Post-surgical enterococcal meningitis: clinical and epidemiological study of 20 cases

Enterococcal post-surgical meningitis is an uncommon disease. 20 episodes of nosocomial post-surgical enterococcal meningitis diagnosed between 1994 and 2003 were retrospectively studied. During the period of study 20 cases of post-surgical enterococcal meningitis (60% female, mean age 55+/-18 y, range 16-78 y) were reviewed. The mean time between admission at the hospital and surgery was 26 (SD = 15) d (range 7-61 d). The most frequent underlying diseases were: intracerebral haemorrhage (55%), brain neoplasms (25%), head trauma (15%) and hydrocephalus (5%). 11 patients had previously received antibiotic treatment. The isolates identified were Enterococcus faecalis (n = 18) (90%), E. faecium (1) and E. durans (1). 11 patients had polymicrobial infections. The treatment most frequently used was vancomycin alone or with other antibiotics (11). In 5 patients intrathecal vancomycin (20 mg/d) was also added. The mortality rate was not different in intrathecally treated patients. Cerebrospinal fluid (CSF) devices were removed in 8 patients. Four patients died due to the infection. Mortality was significantly associated with lack of removal of the CSF devices (p = 0.04). Enterococcal spp. are a cause of nosocomial meningitis associated with neurosurgical procedures and the presence of neurological devices.     

Radiographic remission in seropositive rheumatoid arthritis. A 20-year follow-up study

OBJECTIVE: Rheumatoid arthritis (RA) is in most instances a progressive disease. Very little information is available on halting of the radiographic damage, particularly in later phases of the disease. We studied radiographic remission of RA lasting to the end of follow-up, covering the period 1973-96. METHODS: Radiographs of hands and feet were taken at onset and at 1, 3, 8, 15 and 20 years from entry in 102 cases of recent onset (< 6 months) seropositive and erosive RA. A Larsen score of 0-100 was formed for 20 joints of hands and feet. If the score did not worsen by more than one point between one of the above time points and the end of the study, the patient was considered to be in remission. RESULTS: Remission was confirmed in 27 (26%) of the patients. In 3 cases the remission was from the 1-year check-up, in 5 from the 3-year check-up, in 6 from the 8-year check-up and in 13 cases from the 15-year check-up. Some of the remission cases had a mild disease from the outset, but there were cases in which the disease process had led to marked joint destruction before slowing down. CONCLUSION: This data may serve as a basis for comparison with subsequent cohort studies on new treatments-of-choice.     

Acute bacterial meningitis in adults. A 12-year review

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

Cardiovascular malformation in infant deaths. 10-year clinical and epidemiological study.

The infant mortality from cardiovascular malformations in a region with a population of 2 million inhabitants during a 10-year period has been studied. The study involved validation of the diagnoses and judgement whether the cardiovascular malformation was the dominating or a contributing cause of death. It is shown that the incidence of fatal cardiovascular malformations is probably overestimated in the official death statistics. Evaluation of the clinical findings and necropsy reports are important aids in obtaining more reliable figures of the incidence. The rate of referral of infants with cardiovascular malformations has increased during the period of this study, so that the number of operable lesions not referred has decreased. The infant mortality rate, found in this study, of 1.33 per 1000 liveborn babies constitutes about 20 per cent of all liveborn infants with cardiovascular malformations. The most common lesions found in those who died belonged to the group constituting the hypoplastic left heart syndrome. The proportion of this type of malformation, about 20 per cent of all those dying, is higher than in other similar studies. This difference can probably be explained by variations in selection and classification.     

Pathogenesis and pathophysiology of pneumococcal meningitis

Until the introduction of antibiotics in the 1930s and 1940s, acute bacterial meningitis was fatal in most cases. Since then it has become curable with a variable mortality and morbidity rate for individual pathogens and patients. Neuropathological and clinical studies have shown that a fatal outcome of the disease is often due to central nervous system (CNS) complications including cerebrovascular involvement, brain oedema formation, and hydrocephalus resulting in increased intracranial pressure and seizure activity. During recent years, experimental studies with animal models have substantially increased our knowledge of the interactions of bacterial pathogens with mammalian cells and their entry into the CNS, and the complex pathophysiological mechanisms of brain dysfunction during acute bacterial meningitis. There is now a substantial body of evidence that cytokines, chemokines, proteolytic enzymes, and oxidants are involved in the inflammatory cascade that leads to tissue destruction in bacterial meningitis. Genetic targeting and/or pharmacological blockade of these pathways was beneficial in experimental bacterial meningitis. Apart from dexamethasone, these treatment strategies hold major promise for the adjunctive therapy of acute bacterial meningitis in clinical practice.     

Causes of death in Japanese diabetics. A 20-year study of death certificates

Death certificates filed between 1960 and 1979 in Osaka, Japan were analyzed to study causes of death in diabetic patients. It was observed that diseases of the circulatory system increased continuously from 15.2% in 1960-1964 to 27.2% in 1975-1979. Cerebrovascular disease and disease of heart were the leading causes of death throughout the study period. The rate of increase was much faster for disease of heart than for cerebrovascular disease, and there was only a small difference between them as cause of death in diabetic patients at the end of the observation period. Malignant neoplasms, cirrhosis of the liver, and pneumonia and bronchitis increased, whereas tuberculosis decreased sharply according to age-adjusted mortality rate during the 20-year period. Analysis based on O/E ratios suggested higher risk of dying from ischemic heart disease, tuberculosis and cirrhosis of the liver in Japanese diabetics than in the general population in this country.     

Haematogenous Staphylococcus aureus meningitis. A 10-year nationwide study of 96 consecutive cases

Background  

Haematogenous Staphylococcus aureus meningitis is rare but associated with high mortality. Knowledge about the disease is still limited. The objective of this study was to evaluate demographic and clinical prognostic features of bacteraemic S. aureus meningitis.