Cerebrospinal Fluid Glucose Levels and Sensorineural Hearing Loss in Bacterial Meningitis

Background: Low cerebrospinal fluid (CSF) glucose levels have been associated with sensorineural hearing loss (SNHL) in bacterial meningitis but systematic investigations are lacking.Patients and Methods: A retrospective case control study was conducted comparing CSF glucose levels in 47 cases with and 145 controls without SNHL following bacterial meningitis.Results: The mean CSF glucose level (standard deviation [SD]) was 1.3 mmol/l (1.2) in cases and 2.5 mmol/l (1.6) in controls (p < 0.001). The difference between the groups was significant for Streptococcus pneumoniae and Haemophilus influenzae but not for Neisseria meningitidis infection. It was independent of the delay of treatment if this was greater than 12 h. This delay was significantly longer in cases compared to controls.Conclusion: In bacterial meningitis other than that caused by N. meningitidis and independent of the duration of symptoms prior to diagnosis, CSF glucose levels were significantly lower in patients developing a SNHL compared to controls.     

Epidemiology and antibiotic resistance of bacterial meningitis in Dapaong,northern Togo

ObjectiveTo assess the seasonality of the bacterial meningitis and the antibiotic resistance of incriminated bacteria over the last three years in the northern Togo.MethodsFrom January 2007 to January 2010, 533 cerebrospinal fluids (CSF) samples were collected from patients suspected of meningitis in the Regional Hospital of Dapaong (northern Togo). After microscopic examination, samples were cultured for bacterial identification and antibiotic susceptibility.ResultsThe study included 533 patients (306 male and 227 female) aged from 1 day to 55 years [average age (13.00±2.07) years]. Bacterial isolation and identification were attempted for 254/533 (47.65%) samples. The bacterial species identified were: Neisseria meningitidis A (N. meningitidis A) (58.27%), Neisseria meningitidis W135 (N. meningitidis W135) (7.09%), Streptococcus pneumoniae (S. pneumoniae) (26.77%), Haemophilus influenza B (H. influenza B) (6.30%) and Enterobacteriaceae (1.57%). The results indicated that bacterial meningitis occur from November to May with a peak in February for H. influenzae and S. pneumoniae and March for Neisseriaceae. The distribution of positive CSF with regards to the age showed that subjects between 6 and 12 years followed by subjects of 0 to 5 years were most affected with respective frequencies of 67.82% and 56.52% (P<0.001). Susceptibility tests revealed that bacteria have developed resistance to several antibiotics including aminosides (resistance rate >20% for both bacterial strains), macrolides (resistance rate > 30% for H. influenzae) quinolones (resistance rate >15% for H. influenzae and N. meningitidis W135). Over three years, the prevalence of S. pneumoniae significantly increased from 8.48% to 73.33% (P<0.001), while the changes in the prevalence of H. influenzae B were not statistically significant: 4.24%, vs. 8.89%, (P = 0.233).ConclusionsOur results indicate that data in African countries differ depending on geographical location in relation to the African meningitis belt. This underlines the importance of epidemiological surveillance of bacterial meningitis.     

Cerebrospinal fluid penetration of cefmenoxime in children with bacterial meningitis

Summary Blood and cerebrospinal fluid (CSF) concentrations of cefmenoxime were determined either microbiologically or by means of HPLC in 20 children with proven or suspected bacterial meningitis. Sixteen children suffered from bacterial meningitis: causative organisms wereHaemophilus influenzae type b (n=10),Streptococcus pneumoniae (n=4) andNeisseria meningitidis (n=2). In these patients the cefmenoxime concentration in the CSF ranged from 0.9 to 12.2 mg/l, with a mean concentration of 4.63 mg/l 1.5–3 h after the last intravenous cefmenoxime application and 24–48 h after initiating therapy with 200 mg cefmenoxime/kg/d in four doses. In eight cases the bactericidal titers of the CSF were examined during therapy. Titers between 1:64 and 1:2,048, exceeding the minimal bactericidal concentration, were found. After five doses of cefmenoxime 50 mg/kg, two CSF cultures showed bacterial growth: oneH. influenzae (bactericidal titer in CSF 1:256) and oneS. pneumoniae.

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Liquorspiegel von Cefmenoxim bei Kindern mit bakterieller Meningitis

Zusammenfassung Bei zwanzig Kindern wurden Serum- und Liquorspiegel von Cefmenoxim mittels HPLC oder aber mikroskopisch bestimmt. Sechzehn Kinder litten an bakterieller Meningitis:Haemophilus influenzae Typ b (n=10),Streptococcus pneumoniae (n=4),Neisseria meningitidis (n=2). Die Proben wurden 24–48 h nach Behandlungsbeginn (200 mg cefmenoxim/kg/die) in vier Einzeldosen 1,5–3 h nach der letzten Gabe entnommen. Die Liquorspiegel bei den Kindern mit entzündeten Meningen lagen zwischen 0,9 bis 12,2 mg/l, im Mittel 4,63 mg/l. In acht Fällen wurde die Liquorbakterizidie bestimmt. Die Titer lagen zwischen 1:64 bis 1:2048. Zwei Liquorkulturen nach fünf Dosen 50 mg/kg zeigten bakterielles Wachstum. Einmal fand sichH. influenzae (Liquorbakterizidie 1:256) und einmalS. pneumoniae.

     

Community-Acquired Bacterial Meningitis in Adults: Antibiotic Timing in Disease Course and Outcome

Abstract Objectives: Despite improvements in diagnostic and therapeutic approach to adult patients with bacterial meningitis, the overall mortality rate is still high. The aim of this study was to evaluate antibiotic timing in the course and outcome of bacterial meningitis. Methods: Two hundred and eighty six patients with community-acquired bacterial meningitis aged 14 years and more were included in this retrospective cohort study. Observational period was between 1 January 1990 and 31 December 2004. To assess the association of antibiotic timing and disease outcome we analyzed three timing periods (according to the onset of disease, onset of consciousness disturbance and the time of admission to hospital). Analysis was also performed in a subgroup of culture positive meningitis in 176 patients with altered mental status. Results: Unfavorable outcome was found in 125 (43,7%) patients. In this group, the start of appropriate antibiotic treatment in relation to the onset of first symptoms and particularly to the onset of consciousness disturbance was significantly delayed (p = 0.018 and p < 0.001, respectively) compared to the favorable group. Logistic regression analysis in a subgroup of culture positive meningitis in patients with altered mental status revealed that early adequate antibiotic treatment related to the onset of overt signs of meningitis was independently associated with favorable outcome (OR = 11.19; 95% CI 4.37–32.57; p < 0.001). Advanced age, lower GCS and seizures (OR = 1.05, OR = 1.45 and OR = 3.65, respectively) were other risk factors of poor outcome. The presence of chronic diseases, pneumococcal etiology and clinical and laboratory variables which are indicators of disease severity (renal and/or liver dysfunction, hypotension and low cerebrospinal fluid glucose) were not confirmed as independent risk factors of poor outcome. Conclusions: Our study emphasizes the importance of early and adequate antibiotic treatment in the management of bacterial meningitis which significantly enhances the chances for favorable outcome.     

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)     

Predictive Value of Serum and Cerebrospinal Fluid Procalcitonin Levels for the Diagnosis of Bacterial Meningitis

Background: The value of serum and cerebrospinal fluid (CSF) procalcitonin for differentiating between acute bacterial and viral meningitis was assessed and compared to other parameters which are usually used in clinical practice. Patients: 45 adult patients (20 with bacterial and 25 with tick-borne encephalitis, TBE) were included in this prospective study. Results: The median serum procalcitonin level in patients with bacterial meningitis was 6.45 ng/ml (range 0.25–43.76 ng/ml) and in the group with viral meningitis 0.27 ng/ml (range 0.05–0.44 ng/ml). 11 patients with bacterial meningitis had an elevated procalcitonin concentration not only in serum, but also in CSF. A serum procalcitonin level > 0.5 ng/ml had a positive predictive value for bacterial meningitis of 100% and a negative predictive value of 93%, while corresponding values for CSF procalcitonin were 100% and 74%, respectively. Conclusion: Serum and CSF procalcitonin concentrations > 0.5 ng/ml appear to be a reliable indicator of bacterial central nervous system (CNS) infection, with maximal positive predictive values and high negative predictive values. Received: October 23, 2000 · Revision accepted: June 1, 2001     

Validation of a clinical prediction rule for the differential diagnosis of acute meningitis

Objective: To attempt to validate a previously reported clinical prediction rule derived to assist in distinguishing between acute bacterial meningitis and acute viral meningitis. Design: Retrospective chart review of patients treated at five hospitals between 1981 and 1990. The criterion standard for bacterial meningitis was a positive cerebrospinal fluid (CSF) or blood culture or a positive test for bacterial antigen in the CSF. For viral meningitis, the criterion standard was a positive viral culture from CSF, stool, or blood or a discharge diagnosis of viral meningitis with no other etiology evident. Setting: Two Department of Veterans Affairs (VA) hospitals, two county hospitals, and one private hospital, each affiliated with one of two medical schools. Patients: All persons aged more than 17 years who were hospitalized over a ten-year period at one of five academically affiliated hospitals for the management of acute meningitis. Measurements and main results: Sixty-two cases of bacterial meningitis and 98 cases of viral meningitis were confirmed. With all patients included, the discriminatory power of the model as measured by the area under the receiver operating characteristic curve (AUC) was 0.977 (95% CI, 0.957–0.997), compared with the AUC of 0.97 in the derivation set of the original publication. The AUCs (95% CIs) for data subsets were: Dallas cases 0.994 (0.986–1.0), Milwaukee cases 0.912 (0.834–0.990); ages 18–39 years 0.952 (0.892–1.0), ages 40–59 years 0.99 (0.951–1.0), and age >60 years 0955 (0.898–1.0). Conclusions. The authors conclude that the clinical prediction rule proved robust when applied to a geographically distinct population comprised exclusively of adults. There was sustained performance of the model when applied to cases from each city and from three age strata. Prospective validation of this prediction rule will be necessary to confirm its utility in clinical practice. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29, 1992. Supported by an Institutional Research Grant under the Regents Appropriations program at UT/Southwestern Medical School.     

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.     

Treatment of childhood bacterial meningitis

Summary One hundred and eighty-seven children with identified bacterial meningitis were treated with intravenous cefotaxime: 15 patients were neonates, 79 infants, and 93 were aged from 1 to 14 years. Causative organisms were:Neisseria meningitidis in 80 cases,Streptococcus pneumoniae in 41,Haemophilus influenzae in 40, enteric gram-negative bacilli in 20 andStaphylococcus spp. in six. Enteric gram-negative bacilli included:Salmonella spp. in 14 cases,Klebsiella pneumoniae in two, andEscherichia coli, Enterobacter sakazakii andAcinobacter calcoaceticus in one each; in one case the organism was not specified. Daily dose of cefotaxime was 150 to 300 mg/kg. Concomitant treatment with an aminoglycoside was used in seven cases. One hundred and seventy-two patients (92.0%) were cured. Fever persisted for a mean of five days and meningeal signs for a mean of four days. Fifteen (8.0%) patients died: most [13] of them were admitted in coma, and two in shock. Death occurred in the first 48 h in ten cases. Sterilization of CSF was achieved in the first 72 h of treatment in 155 (90.1%) of the cured patients. Cefotaxime was well tolerated. CSF penetration of cefotaxime was evaluated in seven patients: concentrations ranged from 0.499 mg/l to 2.829 mg/l. Based on this clinical study, cefotaxime is an effective and safe drug for the treatment of childhood bacterial meningitis.

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Behandlung der bakteriellen Meningitis im Kindesalter

Zusammenfassung 187 Kinder mit bakterieller Meningitis gesicherter Atiologie wurden intravenös mit Cefotaxim behandelt. 15 der Patienten waren Neugeborene, 79 Säuglinge, und 93 waren im Alter von 1–14 Jahren. Als kausale Erreger wurden in 80 FällenNeisseria meningitidis, in 41Streptococcus pneumoniae, in 40Haemophilus influenzae, in 20 gramnegative Darmbakterien und in sechs FällenStaphylococcus spp. identifiziert. Unter den gramnegativen Darmbakterien fanden sichSalmonella spp. in 14,Klebsiella pneumoniae in zwei sowieEscherichia coli, Enterobacter sakazakii undAcinetobacter calcoaceticus in je einem Fall; in einem Fall gelang die Erregerspezifizierung nicht. Die tägliche Cefotaxim-Dosis lag zwischen 150 und 300 mg/kg. In sieben Fällen wurde eine Kombinationstherapie mit einem Aminoglykosid durchgeführt. Bei 172 Patienten trat eine Heilung ein (92,0%). Das Fieber hielt im Mittel fünf und die Meningitis-Zeichen vier Tage an. 15 Patienten verstarben, davon waren 13 im Koma und zwei im Schock eingeliefert worden. Zehn Kinder verstarben innerhalb der ersten 48 Stunden. Bei 155 (90,1%) der geheilten Patienten wurde der Liquor innerhalb der ersten 48 h nach Therapiebeginn steril. Die Verträglichkeit von Cefotaxim war gut. Bei sieben Patienten wurde die Liquorpenetration von Cefotaxim untersucht: Die Konzentrationen lagen zwischen 0,499 und 2,829 mg/l. Die Ergebnisse dieser Studie zeigen, daß Cefotaxim ein wirksames und sicheres Therapeutikum für die bakterielle Meningitis im Kindesalter ist.

     

Respiratory symptoms,asthma, atopy and Chlamydia pneumoniae IgG antibodies in a general population sample of young adults

Background: This study was designed to test the association of Chlamydia pneumoniae infection with respiratory symptoms and atopy. Methods: A general population sample of 369 young adults (aged 20-44 years) completed a questionnaire on respiratory symptoms and underwent skin prick testing. C pneumoniae IgG and IgM serum titers were measured by micro-immunofluorescence. Prior infection was defined by titers of IgG ≥ 1:32, acute infection by titers of IgG ≥ :512 and/or IgM ≥ 1:16. Results: The prevalence of cough and phlegm was higher in subjects with (19.0%) than in those without (11.4%) prior C. pneumoniae infection (p = 0.01). A similar difference was found for wheezing (14.3% vs 8.0%; p = 0.05), whereas the percentage of asthmatics was equally distributed between seropositive and seronegative subjects. IgG titers ≥ 1:128 were found more frequently in atopic subjects (p = 0.04). After adjusting for any confounding factors, cough and phlegm (but not wheezing) were found significantly associated with C. pneumoniae positivity, both for 1 : 32 (OR 1.80; 95% CI: 1.01-3.36; p = 0.05) and for 1 : 128 titers (OR 2.31; 95% CI: 1.20-4.42; p = 0.01). A significant association was also found for atopy, for titers ≥ 1 : 128 (OR 1.73; 95% CI: 1.01-3.20, p = 0.05). Acute infection was not associated with respiratory symptoms or asthma. Conclusion: We conclude that C. pneumoniae infection is associated with cough and phlegm and may have a role in the pathogenesis of chronic respiratory diseases. Moreover, our results indicate a relationship between atopy and C. pneumoniae infection. Received: October 9, 2001 · Revision accepted: March 3, 2002     

Adult Enterobacter Meningitis: A High Incidence of Coinfection with Other Pathogens and Frequent Association with Neurosurgical Procedures

Background: The clinical characteristics of Enterobacter infection in adult bacterial meningitis were defined. Patients and Methods: The clinical manifestations and therapeutic outcomes of ten adult patients with Enterobacter infections in acute bacterial meningitis were analyzed. Results: Enterobacter infection was found in 4.5% (10/223) of our adult patients with culture-proven bacterial meningitis. The ten patients comprised seven men and three women aged between 16–69 years (mean 47 years). Coinfections with other pathogens were found in 50% of the cases, the most common pathogen being Klebsiella pneumoniae. Nine of the ten patients had a history of neurosurgery, and seven patients contracted the infection nosocomially. Multiple antibiotic-resistant strains, including resistance to third-generation cephalosporins, were found in three patients with polymicrobial infections. These three patients received iv imipenem/cilastin therapy. The therapeutic results showed that two of the ten patients died; five of the eight surviving patients had neurological sequelae. Conclusion: The predominant coinfection with Enterobacteriaceae in adult Enterobacter meningitis may reflect the fact that most of the cases of polymicrobial Enterobacter infections have a potential gastrointestinal source. A postneurosurgical state was the most important predisposing factor for the development of Enterobacter infection in adult bacterial meningitis in our patients. The strains of the Enterobacter species in adult polymicrobial Enterobacter meningitis were commonly resistant to multiple antibiotics, including third-generation cephalosporins. In light of the high incidence of multiple antibiotic-resistant Enterobacter strains in adult polymicrobial Enterobacter meningitis, the choice of initial empiric antibiotics may include carbapenem (imipenem/cilastin or meropenem). Although the mortality rate was not high in this group of patients, most survivors suffered neurological sequelae. Received: June 2, 2000 · Revision accepted: December 30, 2000     

Changing epidemiology of bacterial meningitis

Immunization against the most common meningeal pathogens is the leading factor associated with decreased incidence of bacterial meningitis in countries where routine vaccination is available. This is most dramatically illustrated by the reduction in the incidence of Haemophilus influenzae type b meningitis. The incidence of bacterial meningitis has decreased by 55% since the introduction of the H. influenzae type b conjugate vaccine in 1990. H. influenzae occurred primarily in children younger than 5 years of age, and so the median age of patients with bacterial meningitis has now increased to 39 years of age in the United States, and the leading pathogen is currently Streptococcus pneumoniae. Three other control measures (ie, universal screening and antibiotic prophylaxis of pregnant women for Group B streptococci and the implementation and availability of the S. pneumoniae and Neisseria meningitidis conjugate vaccines) have likely further decreased the incidence of these meningeal pathogens. Lastly, the worldwide emergence of multidrug-resistant pneumococci has complicated the empiric therapy of bacterial meningitis.     

Invasive Meningococcal Disease: Patient and Strain Characteristics Set New Challenge for Prevention and Control

Summary Differences in the course of invasive meningococcal disease, in prevalence, case-to-carrier ratio, geographical pattern, age distribution and antibiotic resistance have been related to major serogroups and their serotypes. The relationship between Neisseria meningitidis serogroups and clinical manifestation, outcome and patient characteristics are assessed. All hospitalized patients in six major hospitals in central Isral with a verified meningococcal disease during 1990–1994 were included (n = 66). Their personal and clinical data and the results of bacteriological and serological tests of their blood and cerebrospinal fluid (CSF) were recorded. Meningococci were isolated from both blood and CSF, from blood alone, and from CSF alone in 60.6%, 18.2% and 21.2% of the cases, respectively. The highest proportion of isolations were from infants < 1 year (34.8%), followed by children aged 1 to 5 years (25.8%). Serogroup B prevailed in 62.1%, while group C and W135 accounted for 28.8% and 9.1%, respectively. Serogroup B predominated in children < 1 year, while in patients aged 5–22 years, C strains were the major pathogen (P < 0.001). Serogroup B accounted for 93% of the cases of meningitis, 58% of meningococcemia and 42% of fulminant meningococcemina, while group C strains were the major cause of fulminant meningococcemia (50%). The overall case fatality rate was 7.6%: fulminant meningococcemia 8.3%, and meningococcemia 10%. It was concluded that N. meningitidis group C continues to account for almost a third of the cases of meningococcal disease and is the major cause of fulminant meningococcemia. Received: August 17, 1998 · Revision accepted: January 24, 1999     

Risk factors for mortality in Paraguayan children with pneumococcal bacterial meningitis

Background Over the last decade Streptococcus pneumoniae has emerged as the most common bacterial pathogen for meningitis in all age groups, beyond the neonatal period. Objective To determine the epidemiological and clinical characteristics; and risk factors for mortality of pneumoccocal meningitis in children in a developing transitional country. Materials and methods A retrospective study that included patients <15 years of age admitted at the Instituto de Medicina Tropical of Paraguay, from January 1990 until December 2003 with the diagnosis of bacterial meningitis caused by S. pneumoniae. Clinical and laboratory data were collected and analysed in order to identify risk factors associated with morbidity and mortality outcomes of this infection. Results Seventy-two patients (between the ages of 35 days and 14 years) were identified. Forty-two per cent of patients had seizures prior to or at the time of admission, 36% were admitted in a comatose state, and 19% with shock. Mortality was 33% (24/72), and 18% of the survivors (11/60) developed severe sequelae. Upon admission, the following variables were strongly correlated with mortality: age <12 months (P = 0.007), the presence of seizures (P = 0.0001) or development of seizures 48 h after admission (P = 0.01), a cerebrospinal fluid (CSF) glucose level of <10 mg/dl (P = 0.01), CSF albumin >200 mg/dl (P = 0.0003), an absolute blood neutrophil count <2000/mm³ (P = 0.006) and a haemoglobin value of <9 g/dl (P = 0.0001). Conclusions This study confirms the high morbidity and mortality associated with S. pneumoniae meningitis in Paraguay. Certain clinical parameters and laboratory findings in blood and CSF at the time of admission could be used as predictors for mortality or severe sequelae among survivors.     

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     

Prevalence,risk factors,and management of uncontrolled hypertension among patients with diabetes: A hospital-based cross-sectional study

AimsThis research examines the prevalence of uncontrolled hypertension and associated risk factors among patients with diabetes in Saudi Arabia.MethodsA hospital-based, cross-sectional study was used in patients with diabetes and hypertension attending outpatient diabetes clinics in King Khaled Hospital and Prince Sultan Center for Health Care in Al-Kharj, Riyadh. Patients’ information, data on hypertension, type of treatment, and comorbidities were captured through electronic medical records. Uncontrolled hypertension was defined as blood pressure (BP) measurements greater than or equal to 140/90 mmHg. Antihypertensive medication use among these patients was analyzed. Multivariate analysis was performed to detect the associated factors of uncontrolled hypertension.ResultsOf 1178 outpatients‬ with diabetes who were included in the study sample, uncontrolled hypertension presented in 846 (71.8%). Most patients were on two antihypertensive medications, and the most frequently used was calcium channel blockers, followed by angiotensin-converting enzyme inhibitors. Individuals most likely to have uncontrolled hypertension were those older than 65 years (OR 1.99, 95%CI: 1.059, 3.77), male (OR = 1.51, 95%CI: 1.031, 2.22), and obese (OR = 2.39, 95%CI: 1.63, 3.504), with two (OR = 3.894, 95% CI: 2.481, 6.114) or three or more comorbidities (OR = 4.020, 95% CI: 2.510, 6.439), and with polypharmacy (OR = 1.814, 95% CI: 1.238, 2.656).ConclusionThe extent of uncontrolled hypertension among patients with diabetes in the study sample was found to be high. Age, sex, obesity, number of comorbidities, and polypharmacy are the most important correlates with increased risk of uncontrolled hypertension.     

BKV-DNA and JCV-DNA in CSF of Patients with Suspected Meningitis or Encephalitis

Abstract. Background: Few studies have looked for the polyoma viruses JC or BK virus in the central nervous system (CNS) of patients without neurological symptoms or with neurological symptoms other than progressive multifocal leukoencephalopathy (PML). PCR-microplate hybridization method was employed for the detection of BKV-DNA or JCV-DNA in cerebrospinal fluid (CSF) specimens from patients with suspected meningitis or encephalitis. Materials and Methods: A total of 181 CSF specimens from 151 patients with suspected meningitis or encephalitis was examined for BKV or JCV using PCR-microplate hybridization method. None of the patients had (clinically diagnosed) PML. A control group consisting of 20 CSF specimens from normal subject was also included. Results: BKV DNA was found in five out of 131 (3.8%) and JCV DNA in two out of 131 (1.5%) of the patients with suspected meningitis or encephalitis by PCR ELISA. BKV or JCV DNA was not detected in CSF samples of any of 19 HIVpositive patients. BKV and JCV DNAs were detected respectively in two CSF samples in which Mycobacterium tuberculosis (TB) PCR was also positive. Another patient who was positive for JCV PCR died with a diagnosis of cerebral lymphoma. Among the BK virus infected patients there was a patient with a previous history of hemolytic uremia and acute renal failure. Neither BKV nor JCV DNA was found in any of the 20 CSF samples from normal patients undergoing lumbar puncture for myelography as a part of an investigation of lower back pain. Conclusion: These results suggest that BK virus may be associated with neurological diseases either in immunocompetent or immunocompromised patients. Detection of BKV and JCV DNA in the CSF of the patients suspected to have either meningitis or encephalitis suggests that these viruses may have an etiological role. Thus, diagnostic tests for BK and JC viruses should be included in the investigative program for meningitis or encephalitis patients.     

Changing Epidemiology of Adult Bacterial Meningitis in Southern Taiwan: A Hospital-Based Study

Abstract Background: Many factors may influence the epidemiologic trend of adult bacterial meningitis (ABM). The objective of this study was to analyze recent epidemiologic trends of ABM in order to provide a better therapeutic strategy. Materials and Methods: The clinical features, laboratory data, and therapeutic outcomes of 181 ABM cases collected in the last 6.5 years (July 1999–December 2005) were analyzed. The results were compared with those of our previous study (202 cases, January 1986–June 1999). Results: The 181 cases consisted of 130 men (age range: 18–82 years) and 51 women (age range: 18–78 years). Monomicrobial infection and mixed infection were found in 165 cases and 16 cases, respectively. A preceding postneurosurgical state was noted in 56.9% (103/181) of cases. Despite a decrease in incidence, Klebsiella pneumoniae (25.5%, 42/165) was still the most common pathogen. A marked increase of Acinetobacter meningitis (11.5%, 19/165) was noted, which replaced Pseudomonas meningitis as the second most common Gram-negative pathogen in ABM. A marked increase in staphylococcal infection, accounting for 23% (38/165) of all cases, was also noted, of which 76% (29/38) were methicillin-resistant strains. The therapeutic result showed a mortality rate of 30.3% (55/181). Significant prognostic factors included septic shock and age at infection. Conclusions: This study revealed a change in the epidemiologic trend of ABM, with an increase in the number of patients with a postneurosurgical state and a rising incidence of Acinetobacter and staphylococcal infections. Clinicians should pay greater attention to these changes, which may affect their management of ABM.     

Risk Factors of Nosocomial Infection with Extended-Spectrum Beta-Lactamase-Producing Bacteria in a Neonatal Intensive Care Unit in China

Abstract Background: To study risk factors of neonatal nosocomial infection caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria in a neonatal intensive care unit (NICU). Patients and Methods: A retrospective cohort study was conducted in a university hospital NICU in south China. Medical records of neonatal nosocomial infection caused by Escherichia coli or Klebsiella pneumoniae were reviewed. Twenty-two neonates infected with ESBL-producing bacteria (case patients) were compared with 17 patients infected with non-ESBL producing strains (controls). Univariable and multivariable logistic regression were performed to analyze risk factors for infection with ESBL-producing strains. The spectrum of antimicrobial resistance of ESBL-positive E. coli or K. pneumoniae was also examined. Results: Both univariable and multivariable logistic regression analysis revealed that preterm low birth weight, prolonged mechanical ventilation (≥ 7 days) and prior use of third-generation cephalosporins were risks factors for ESBL-producing E. coli or K. pneumoniae infection (p < 0.05), with an odd ratio of 6.43 (95% CI: 1.51–27.44; p = 0.017), 7.50 (95% CI: 1.38–40.88; p = 0.017) and 9.00 (95% CI: 1.65–49.14; p = 0.008) respectively. However, the length of hospital stay before isolation of pathogens, endotracheal intubation, presence of a central venous catheter, days on third-generation cephalosporins and prior use of beta-lactamase inhibitors were not statistically significant (p > 0.05). Resistance of ESBL-positive strains to piperacillin, tobramycin, aztreonam and cephalosporins was significantly higher than that of ESBL-negative ones (p < 0.05). ESBL-producing strains appeared susceptible to carbapenem, fluoroquinolones, and beta-lactamase inhibitor combination piperacillin-tazobactam. Conclusions: Preterm low birth weight, prolonged mechanical ventilation and prior use of third-generation cephalosporins are risks factors for nosocomial infection with ESBL-producing bacteria in NICU.     

Isolated Bacterial Meningitis as the Key Syndrome of Infective Endocarditis

Abstract.Background: Bacterial meningitis is an unusual first manifestation but a major complication of infective endocarditis.Patients and Methods: We present three well documented cases of isolated bacterial meningitis in endocarditis. Against this background we review the literature.Results: All patients presented with bacterial meningitis. Staphylococcus aureus was isolated in blood cultures of all patients, but was found only in the cerebrospinal fluid (CSF) of one patient. The underlying endocarditis was confirmed histologically in all three cases. Two patients recovered completely and one died.Conclusion: An extensive search for endocarditis is recommended in every case of an unusual isolate in bacterial meningitis whether it is isolated from blood or CSF.