Dramatic reduction of mortality in pneumococcal meningitis
Buchholz et al. Critical Care
Dramatic reduction of mortality in pneumococcal meningitis
Grete Buchholz 1 3
Uwe Koedel 1 3
Hans-Walter Pfister 1 3
Stefan Kastenbauer 1 2
Matthias Klein 0 1
0 Emergency Department, Klinikum Grosshadern, Ludwig Maximilians University , Marchioninistr, 15, 81377 Munich , Germany
1 Methods All inpatients suffering from bacterial meningitis and treated at the Neurological Department of the University of Munich from 2003 to 2015 were identified. The
2 Praxis für Neurologie , Destouchesstrasse 73, 80796 Munich , Germany
3 Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University , Marchioninistr. 15, 81377, Munich , Germany
Background: Acute bacterial meningitis is still a life threatening disease. Methods: We performed a retrospective observational study on the clinical characteristics of consecutively admitted patients with acute pneumococcal meningitis in a single tertiary care center in central Europe (from 2003 until 2015). Data were compared with a previously published historical group of 87 patients treated for pneumococcal meningitis at the same hospital (from 1984 until 2002). Results: Fifty-five consecutive patients with microbiologically proven pneumococcal meningitis were included. Most striking, mortality was down to 5.5 %, which was significantly lower than in the historical group where 24.1 % of the patients did not survive. Intracranial complications during the course of the disease were common and affected half of the patients. Unlike in the historic group, most of the intracranial complications (except ischemic stroke) were no longer associated with a low Glasgow Outcome Score at discharge. Conclusion: The drastic reduction of mortality proves there have been important advances in the treatment of pneumococcal meningitis. Nevertheless, the fact that only 44.2 % of survivors had a full recovery indicates that the search for new adjunctive treatment options must be ongoing.
Bacterial meningitis; Pneumococcal meningitis; Neurocritical care; CNS infection; Streptococcus pneumoniae; Intracranial complications
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Background
Streptococcus pneumoniae is not only the most frequent
but also one of the most threatening pathogens causing
acute bacterial meningitis. Fatality rates are still high,
and up to 17 % of patients die [1, 2]. Patients surviving
pneumococcal meningitis often suffer from long-term
neurological sequelae such as impaired
neuropsychological abilities or focal neurological deficits ranging from
cranial nerve palsy to hemiparesis [3–5]. Frequently, those
sequelae are consequences of intracranial complications
occurring during the course of the disease, such as
intracranial hemorrhage, brain edema, cerebritis, empyema,
sinus thrombosis, cerebral ischemia and others. Moreover,
potentially fatal systemic complications such as septic
shock, intravasal coagulation, acute respiratory distress
syndrome and others occur frequently [6].
In a previous study from our center, 87 cases of
patients suffering from pneumococcal meningitis from
1984 until 2002 were analyzed. The reported in-hospital
mortality rate in that study period was 24 %. Among the
patients, 75 % suffered from intracranial complications
with brain edema being the most frequent (29 %),
followed by hydrocephalus (16 %), arterial complications
(22 %) and venous cerebrovascular complications (9 %).
Only 48 % of patients had a good clinical outcome
defined by a Glasgow Outcome Scale (GOS) of 5 [3].
We have since reviewed the patients’ records from the
previous study to assess the current characteristics of
medical care and outcome in patients with
pneumococcal meningitis, beginning in 2003 and leading up to
today.
Neurological Department of the University of Munich is
part of a tertiary care hospital (Klinikum Grosshadern)
in Munich, Germany. A neurologist is present at the
emergency department 24 h a day, 7 days a week. This
neurologist is not involved in the patient workup as a
consultant, but sees all patients with a presumed
neurological diagnosis “front line”.
In the case of suspected bacterial meningitis,
diagnostic workup and empiric therapy are initiated according
to national guidelines (steroids were introduced after
publication of the Dutch dexamethasone study [7–9]).
All patients received cerebral imaging (usually cerebral
computed tomography (CCT), except when there were
contraindications such as suspected pregnancy), before
admission to the ward to check for (i) intracranial
complications and (ii) infectious foci. The
neurological intensive care unit (NICU) with a capacity for
12 simultaneous patients is run by a team of
neurologists and neuro-intensivists with a focus on the
treatment of patients with life-threatening neurological
diseases: more than 95 % of the patients primarily
suffer from a neurologic disease (admission diagnosis).
One main focus of the center is treatment of
infectious diseases of the brain [10].
All patients with bacterial meningitis recei (...truncated)