Bacterial Meningitis in Young Adults in Southern Taiwan: Clinical Characteristics and Therapeutic Outcomes

Abstract Background: To delineate the epidemiologic trend, clinical characteristics and therapeutic outcomes of bacterial meningitis in young adults in southern Taiwan. Patients and Methods: Over a period of 18 years, 329 cases of culture-proven adult bacterial meningitis were identified at our hospital. Among these 329 cases, 62 were identified as young adults (≤ 40 years) and their clinical features, laboratory data and therapeutic outcomes were reviewed. The prognostic factors between fatal and non-fatal groups were compared. Results: The 62 young adults were 48 men and 14 women, aged 17–40 years. Thirty of the 62 patients belonged to nosocomial infection, and the other 32 belonged to community-acquired infection. A total of 74% (46/62) of the patients had a postneurosurgical state as the underlying condition. Alcoholism (n = 8) was the most common underlying condition of the other 16 patients with spontaneous meningitis. Of these 62 patients, Klebsiella pneumoniae (12) and Pseudomonas aeruginosa (9) were the most common implicated gram-negative pathogens. During the late study period, there was an increase in coagulase-negative staphylococcus and Staphylococcus aureus infections. The therapeutic results of this group of patients are as follows: 13 patients died, 18 had full recovery and 31 had varying degrees of neurologic deficits. Impaired consciousness and thrombocytopenia were significant prognostic factors. Conclusion: A postneurosurgical state is an important preceding event for young adults to develop bacterial meningitis. Of the implicated gram-negative pathogens, K. pneumoniae and P. aeruginosa are common; however, there has been an increase in staphylococcal infection in recent years. Therapeutic results of this specific group of patients showed that 20% (13/62) of the patients died, and 50% (31/61) of the patients in this study had neurologic deficits. However, the small case number and possible bias of case selection has limited the analytical conclusions of this study. Further large-scale studies are needed to delineate the clinical characteristics and therapeutic outcomes of bacterial meningitis in this specific group of patients.     

Mixed Infection in Adult Bacterial Meningitis

Summary 12 adult patients suffering from bacterial meningitis caused by mixed infection were identified at Kaohsiung Chang Gung Memorial Hospital over a period of 13 years (1986–1998), and they accounted for 6.5% (12/184) of our culture-proven adult bacterial meningitis. The 12 cases included seven males and five females, aged 17–74 years. Six of the 12 cases had community-acquired infections and the other six had nosocomially-acquired infections. Ten of the 12 cases had associated underlying diseases, with head trauma and/or neurosurgical procedure being the most frequent. Both gram-negative and gram-positive pathogens were identified in these 12 cases with gram-negative pathogens outnumbering the gram-positive ones. The implicated pathogens, starting with the most frequent, included Enterobacter species (Enterobacter cloacae, Enterobacter aerogenes), Klebsiella species (Klebsiella pneumoniae, Klebsiella oxytoca), Escherichia coli, Staphylococcus species (Staphylococcus aureus, Staphylococcus haemolyticus), Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus, Serratia marcescens, Citrobacter diversus, Proteus mirabilis, Streptococcus viridans and Neisseria meningitidis. Six of the 12 cases were found to have multi-antibiotic-resistant strains, which included E. cloacae in one, A. baumannii in one, K. pneumoniae in one and S. aureus in three. The management of these 12 cases included appropriate antibiotics and neurosurgical procedures including shunt revision. Despite the complexity of implicated pathogens and the high incidence of emergence of resistant strains, the overall mortality rate (8.3%, 1/12) was not higher than that in adult bacterial meningitis. However, complete recuperation was difficult in adult patients with mixed bacterial meningitis. Received: October 5, 1999 · Accepted: November 23, 1999     

Community-Acquired Spontaneous Bacterial Meningitis in Adult Diabetic Patients: An Analysis of Clinical Characteristics and Prognostic Factors

Background: We analyzed the clinical characteristics and prognostic factors of community-acquired spontaneous bacterial meningitis (CASBM) in adult diabetic patients. Patients and Methods: Over a period of 15 years, 47 adult diabetic patients with CASBM were identified. The clinical characteristics, laboratory data and therapeutic outcome of these 47 patients were statistically analyzed. Results: The 47 patients were 31 men and 16 women, aged 22 to 79 years, and they accounted for 38.5% (47/122) of our adult patients with culture-proven CASBM. The most common causative pathogen was Klebsiella pneumoniae (n = 32), followed by pathogens of the streptococcal species (n = 6). Besides classic manifestations of bacterial meningitis, bacteremia and focal suppuration, especially liver abscess, were common features in this group of patients. Liver cirrhosis and/or alcoholism were the other frequent underlying conditions. 27 patients survived in the course of therapy. The prognostic factors with statistical significance were glucose ratio and cerebrospinal fluid (CSF) white blood cell (WBC) count. Conclusion: This study showed the high incidence of diabetes mellitus (DM) among the adult patients with CASBM in Taiwan. K. pneumoniae was the most frequent causative pathogen. Bacteremia and focal suppuration, especially liver abscess, were common findings. The values of glucose ratio and CSF WBC count had a statistically significant influence on the prognosis of our patients. Received: January 15, 2002 · Revision accepted: July 8, 2002 W. N. Chang (corresponding author)     

Bacterial Meningitis in an Urban Area: Etiologic Study and Prognostic Factors

Abstract Objectives: The study of clinical features, diagnostic methods and prognostic factors of bacterial meningitis, in an urban area. Patients and Methods: All patients admitted between June 2001 and July 2004 in the emergency departments of a few hospitals, with the diagnosis of bacterial meningitis were included. CSF and blood cultures were performed in every case. Phenotypic characterization of strains of Streptococcus pneumoniae and Neisseria meningitidis identified by culture were performed. In order to detect the three most common agents it was done a PCR assay in culture negative CSF samples. Results: Bacterial meningitis was diagnosed in 201 patients. Etiologic definition was based on culture in 142 patients (70.6%), done by CSF PCR assay in 33 (16.4%) other patients and exclusively by latex agglutination test results in two cases. Thus, an etiologic diagnosis was established in 177 (88%) cases. Antigenic characterization showed a slight prevalence of N. meningitidis phenotype C:2b:P1; the S. pneumoniae serotype characterization showed that 43.8% of identified serotypes are not included in any of the available vaccines. Eighteen patients died (8.9%). The statistic analysis found that factors associated with an adverse outcome were age older than 50 years (OR 7.07; IC 95% 1.1–27.4), the presence of comorbidities (OR 3.3; IC 95% 1.1–9.6) and the occurrence of systemic complications (OR 5.8; IC 95% 2.1–16.0). Conclusions: This epidemiologic pattern is similar to that found in other countries after the introduction of Haemophilus influenzae b conjugated vaccine. The association of culture and noncultural methods of diagnosis had a better performance in defining the etiology. Comparing to other series, in-patients mortality rate was lower (8.9%) than usually referred to, being considered unfavourable prognostic factors the age more than 50 years, the presence of comorbidities and of systemic complications.     

Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study

Acute aortic dissection (AD) is a catastrophic condition associated with a high rate of mortality. However, current epidemiological information regarding AD remains sparse. The objective of the present study was to investigate the current epidemiological profile and medication utilization patterns associated with aortic dissection in Taiwan.In this population-based study, we identified cases of AD diagnosed during 2005 to 2012 in the complete Taiwan National Health Insurance (NHI) Research Database. Patients with AD were identified using the International Classification of Disease, Ninth Revision (ICD-9) code 441.0, and surgical interventions were defined using NHI procedure codes.A total of 9092 individuals with a mean age of 64.4 ± 15.1 years were identified. The cases were divided into 3 groups: Group A included 2340 patients (25.74%) treated surgically for type A AD; Group B included 1144 patients (12.58%) treated surgically for type B AD, and Group C included 5608 patients (61.68%) with any type of AD treated with medical therapy only. The average annual incidence of AD was 5.6 per 100,000 persons, and the average prevalence was 19.9 per 100,000 persons. Hypertension was the most common risk factor, followed by coronary artery disease and chronic obstructive pulmonary disease. Within 1 year of AD diagnosis, 92% of patients were taking antihypertensive medication. Calcium channel blockers were the most frequently prescribed antihypertensive medication for long-term observation in Taiwan.The annual trends revealed statistically significant increases in the numbers and percentages of prevalence, incidence, and mortality. Changes in patients’ drug utilization in patterns were observed after AD diagnosis. Our study provides a local profile that supports further in-depth analyses in AD-affected populations.     

Appropriateness of Upper Gastrointestinal Endoscopy: A Hospital-Based Study

Aims of this study were to evaluate: (1) whether upper gastrointestinal endoscopy (UGE) is used appropriately according to the American Society for Gastrointestinal Endoscopy (ASGE) and British Society of Gastroenterology (BSG) guidelines in a hospital setting and (2) whether there is any relationship between appropriateness of UGE and the presence of lesions detected by endoscopy. Indications and endoscopic findings for 734 consecutive UGE performed in 697 inpatients were retrospectively evaluated using ASGE and BSG guidelines to determine appropriateness of referrals. UGE showing endoscopic findings that had direct therapeutic or prognostic consequences were classified as "positive"; the other UGEs were classified as "negative." In all, 46% of UGEs were "positive," 54% "negative," and 61.7% and 23.2% of UGEs were inappropriate according to ASGE and BSG guidelines, respectively (P < 0.001). The probability of finding a positive endoscopy was significantly higher in UGE rated as appropriate than in those rated as inappropriate on the basis of ASGE guidelines (P < 0.001), but not on the basis of BSG guidelines. Endoscopies rated as inappropriate according to ASGE and BSG criteria showed a positive finding in 37.3% and 42.3% of cases, respectively (not significant difference). Multivariate analysis showed that the positive finding is directly related to age (P < 0.05), male gender (P < 0.001), prior UGE (P < 0.05), hematemesis (P < 0.001), and inversely related with upper abdominal pain (P < 0.01) and dyspepsia (P < 0.05). In hospitalized patients, UGE is frequently used for inappropriate indications, according to both ASGE and BSG guidelines. However, the actual clinical usefulness of appropriateness criteria, such as those proposed by ASGE and BSG, is questionable, as their strict observance could lead to missing a large number of significant endoscopic findings.     

Hospital-Based Management of Acute Asthmatic Exacerbation: An Assessment of Physicians' Behavior in Taiwan

This retrospective study was conducted to assess Taiwanese emergency physicians for their preference in management and adherence to guidelines in treating patients with acute exacerbation of asthma. One hundred twenty patients from hospitals of three different levels were evaluated by reviewing their medical records. Our study revealed that physicians from medical centers and regional hospitals assessed patients more often with arterial blood gas or pulse oxymetry; prescribed more doses of β₂-agonist nebulizers; administered more doses of β₂-agonist nebulizers before administering parenteral aminophylline; and prescribed ipratropium nebulizers more often as adjunctive therapy. On the other hand, physicians from district hospitals more frequently prescribed parenteral aminophylline as the first-line medication and more often prescribed only a single dose of β₂-agonist nebulizer. Most emergency physicians in Taiwan did not adhere to guidelines. Specifically, these included omission of peak expiratory flow as the means to assess the severity of asthma exacerbation and response to treatment; suboptimal use of inhaled bronchodilators, such as β₂-agonists and ipratropium; and inappropriate use of parenteral aminophylline as the first-line medication.     

Long-Term Sequelae of Childhood Bacterial Meningitis

In most high-income countries, fewer children now acquire meningitis, and many of those who do will survive. Globally, however, meningitis still remains a significant cause of child morbidity and mortality. In this article, the authors review recent evidence on the morbidity faced by childhood survivors of bacterial meningitis. Outcomes vary by bacterial pathogen, with around a 20 % risk for severe sequelae (most commonly, neurocognitive) by all pathogenic causes. Pneumococcal, tuberculosis, and group B streptococcal meningitis lead to the highest rates of sequelae. Recent epidemiological shifts in the major pathogens causing meningitis, as well as varied regional settings between studies, limit generalizability of evidence in the literature, and better research using longitudinal data and case–control methodology is required, especially in low-income countries. However, the consistently high levels of complications described in the literature call for more widespread vaccination programs for prevention and a greater focus on potential complications by educators and health-care providers to support childhood survivors of bacterial meningitis and their families.     

Nationwide Hospital-Based Survey of Adult T-Cell Leukemia/Lymphoma in Japan

Nationwide surveys of adult T-cell leukemia/lymphoma (ATL) have played an important role in helping us to understand the pathophysiology of this disease and analyze its prognosis in Japan. Classifications of clinical subtypes have been proposed based on the results of nationwide surveys of patients with ATL diagnosed in the 1980s. This article highlighted the classification and prognosis of ATL based on different surveys and focused on the comparison of data derived from the available surveys. The 11th nationwide hospital-based survey was conducted in patients with ATL diagnosed in 2010–2011 using the same method as that used in the 1980s survey. The median age of disease onset was 68 years, which was increased compared with previous surveys. While median survival of patients with the acute and lymphoma types had not improved much since the 1980s, the 4-year survival rate was higher. Little improvement in the prognosis was observed for the chronic and smoldering types. The 12th nationwide survey of patients with ATL diagnosed in 2012–2013 also showed an increase in age at onset. Further epidemiological research that includes more cases is needed to deepen our understanding of the actual state of treatment and prognosis of this disease.     

Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. The Bacterial Meningitis Study Group

A prospective, laboratory-based surveillance project obtained accurate data on meningitis in a population of 34 million people during 1986. Haemophilus influenzae was the most common cause of bacterial meningitis (45%), followed by Streptococcus pneumoniae (18%), and Neisseria meningitidis (14%). Rates of H. influenzae meningitis varied significantly by region, from 1.9/100,000 in New Jersey to 4.0/100,000 in Washington state. The overall case fatality rates for meningitis were lower than those reported in several studies from the early 1970s, suggesting that improvements in early detection and antibiotic treatment may have occurred since that time. Concurrent surveillance was also performed for all invasive disease due to the five most common causes of bacterial meningitis. Serotypes of group B streptococcus other than type III caused more than half of neonatal group B streptococcal disease and mortality, suggesting that an optimal vaccine preparation must be multivalent. Of the organisms evaluated, group B streptococcus was the second most common cause of invasive disease in persons greater than 5 years old.     

The Prognostic Factors of Adult Tuberculous Meningitis

Background: Our aim was to analyze the prognostic factors and therapeutic outcomes of adult tuberculous meningitis (TBM). Patients and Methods: Clinical data of 36 patients with adult TBM were retrospectively identified at our institution over a period of 5 years. Results: 36 adult TBM patients, 23 males and 13 females, aged 16–83 years, were included in this study. The 36 patients were also divided into three groups (stages I, II and III) according to the severity of TBM on admission. Therapeutic outcomes at 3 months were determined using a modified Barthel Index (BI). For the purpose of statistical analysis, the patients were divided into two groups: good outcome (BI ≥ 12) and poor outcome (BI < 12). Positive cerebrospinal fluid (CSF) culture was found in 47% (17/36) of patients and isoniazid-resistant strains were found in 18% (3/17) of culture-proven TBM. We statistically compared clinical manifestations, CSF features and therapeutic results of the two patient groups. Significant prognostic factors included severity of TBM at the time of admission, the presence of headache, fever, hydrocephalus, high CSF protein concentration and high CSF lactate concentration. In stepwise logistic regression analysis, only the presence of hydrocephalus and severity of TBM on admission were strongly associated with therapeutic failure even after adjusting for other potentially confounding factors. Conclusion: In Taiwan, TBM is an important public health issue and the emergence of resistant strains of this disease in recent years presents a therapeutic challenge. Because delay in diagnosis is directly related to poor outcome, early diagnosis and early treatment are essential for survival. Received: July 17, 2000 · Revision accepted: July 16, 2001     

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.