposed. AGAINST THE INFLAMMATORY CASCADE Immunotherapy, such as antiserum to Escherichia coli J5 and human antilipid A monoclonal antibodies/centoxin (HA-1A), did not significantly alter the mortality rate of MSS; we are awaiting the results of the bactericidal/permeability-increasing protein multicenter trial. Two series reported the effects of hemofiltration and hemodiafiltration in MSS, but the true benefits remain unknown. TO TREAT HEMOSTATIC ABNORMALITIES In MSS, heparin is still controversial and antithrombin concentrate use has been reported in only one child. Several case reports on protein C and recombinant tissue plasminogen activator have been published; the efficacy (improvement in shock and organ dysfunction and reduction in amputation rate) and safety (intracerebral hemorrhage with recombinant tissue plasminogen activator) of these treatments need further evaluation. Blood and plasma exchange appear to be safe and are supposed to reduce mortality, but it is difficult to draw firm conclusions from published studies. Finally, local application of medicinal leeches has been reported to improve purpuric lesions. TO INDUCE VASODILATION Prostacyclin, or epoprostenol, infusion, sodium nitroprussiate infusion, sympathetic blockade, and topical nitroglycerin have been reported to improve distal perfusion; however, these reports are all anecdotal. OTHER STRATEGIES Improvement in limb perfusion was achieved after hyperbaric oxygenation in patients with purpura fulminans caused by different pathogens. Most authors recommend monitoring of compartment pressures and performing fasciotomy as indicated. Finally, extracorporeal membrane oxygenation was recently proposed to support seven children with intractable MSS. CONCLUSIONS There is no proof that unconventional treatments have a significant impact on outcome in MSS; prospective multicenter trials are needed. At present, early recognition of meningococcal sepsis and appropriate treatment seem to be the optimal methods of improving outcome. Efforts to find an effective meningococcal vaccine must be continued.
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Affiliation(s)
- F Leclerc
- Pediatric Intensive Care Unit, University Hospital of Lille, France.
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Cartwright K. Laboratory Investigation and Diagnosis of Meningitis and Meningococcal Septicaemia. J R Coll Physicians Edinb 2000. [DOI: 10.1177/147827150003000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
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.
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Affiliation(s)
- F A Riordan
- Birmingham Heartlands and Solihull NHS Trust (Teaching), England
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Abstract
Meningococcal disease is increasing in incidence in many countries, and effective vaccines for serogroup B strains will not be available for at least 5 to 10 years. In the interim, it is attention to principles of good clinical practice, particularly in the early management of the disease, that have the potential to reduce by half the current case fatality rate of approximately 10%. As discussed in this article, those principles include increased awareness, understanding of the disease and its early symptoms by parents and healthcare professionals, and careful attention to the patient before admission and during the hospital stay.
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Affiliation(s)
- K A Cartwright
- Department of Clinical Microbiology, Gloucestershire Royal Hospital, United Kingdom
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26
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Morgenlander JC. Concerns about meningitis. Postgrad Med 1998; 104:31. [PMID: 9676559 DOI: 10.1080/00325481.1998.11444688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Granier S, Owen P, Stott NC. Recognizing meningococcal disease: the case for further research in primary care. Br J Gen Pract 1998; 48:1167-71. [PMID: 9667096 PMCID: PMC1410038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Most studies describing the clinical presentation of meningococcal disease use data derived from hospital-based studies. This paper reviews current knowledge on the presentation of meningococcal disease from a primary care perspective. In a small proportion of cases with classical features, making the diagnosis may be relatively simple. In many cases, however, the general practitioner (GP) is faced with the difficulty of discriminating between the rare patient with life-threatening illness and the vast majority who present with similar symptoms secondary to self-limiting viral illness. In the absence of reliable means of excluding the disease, GPs will need to consider the possibility of meningococcal disease in all ill and febrile patients in whom no cause is apparent. Planned follow-up and clearer explanation to patients may increase the chance of identifying earlier those cases that evolve with time. More research is required to identify key clinical and contextual features that help GPs to predict or exclude serious disease, and to describe how this information is used in decision-making. A framework for conceptualizing the problems of researching illness is provided, which takes into account the many factors that influence clinical practice in primary care.
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Affiliation(s)
- S Granier
- Department of General Practice, University of Wales College of Medicine, Llanedeyrn, Cardiff.
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Collignon P, Patel M, Watson C. Benefits of broad spectrum antibiotics outweigh the risks. Med J Aust 1998. [DOI: 10.5694/j.1326-5377.1998.tb126787.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Peter Collignon
- Department of Infectious DiseasesACT PathologyPO Box 11WodenACT2606
| | - Mahomed Patel
- National Centre for Epidemiology and Population HealthAustralian National UniversityCanberraACT
| | - Charles Watson
- Chair of the Meningococcal Disease Working Party of the National Health and Medical Research Council, and Deputy Vice‐Chancellor (Health Sciences)Curtin University of TechnologyPerthWA
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Olcén P, Lantz PG, Bäckman A, Rådström P. Rapid diagnosis of bacterial meningitis by a seminested PCR strategy. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1995; 27:537-9. [PMID: 8588152 DOI: 10.3109/00365549509047063] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A polymerase chain reaction (PCR) based diagnostic assay has been developed for the simultaneous detection in cerebrospinal fluid (CSF) of Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus agalactiae, Listeria monocytogenes and bacteria in general. In the present communication we describe the design of primers for S. pneumoniae, S. agalactiae, and L. monocytogenes, and a general PCR protocol for the assay. The diagnostic outcome is presented for a small collection of CSF specimens including 2 samples from patients with culture-negative purulent meningitis.
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Affiliation(s)
- P Olcén
- Department of Clinical Microbiology, Orebro Medical Center Hospital, Sweden
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31
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Riordan FA, Marzouk O, Thomson AP, Sills JA, Hart CA. Initial management of suspected meningococcal infection. On the spot treatment needed. BMJ (CLINICAL RESEARCH ED.) 1994; 309:1661-2. [PMID: 7819970 PMCID: PMC2541998 DOI: 10.1136/bmj.309.6969.1661a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Michaeli D. Clinical problem-solving: prevention of meningococcal infection. N Engl J Med 1994; 330:511-2. [PMID: 8135948 DOI: 10.1056/nejm199402173300720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Affiliation(s)
- H Peltola
- Children's Hospital, University of Helsinki, Finland
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