足月儿与早产儿细菌性脑膜炎的临床分析

目的 探讨足月儿和早产儿细菌性脑膜炎的临床特征及转归特点。方法 回顾性分析102例新生儿细菌性脑膜炎患儿的临床资料,根据胎龄分为早产儿组（n=46）及足月儿组（n=56）,比较两组患儿临床表现、实验室结果、影像学结果及临床转归。结果 早产儿组临床表现主要为反应差和呼吸暂停/急促（P < 0.05）,足月儿组则以发热及抽搐多见（P < 0.05）。足月儿组脑脊液糖高于早产儿组（P < 0.05）,早产儿组C-反应蛋白、血培养阳性率及不良预后发生率高于足月儿组（P < 0.05）。两组外周血白细胞计数、脑脊液白细胞、脑脊液蛋白及脑脊液培养阳性率差异无统计学意义（P > 0.05）。结论 早产儿及足月儿细菌性脑膜炎临床表现有所不同,早产儿组不良预后发生率更高。     

Sequelae of acute bacterial meningitis in children treated for seven days

The sequelae of acute bacterial meningitis in children who were treated with ampicillin or chloramphenicol for seven days during the period January 1979 to June 1983 were assessed prospectively. The 235 patients (117 boys and 118 girls) ranged in age from four days to 18 years (mean 26.4 months). Haemophilus influenzae type b was isolated in 70% of patients, Streptococcus pneumoniae in 20%, and Neisseria meningitidis in 10%. The mortality rate was 6.4%. No relapses occurred. Of the 220 survivors, 171 had neurologic psychometric, audiologic, and ophthalmologic assessments performed for a minimum of 1 year following their illness. One hundred thirty-six (80%) children had no detectable sequelae; 20% had mild to severe handicaps. The frequency of sequelae was greatest among children with S pneumoniae meningitis (57%) and least among children with N meningitidis (0%). The sequelae observed included: sensorineural hearing loss (12.9%), developmental delay (5.3%), speech defect (4.7%), motor defect (3.0%), hydrocephalus (1.7%), and seizure disorder (1%). The frequency of observed sequelae among these patients is similar to that previously reported in children treated for ten to 14 days. Our findings indicate that seven days of intravenous antibiotic therapy is adequate for the treatment of bacterial meningitis in children.     

Nonvaccine Streptococcus pneumoniae serotypes causing acute bacterial meningitis

The pneumococcal heptavalent conjugate vaccine protects children aged less than 2 years old from invasive pneumococcal disease (IPD). Efficacy is 89-93% in the US population and 71-86% in European studies. The vaccine confers active immunization against the main serotypes causing IPD (4, 6B, 9V, 14, 18C, 19F y 23F). We describe 2 children who presented with pneumococcal meningitis caused by nonvaccine serotypes. As a result of the widespread use of the heptavalent vaccine, there may be a shift in the serotypes causing IPD.     

Prospective study of computed tomography in acute bacterial meningitis

We performed serial CT scans at the time of admission and discharge, and again after 6 to 18 months, in children older than 2 months of age with bacterial meningitis. During the 2-year study period, 60 patients with bacterial meningitis were admitted to British Columbia's Children's Hospital. Forty-one were included in the study, two of whom died soon after admission. The infecting organism was Haemophilus influenzae in 29, Neisseria meningitidis in six, and Streptococcus pneumoniae in six. Abnormalities on the first two CT scans included subdural effusion in eight patients, focal infarction in five, and pus in the basal cisterns in one. All patients with focal infarction or cisternal pus had hemiparesis. Marked cerebral edema was seen in the two patients who died. Transient mild dilation of the subarachnoid space was a common finding; the size of the ventricles or subarachnoid space was increased on the second scan in 29 of 36 patients, and decreased to normal on the third scan in 30 of 33 patients. Clinical management was not influenced by the CT findings, which failed to reveal any clinically significant abnormalities that were not suspected on neurologic examination.     

Sensorineural hearing loss following acute bacterial meningitis in non-neonates

OBJECTIVE: Sensorineural hearing loss (SNHL) is an important sequelae of acute bacterial meningitis (ABM) in children. This study was undertaken to determine the incidence of SNHL following meningitis in non-neonates and its correlation with various factors. METHODS: Children between the ages of 1 month and 12 years with ABM admitted in a teaching hospital over a period of 18 months were enrolled. Detailed history was taken, clinical examination performed and cerebrospinal fluid analyzed at commencement of therapy, 48 hours later and at the end of treatment. On discharge brainstem evoked response audiometry (BERA) was recorded. Data were analyzed using appropriate statistical tests. RESULTS: Out of 32 children enrolled, 9 (28.1%) developed SNHL, bilateral in 21.9% and unilateral in 6.2%. Among hearing impaired subjects, 11.2% had mild while 44.4% each had moderate and profound hearing loss. Age, presence of vomiting, altered sensorium seizures and aminoglycoside usage were not significantly different in those with and without SNHL, but the total duration of fever was (p<0.05). There was significantly higher protein content and neutrophils in the second CSF sample of those with SNHL. CONCLUSION: There is a greater than 50% probability of the child developing SNHL if neutrophil percentage in the second CSF is 80% or more. Since the overall risk of SNHL is significant in children with meningitis, it is recommended that BERA be recorded in all, so that early intervention may be possible.     

Sensorineural hearing loss following acute bacterial meningitis in non-neonates

Objective : Sensorineural hearing loss (SNHL) is an important sequelae of acute bacterial meningitis (ABM) in children. This study was undertaken to determine the incidence of SNHL following meningitis in non-neonates and its correlation with various factors.Methods : Children between the ages of 1 month and 12 years with ABM admitted in a teaching hospital over a period of 18 months were enrolled. Detailed history was taken, clinical examination performed and cerebrospinal fluid analyzed at commencement of therapy, 48 hours later and at the end of treatment. On discharge brainstem evoked response audiometry (BERA) was recorded. Data were analyzed using appropriate statistical tests.Results : Out of 32 children enrolled, 9 (28.1%) developed SNHL, bilateral in 21.9% and unilateral in 6.2%. Among hearing impaired subjects, 11.2% had mild while 44.4% each had moderate and profound hearing loss. Age, presence of vomiting, altered sensorium seizures and aminoglycoside usage were not significantly different in those with and without SNHL, but the total duration of fever was (p <0.05). There was significantly higher protein content and neutrophils in the second CSF sample of those with SNHL.Conclusion : There is a greater than 50% probability of the child developing SNHL if neutrophil percentage in the second CSF is 80% or more. Since the overall risk of SNHL is significant in children with meningitis, it is recommended that BERA be recorded in all, so that early intervention may be possible.     

Corticosteroids as adjunctive therapy in bacterial meningitis. A meta-analysis of clinical trials

A meta-analysis of all nine available controlled trials of corticosteroids for adjunctive therapy for bacterial meningitis was performed. Risks of various outcomes were assessed for control and treatment groups from each study, and risk differences were determined. For each outcome a weighted average of the individual risk differences was calculated. The results show that corticosteroid administration did not reduce the risk of death or neurologic abnormality at hospital discharge or follow-up examination. Based on statistically combined results of the three most recent trials, there is evidence that dexamethasone reduces the risk of bilateral moderate or more severe hearing loss (risk difference, -9%; 95% confidence limits, -15% and -3%). However, this may be true only for children with meningitis caused by Haemophilus influenzae type b. There are inadequate data in adults or in children with meningitis due to other organisms to demonstrate the benefit of dexamethasone administration. Further study is necessary to fully assess the benefits and risks of corticosteroids for adjunctive therapy for bacterial meningitis.     

Dexamethasone treatment for bacterial meningitis

In the pre-antibiotic era more than 9096 of children with bacterial meningitis died from their disease. The introduction of antibiotics and intensive care reduced mortality to approximately 5%, but significant morbidity remained. A prospective study of 50 children who recovered from Haemophilus influenzae type b meningitis reported that 28% had significant physical or intellectual disabilities 3 years after their illness.¹ The failure of new and more powerful antibiotics to improve the outcome of meningitis meant that other treatment modalities needed to be evaluated.