Original article
Community acquired acute bacterial meningitis in children and adults: An 11-year survey in a community hospital in Israel

https://doi.org/10.1016/j.ejim.2007.12.005Get rights and content

Abstract

Objectives

We aimed to investigate the association between the presenting clinical manifestations of bacterial meningitis and the duration of time elapsed before lumbar puncture and start of antibiotic treatment.

Design

Retrospective epidemiologic study using the clinical records in Barzilai Medical Center Emergency Department between 1988 and 1999.

Results

97 patients, 72 children and 25 adults with ABM were identified. 30 of 97 (31%) were diagnosed by the primary physicians at primary care units. Acute meningitis was suspected by emergency department (ED) physicians in 51% of the referred patients. Patients with a scarce clinical picture at hospital arrival (those without fever, headache or nuchal rigidity) showed a trend toward a longer median delay until a diagnostic lumbar puncture was performed and antibiotic therapy was started (median of 14.7 h compared with 2.1 h for those with severe clinical picture) (p < 0.02). Nevertheless, the clinical outcome for the total cohort did not yield a significant difference when analyzed regarding the duration of time between arrival to emergency department and antibiotic treatment initiation (p > 0.3).

Conclusions

The interval before diagnosis of community acquired ABM in both children and adults is longer for those patients who present to the emergency department with an atypical clinical picture, mostly, without fever and without nuchal rigidity. Until bacterial meningitis can be effectively prevented, we can expect this life-threatening infection to continue to cause diagnostic and medical difficulties.

Introduction

Community acquired acute bacterial meningitis (ABM) is a serious bacterial infection, associated with a relatively high mortality rate, despite the availability of effective antibiotic therapy. Delays in initiation of antibiotic therapy can adversely affect clinical outcome [1], [2], [3], [4]. Patients with meningitis classically present with fever, headache, meningismus, and signs of cerebral dysfunction (confusion, delirium, or altered level of consciousness). Only two thirds of the patients with bacterial meningitis will manifest the classical triad of fever, nuchal rigidity, and change in mental status, but nearly all will have at least 1 of these findings [5].

In adults, physical findings of nuchal rigidity with Kernig's and/or Brudzinski's signs, are considered to be more reliable (better positive predictive value) compared to the clinical history alone, in establishing a diagnosis of bacterial meningitis [5].

Nuchal rigidity in the initial physical examination may be subtle, marked, or accompanied by Kernig's, Brudzinski's or both signs of meningeal irritation [6]. These clinical signs have been used as indicators of meningeal inflammation for almost a century [7]. However Kernig's and Brudzinski's signs alone, without nuchal rigidity, have low sensitivity and poor diagnostic accuracy, thus they should not be used as the sole determinants for further diagnostic testing, such as CSF sampling [8].

There are several previous studies of ABM in Israel [9], [10], [11], [12]. In this study we reviewed our experience with ABM in children and adult patients at the Barzilai Medical Center over an 11-year period, from 1988 through 1999. We aimed to investigate the association between the clinical presenting manifestations of bacterial meningitis and the duration of time elapsed before lumbar puncture and start of antibiotic treatment.

Section snippets

Patients and data collection

The clinical records of children and adults (age> 18 years), admitted to Barzilai Medical Center emergency department, between 1988 and 1999 with microbiologically proven ABM were reviewed. Medical charts were reviewed for recorded clinical symptoms compatible with meningitis (i.e., fever, headache, stiff neck, photophobia, nausea, and vomiting). All patients were examined at least by one experienced and highly qualified physician, specialist in pediatrics or family, internal or emergency

Results

Following the initial screening of 102 medical records with the diagnosis of “bacterial meningitis”, 5 patients were excluded for the following reasons: the medical record was incomplete (n = 3), an incorrect International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code was applied (n = 1), the case definition was not fulfilled (n = 1). A total of 97 patients, 72 children and 25 adults, with community acquired, microbiologically proven bacterial meningitis were identified in our

Discussion

Our study shows that community acquired acute bacterial meningitis both in children and adults is correctly diagnosed in the community only in about one third of the cases. Moreover, repeated examination of the patients by emergency department physicians did not elevate primary diagnostic accuracy to more than 51%. The interval before the diagnosis of meningitis is made, is longer for those patients who either: 1) presented to the emergency department with an atypical clinical picture, mostly,

Learning points

  • Community acquired acute bacterial meningitis both in children and adults is accurately diagnosed in the community only in one third of the cases.

  • Repeated examination by emergency department physicians did not elevate primary diagnostic accuracy to more than 51%.

  • The interval before the diagnosis of meningitis and initiation of appropriate antibiotic therapy, is longer for those patients who: 1) presented to the emergency department with an atypical clinical picture, mostly without fever and

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