Adult bacterial meningitis—a quality registry study: earlier treatment and favourable outcome if initial management by infectious diseases physicians

Abstract

Acute bacterial meningitis (ABM) is challenging for the admitting physician because it is a rare but fulminant disease, usually presenting without typical symptoms, and rapid treatment is pivotal. The purpose of this study was to evaluate the effect of initial management by infectious diseases (ID) physicians vs. non-ID physicians. A total of 520 consecutive adults (>17 years old), 110 with initial ID management and 410 with non-ID management, registered in the Swedish quality registry for community-acquired ABM January 2008 to December 2013, were analysed retrospectively. Primary outcome was appropriate treatment with antibiotics and corticosteroids <1 hour from admission. Secondary analyses were mortality during hospital stay and persisting neurological and hearing deficits at follow-up after 2 to 6 months. Differences in diagnostic treatment sequences also were analysed. Appropriate treatment <1 hour from admission was achieved significantly more often (41%) by ID physicians vs. non-ID physicians (24%) with an odds ratio (OR) of 2.4 (95% confidence interval [CI]: 1.40 to 4.14; p < 0.01) adjusted for confounders. The door-to-antibiotic time was significantly shorter, and significantly more patients were administered corticosteroids together with the first doses of antibiotics in the ID group. A trend of decreased mortality (4.5% vs. 8.0%) and sequelae at follow-up (24% vs. 44%; adjusted OR 0.55: 95% CI 0.31 to 1.00; p 0.05) were observed in the ID group vs. the non-ID group. Antibiotics were started without prior neuroimaging more often in the ID group (86% vs. 57%; p < 0.001). Initial management at the emergency department by ID physicians is associated with earlier appropriate treatment, more appropriate diagnostic treatment sequences and favourable outcome.

Infectious immunity in the central nervous system and brain function

“…Although antimicrobials are critical for limiting CNS damage by proliferating pathogens, antimicrobial treatment without control of inflammation may result in paradoxically worse outcomes by stimulating the release of bacterial or fungal components that further provoke immunopathological responses adjacent to brain parenchyma 69,70 . Consistent with this, survivors of acute bacterial meningitis caused by Streptococcus pneumoniae or Neisseria meningitides may show persistent neurological deficits, including cognitive dysfunction or dementia, even if they received a timely diagnosis and treatment 71 . Monocyte-derived macrophages in the CNS, particularly meningeal and perivascular macrophages, have a protective role during bacterial meningitis 72 .…”

Early Antimicrobial Therapy for Sepsis: Does Each Hour Really Count?

“…The study compared initial treatment performed by ID versus non-ID physicians. 24 The authors observed that appropriate treatment was achieved more frequently by ID physicians than by non-ID physicians with a trend for decreased mortality and sequelae at follow-up. Another retrospective study performed in Denmark evaluated the outcome of patients with late diagnosis of CABM.…”

Meningitis in adults: diagnosis and management

“…In one study, patients with bacterial meningitis who were managed by infectious diseases physicians were significantly more likely to commence antibiotics within 1 h of presentation and to receive dexamethasone, and were less likely to experience treatment delays while awaiting neuroimaging. 5…”

“…1 Despite ongoing advances in diagnostic methods and treatment strategies, mortality remains as high as 30% in pneumococcal meningitis and 5-10% in meningococcal meningitis. [4][5][6] It is critical that clinicians recognise the need to prioritise initial investigations while not delaying life-saving treatment with dexamethasone and antibiotics, which should be administered as soon as possible within the first hour following presumptive diagnosis. [4][5][6] It is critical that clinicians recognise the need to prioritise initial investigations while not delaying life-saving treatment with dexamethasone and antibiotics, which should be administered as soon as possible within the first hour following presumptive diagnosis.…”

“…2,3 However, outcomes are improved by prompt therapy. [4][5][6] It is critical that clinicians recognise the need to prioritise initial investigations while not delaying life-saving treatment with dexamethasone and antibiotics, which should be administered as soon as possible within the first hour following presumptive diagnosis. This article will focus on diagnostic and management issues that a clinician will face when dealing with a suspected case of community-acquired bacterial meningitis in an adult.…”