Community-Acquired Bacterial Meningitis: Risk Stratification for Adverse Clinical Outcome and Effect of Antibiotic Timing
Publication: Annals of Internal Medicine
Volume 129, Number 11_Part_1
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Abstract
Background:
Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults.
Objective:
To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome.
Design:
Retrospective cohort study; patients were divided into derivation and validation samples.
Setting:
Four hospitals in Connecticut.
Patients:
269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department.
Measurements:
Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge).
Results:
For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21%) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P = 0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P = 0.008) or intermediate risk (P = 0.003) at arrival in the emergency department to high risk before administration of antibiotics.
Conclusions:
In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.
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References
1.
Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS Jr, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993; 328:21-8.
2.
Talan DA, Zibulewsky J. Relationship of clinical presentation to time to antibiotics for the emergency department management of suspected bacterial meningitis. Ann Emerg Med. 1993; 22:1733-8.
3.
Meadow WL, Lantos J, Tanz RR, Mendez D, Unger R, Wallskog P. Ought “standard care” be the “standard of care”? A study of the time to administration of antibiotics in children with meningitis. Am J Dis Child. 1993; 147:40-4.
4.
Bryan CS, Reynolds KL, Crout L. Promptness of antibiotic therapy in acute bacterial meningitis. Ann Emerg Med. 1986; 15:544-7.
5.
Olsson RA, Kirby JC, Romansky MJ. Pneumococcal meningitis in the adult. Clinical, therapeutic, and prognostic aspects in forty-three patients. Ann Intern Med. 1961; 55:545-9.
6.
Carpenter RR, Petersdorf RG. The clinical spectrum of bacterial meningitis. Am J Med. 1962; 33:262-75.
7.
Swartz MN, Dodge PR. Bacterial meningitis-a review of selected aspects. I. General clinical features, special problems and unusual meningeal reactions mimicking bacterial meningitis. N Engl J Med. 1965; 272:725-31, 779-87, 898-902.
8.
Dodge PR, Swartz MN. Bacterial meningitis-a review of selected aspects. II. Special neurologic problems, postmeningitic complications and clinicopathological correlations. N Engl J Med. 1965; 272:954-60, 1003-10.
9.
Wiebe RA, Crast FW, Hall RA, Bass JW. Clinical factors relating to prognosis of bacterial meningitis. South Med J. 1972; 65:257-64.
10.
Hodges GR, Perkins RL. Acute bacterial meningitis: an analysis of factors influencing prognosis. Am J Med Sci. 1975; 270:427-40.
11.
Baird DR, Whittle HC, Greenwood BM. Mortality from pneumococcal meningitis. Lancet. 1976; 2:1344-6.
12.
Herson VC, Todd JK. Prediction of morbidity in Hemophilus influenzae meningitis. Pediatrics. 1977; 59:35-9.
13.
Romer FK. Bacterial meningitis: a 15-year review of bacterial meningitis from departments of internal medicine. Dan Med Bull. 1977; 24:35-40.
14.
Finland M, Barnes MW. Acute bacterial meningitis at Boston City Hospital during 12 selected years, 1935-1972. J Infect Dis. 1977; 136:400-15.
15.
Magnussen CR. Meningitis in adults: ten-year retrospective analysis at community hospital. N Y State J Med. 1980; 80:901-6.
16.
Davey PG, Cruikshank JK, McManus IC, Mahood B, Snow MH, Geddes AM. Bacterial meningitis-ten years experience. J Hyg (Lond). 1982; 88:383-401.
17.
Ispahani P. Bacterial meningitis in Nottingham. J Hyg (Lond). 1983; 91:189-201.
18.
Bohr V, Hansen B, Jessen O, Johnson N, Kjersem H, Kristensen HS, et al. Eight hundred and seventy-five cases of bacterial meningitis. Part I of a three-part series: clinical data, prognosis, and the role of specialised hospital departments. J Infect. 1983; 7:21-30.
19.
Fong IW, Rinalli P. Staphylococcus aureus meningitis. Q J Med. 1984; 53:289-99.
20.
Gorse GJ, Thrupp LD, Nudleman KL, Wyle FA, Hawkins B, Cesario TC. Bacterial meningitis in the elderly. Arch Intern Med. 1984; 144:1603-7.
21.
Schlesinger LS, Ross SC, Schaberg DR. Staphylococcus aureus meningitis: a broad-based epidemiologic study. Medicine (Baltimore). 1987; 66:148-56.
22.
Behrman RE, Meyers BR, Mendelson MH, Sacks HS, Hirschman SZ. Central nervous system infections in the elderly. Arch Intern Med. 1989; 149:1596-9.
23.
Lebel MH, McCracken GH Jr. Delayed cerebrospinal fluid sterilization and adverse outcome of bacterial meningitis in infants and children. Pediatrics. 1989; 83:161-7.
24.
Rasmussen HH, Sorensen HT, Moller-Petersen J, Mortensen FV, Nielsen B. Bacterial meningitis in elderly patients: clinical picture and course. Age Aging. 1992; 21:216-20.
25.
Jensen AG, Espersen F, Skinhoj P, Rosdahl VT, Frimodt-Moller N. Staphylococcus aureus meningitis. A review of 104 nationwide, consecutive cases. Arch Intern Med. 1993; 153:1902-8.
26.
Kallio MJ, Kilpi T, Anttila M, Peltola H. The effect of a recent previous visit to a physician on outcome after childhood bacterial meningitis. JAMA. 1994; 272:787-91.
27.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40:373-83.
28.
Feinstein AR. Multivariable Analysis: An introduction. New Haven, CT: Yale Univ Pr; 1996.
29.
Concato J, Feinstein AR, Holford TR. The risk of determining risk with multivariable models. Ann Intern Med. 1993; 118:201-10.
30.
Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996; 49:1373-9.
31.
Braitman LE, Davidoff F. Predicting clinical states in individual patients. Ann Intern Med. 1996; 125:406-12.
32.
Feinstein AR. Evaluation of prognosis and transitions: general strategic principles and applications to AIDS. In: Sechrest L, Freeman HE, Mullay AG, eds. Health Services Research Methodology: A Focus on AIDS. Rockville, MD: National Center for Health Services Research and Health Care Technology Assessment, Public Health Service, U.S. Dept. of Health and Human Services 1989:189-96. Publication no. (PHS) 89-3439/G.
33.
Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules. Applications and methodological standards. N Engl J Med. 1985; 313:793-9.
34.
Harrell FE Jr, Lee KL, Matchar DB, Reichert TA. Regression models for prognostic prediction: advantages, problems, and suggested solutions. Cancer Treatment Rep. 1985; 69:1071-7.
35.
Quagliarello VJ, Wispelwey B, Long WJ Jr, Scheld WM. Recombinant human interleukin-1 induces meningitis and blood-brain barrier injury in the rat. Characterization and comparison with tumor necrosis factor. J Clin Invest. 1991; 87:1360-6.
36.
Ramilo O, Saez-Llorens X, Mertsola J, Jafari H, Olsen KD, Hansen EJ, et al. Tumor necrosis factor α/cachectin and interleukin 1 β initiate meningeal inflammation. J Exp Med. 1990; 172:497-507.
37.
Quagliarello V, Scheld WM. Bacterial meningitis: pathogenesis, pathophysiology, and progress. N Engl J Med. 1992; 327:864-72.
38.
Leib SL, Kim YS, Chow LL, Sheldon RA, Tauber MG. Reactive oxygen intermediates contribute to necrotic and apoptotic neuronal injury in an infant rat model of bacterial meningitis due to group B streptococci. J Clin Invest. 1996; 98:2632-9.
39.
Tureen JH, Dworkin RJ, Kennedy SL, Sachdeva M, Sande MA. Loss of cerebrovascular autoregulation in experimental meningitis in rabbits. J Clin Invest. 1990; 85:577-81.
40.
Quagliarello VJ, Long WJ, Scheld WM. Morphologic alterations of the blood-brain barrier with experimental meningitis in the rat. Temporal sequence and role of encapsulation. J Clin Invest. 1986; 77:1084-95.
41.
Quagliarello VJ, Ma A, Stukenbrok H, Palade GE. Ultrastructural localization of albumin transport across the cerebral microvasculature during experimental meningitis in the rat. J Exp Med. 1991; 174:657-72.
42.
Fine MJ, Orloff JJ, Arisumi D, Fang GD, Arena VC, Hanusa BH, et al. Prognosis of patients hospitalized with community-acquired pneumonia. Am J Med. 1990; 88(5N):1N-8N.
43.
Scheld WM. Bacterial meningitis and brain abscess. In: Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, eds. Harrison's Principles of Internal Medicine. 13th ed. New York: McGraw-Hill; 1994:2296-309.
44.
Tunkel AR, Scheld WM. Acute meningitis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 4th ed. New York: Churchill Livingstone; 1995:831-65.
45.
Talan DA, Guterman JJ, Overturf GD, Singer C, Hoffman JR, Lambert B. Analysis of emergency department management of suspected bacterial meningitis. Ann Emerg Med. 1989; 18:856-62.
46.
Kilpi T, Anttila M, Kallio MJ, Peltola H. Length of prediagnostic history related to the course and sequelae of childhood bacterial meningitis. Pediatr Infec Dis J. 1993; 12:184-8.
47.
Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med. 1997; 336:708-16.
Information & Authors
Information
Published In
Annals of Internal Medicine
Volume 129 • Number 11_Part_1 • 1 December 1998
Pages: 862 - 869
History
Published in issue: 1 December 1998
Published online: 15 August 2000
Keywords
Copyright
© 1998 American College of Physicians.
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Community-Acquired Bacterial Meningitis: Risk Stratification for Adverse Clinical Outcome and Effect of Antibiotic Timing. Ann Intern Med.1998;129:862-869. doi:10.7326/0003-4819-129-11_Part_1-199812010-00004
Community-Acquired Bacterial Meningitis: Risk Stratification for Adverse Clinical Outcome and Effect of Antibiotic Timing. Ann Intern Med.1998;129:862-869. doi:10.7326/0003-4819-129-11_Part_1-199812010-00004
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