Methicillin-Resistant Staphylococcus aureus Meningitis in Adults

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) meningitis is an uncommon disease, and little is known about its epidemiology, clinical features, therapy, and outcome. We performed a multicenter retrospective study of MRSA meningitis in adults. Eighty-six adult patients were included and the following data were obtained: underlying diseases, clinical presentation, analytical and microbiologic data, response to therapy, and outcome.There were 56 men (65%) and the mean age was 51.5 years; 54 of them (63%) had severe comorbidities. There were 78 cases of postoperative meningitis and 8 of spontaneous meningitis. The infection was nosocomial in 93% (80/86) of the cases. Among the 78 patients with postoperative meningitis, the most common predisposing conditions were cerebrospinal fluid (CSF) devices (74%), neurosurgery (45%), CSF leakage (17%), and head trauma (12%). Most patients had fever (89%), altered mental status (68%), headache (40%), and meningeal signs (29%). The most common CSF findings were pleocytosis (90%), elevated protein level (77%), and hypoglycorrhachia (30%). CSF Gram stain and blood cultures were positive in 49% (32/65) and 36% (16/45) of cases, respectively. An associated MRSA infection and polymicrobial meningitis appeared in 33% (28/86) and 23% (20/86) of cases, respectively. Antimicrobial therapy was given to 84 patients. Most of them received vancomycin (92%) either as monotherapy (64%) or in combination with other antibiotics (28%), for a median of 18 days. Overall 30-day mortality was 31% (27/86). Multivariate study identified 2 independent factors associated with mortality: spontaneous meningitis (odds ratio [OR], 21.4; 95% confidence interval [CI], 2.3-195.4; p = 0.007), and coma (OR, 9.7; 95% CI, 2.2-42.3; p = 0.002).In conclusion, MRSA is a relatively uncommon but serious disease. Although most cases are nosocomial infections appearing in neurosurgical patients, spontaneous meningitis may present as a community-onset infection in patients with severe comorbidities requiring frequent contact with the health care system. Most patients have a favorable response to vancomycin, but the beneficial effect of combined and intraventricular therapy, or alternative drugs, remains unclear. MRSA meningitis is associated with a high mortality, and the presence of spontaneous infection and coma are the most important prognostic factors.

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…The mortality rate for hematogenous S. aureus meningitis is higher (43 to 50%) than that occurring postsurgically (14 to 25%) (780,787). Among S. aureus meningitis cases, methicillin resistance has been increasing in recent years (786,(789)(790)(791). Specifically, Pintado et al conducted a retrospective, multicenter study examining MRSA meningitis in adults over a 25-year period (1981 to 2005).…”

“…The 30-day mortality rate for these patients was 31%. Most MRSA meningitis cases are nosocomial and postsurgical (786,789).…”

“…S. aureus is an uncommon cause of bacterial meningitis, accounting for 4.9 to 6.4% of cases (779)(780)(781)(782)(783)(784). S. aureus meningitis may either arise by hematogenous spread from a non-CNS focus of infection or be secondary to neurosurgical intervention (785,786). Hematogenous S. aureus meningitis is usually community acquired (780,785) and, compared with postsurgical S. aureus meningitis, typically affects older individuals (mean age of 59 years versus 40 years; P ϭ 0.04) (787) with severe medical comorbidities such as diabetes or chronic kidney disease (780,787).…”

“…Because meningitis is a rare complication for patients with SAB, occurring in 1.7% of 724 prospectively identified patients with SAB, clinicians need to be alert to its possibility (69). S. aureus meningitis typically presents with one or more of the following signs or symptoms: persistent fever, headache, stiff neck, and vomiting (786,787,792). Fever and change in consciousness are the two most common clinical symptoms (782,789).…”

Review: apoptotic mechanisms in bacterial infections of the central nervous system

“…Meningitis, caused by hematogenous spread, or acquired post-neurosurgery is of rising incidence and importance especially due to an increase in methicillin-resistant S. aureus (MRSA) strains in recent years. Although MRSA-mediated meningitis is rare, it has a high mortality rate, and is therefore a very serious disease (Aguilar et al, 2010; Pintado et al, 2012). Studies on the effect of S. aureus LTA on rat brain cells have shown that it can induce cerebellar neuronal cell death but only in the presence of glial cells.…”