Clinical presentation and prognostic factors of Streptococcus pneumoniae meningitis according to the focus of infection.

BACKGROUND: We conducted a nationwide study in Denmark to identify clinical features and prognostic factors in patients with Streptococcus pneumoniae according to the focus of infection. METHODS: Based on a nationwide registration, clinical information's was prospectively collected from all reported cases of pneumococcal meningitis during a 2-year period (1999-2000). Clinical and laboratory findings at admission, clinical course and outcome of the disease including follow-up audiological examinations were collected retrospectively. The focus of infection was determined according to the clinical diagnosis made by the physicians and after review of the medical records. RESULTS: 187 consecutive cases with S. pneumoniae meningitis were included in the study. The most common focus was ear (30%), followed by lung (18%), sinus (8%), and other (2%). In 42% of cases a primary infection focus could not be determined. On admission, fever and an altered mental status were the most frequent findings (in 93% and 94% of cases, respectively), whereas back rigidity, headache and convulsion were found in 57%, 41% and 11% of cases, respectively. 21% of patients died during hospitalisation (adults: 27% vs. children: 2%, Fisher Exact Test, P < 0.001), and the causes of death were due to neurological- and systemic complications or the combination of both in 8%, 5% and 6% of cases, respectively. Other causes (e.g. gastrointestinal bleeding, incurable cancer) accounted for 2% of cases. 41% of survivors had neurological sequelae (hearing loss: 24%, focal neurological deficits: 16%, and the combination of both: 1%). The mortality varied with the focus of the infection (otogenic: 7%, sinusitic: 33%, pneumonic: 26%, other kind of focus: 50%, no primary infection focus: 21%, Log rank test: P = 0.0005). Prognostic factors associated with fatal outcome in univariate logistic regression analysis were advanced age, presence of an underlying disease, history of headache, presence of a lung focus, absence of an otogenic focus, having a CT-scan prior to lumbar puncture, convulsions, requirement of assisted ventilation, and alterations in various CSF parameters (WBC < 500 cells/microL, high protein levels, glucose levels < 1 mmol/L, low CSF/blood glucose levels), P < 0.05. Independent prognostic factor associated with fatal outcome in multivariate logistic regression analysis was convulsions (OR: 4.53, 95%CI: (1.74-11.8), p = 0.002), whereas presence of an otogenic focus was independently associated with a better survival (OR: 6.09, 95%CI: (1.75-21.2), P = 0.005). CONCLUSION: These results emphasize the prognostic importance of an early recognition of a predisposing focus to pneumococcal meningitis.

[Severe acute respiratory syndrome--SARS]. / Svaer akut respiratorisk syndrom--SARS.

Severe Acute Respiratory Syndrome (SARS) is an acute respiratory illness caused by SARS coronavirus. This virus was possibly transmitted from an animal reservoir to humans, and from February 2003, the epidemic was spread internationally by further person-to-person transmission. The SARS epidemic was managed by well-known principles of infection control, including prompt diagnosis, isolation of patients, and quarantine of contacts. The successful control of the outbreak is a remarkable international achievement, though much about SARS remains poorly understood.

[Surveillance and prevention of nosocomial Legionella pneumonia]. / Overvågning og forebyggelse af nosokomiel Legionella-pneumoni.

Statens Serum Institut surveys the occurrence of nosocomial pneumonia caused by Legionella. The rate is low compared to other nosocomial infections but carries a high mortality. Verification of the diagnosis and acquisition (nosocomial or community acquired infection) is carried out in each suspected case. The criteria used for classification are described. Preventive measures include protection of susceptible patients as well as maintenance of the hot-water supply providing a minimum temperature of 50 degrees C at any hot tap. Technical solutions to reduce the concentration of Legionella in hospital hot-water supply systems are listed, and a guideline for the control and surveillance of the occurrence is suggested.

Prehospital diagnostic and therapeutic management of otogenic Streptococcus pneumoniae meningitis.

Prehospital diagnostics and therapeutic management, as well as clinical and laboratory data from 57 consecutive cases with otogenic pneumococcal meningitis (OPM) in Denmark during a 2-y period (1999-2000) were studied by review of discharge and medical records including a questionnaire sent to the general practitioners responsible for the individual patient. 12 cases were <2 y of age, whereas the remaining 45 cases were >21 y of age. Fever (in 98%) and altered consciousness (in 98%), respectively, were significantly more frequent prehospital symptoms (median duration of symptoms: 2 d (1-4)) than earache (in 71%, p < 0.0001), tympanic perforation (in 38%, p < 0.0001), and back rigidity (in 25%, p < 0.0001) in OPM. Some 82% visited a physician before admission, and an otogenic focus was diagnosed in 57%, a myringotomy was performed in 12%, and antibiotic therapy was initiated in 29% of these cases. Prehospital antibiotic therapy was more likely to be initiated in patients where the physician found an otogenic focus compared to patients where an otogenic was not found (46% vs 6%, respectively, p = 0.01). However, <10% of cases with OPM were treated for otitis media with adequate dosing of antibiotics for more than 1 d based on pharmacodynamic estimates. The clinical course was more severe in adults than in children (e.g. need for assisted ventilation (61% vs 0%, respectively, p < 0.01), development of sequelae (75% vs 8%, respectively, p < 0.01) together with higher CSF WBC and CSF protein levels (3738 vs 1361 cells/microl and 3.8 vs 1.6 g/l, respectively, p < 0.01), whereas corticosteroids were more frequently given to children than to adults (55% vs 3%, p < 0.001). Prehospital antibiotic therapy was not significantly associated with a more favourable outcome of OPM (50% vs 60%, respectively, p = 0.73). In conclusion, our results suggest that an otogenic focus is as frequent in adults as in children with pneumococcal meningitis and that an otogenic examination should be performed on patients presenting with fever and altered consciousness. Moreover, OPM seems predominantly to occur in patients receiving no or inadequate antibiotic therapy for otitis media.

Effectiveness of antibiotics given before admission in reducing mortality from meningococcal disease: systematic review.

OBJECTIVE: To review the evidence for effectiveness of treatment with antibiotics before admission in reducing case fatality from meningococcal disease. DESIGN: Systematic review. DATA SOURCES: Cochrane register of trials and systematic reviews, database of abstracts of reviews of effectiveness, health technology assessment, and national research register in England and Wales, Medline, Embase, and CAB Health. INCLUDED STUDIES: Studies describing vital outcome of at least 10 cases of meningococcal disease classified by whether or not antibiotics were given before admission to hospital. RESULTS: 14 observational studies met the review criteria. Oral antibiotic treatment given before admission was associated with reduced mortality among cases (combined risk ratio 0.17, 95% confidence interval 0.07 to 0.44). In seven studies in which all included patients were seen in primary care, the association between parenteral antibiotics before admission and outcome was inconsistent (chi2 for heterogeneity 11.02, P = 0.09). After adjustment for the proportion given parenteral antibiotics before admission, there was no residual heterogeneity. A higher proportion of patients given parenteral antibiotics before admission was associated with reduced mortality after such treatment and vice versa (P = 0.04). CONCLUSION: Confounding by severity is the most likely explanation both for the beneficial effect of oral antibiotics and the harmful effect observed in some studies of parenteral antibiotics. We cannot conclude whether or not antibiotics given before admission have an effect on case fatality. The data are consistent with benefit when a substantial proportion of cases are treated.

Differences in survival, brain damage, and cerebrospinal fluid cytokine kinetics due to meningitis caused by 3 different Streptococcus pneumoniae serotypes: evaluation in humans and in 2 experimental models.

BACKGROUND: Experimental meningitis with Streptococcus pneumoniae serotypes 1, 3, and 9 has resulted in pronounced differences in disease severity, but clinical meningitis studies addressing serotype-related differences in case-fatality rates are lacking. METHODS: Study subjects were Danish patients with pneumococcal meningitis due to serotype 1 (n=38), 3 (n=69), or 9V (n=59) during 1990-2002 for whom clinical information was available. The 3 serotypes were tested for brain damage and cerebrospinal fluid (CSF) inflammatory kinetics in 2 experimental models of meningitis. RESULTS: Patients with serotype 1 had a significantly lower case-fatality rate (3%), compared with patients with serotypes 3 (23%) and 9V (32%) (P=.0047, log-rank test). Age and serotype were independent prognostic factors for fatal outcome. In experimental meningitis, the median number of areas per brain slide with brain damage was significantly lower in rats infected with serotype 1 than in rats infected with serotypes 3 and 9V. Three distinct patterns of brain damage were observed: serotype 1, cortical hemorrhage; serotype 3, cortical necrosis and abscess formation; and serotype 9V, subcortical (callosal) abscess formation. Serotype 1 caused the poorest bacterial growth and lowest CSF levels of white blood cells, tumor necrosis factor- alpha, and interleukin-8 (P<.05). CONCLUSION: Case-fatality rates of patients with pneumococcal meningitis, the degree and pattern of brain damage, and CSF cytochemical alterations in experimental pneumococcal meningitis differ according to serotype.

A 20-year ecological study of the temporal association between influenza and meningococcal disease.

Both influenza and meningococcal disease (MD) show seasonal variation with peak incidence rates during the winter. We examined whether fluctuations in occurrence of influenza were associated with changes in the incidence rate of MD, either simultaneously or with a delay of one or 2 weeks, and whether age had an impact on these associations. This ecological study was based on weekly surveillance data on influenza and a complete registration of MD cases (n = 413) in North Jutland County, Denmark, during 1980-1999. A total of 379 MD cases occurred during weeks with influenza registration. The analysis was done using a Poisson regression model taking into account the seasonal variation and trend over time in incidence rate of MD, and stratified by age: < 1 year (n = 38), 1-14 years (n = 189), and > or = 14 years (n = 152). An increase of 100 registered cases of influenza per 100,000 inhabitants was associated with a 7% (95% CI: -1 to 15%) increase in the number of MD cases during the same week. The association was most marked for < 1 year-olds, corresponding to a 29% (95% CI: 6-58%) increase in the number of MD cases per 100 cases of influenza per 100,000 inhabitants. Our findings support the theory that the influenza detection rate is associated with the number of MD cases in the population during the same week.

Effectiveness of antibiotics in preventing meningococcal disease after a case: systematic review.

OBJECTIVE: To summarise the evidence for the role of antibiotics in preventing further cases of meningococcal disease through chemoprophylaxis given to the index patient, household contacts, and children in day care settings after a single case. DESIGN: Systematic review. METHODS: Studies were identified by searching Embase (1983-2003), Medline (1965-2003), and CAB Health (1973-2003) and by contacting the World Health Organization and the European meningococcal disease surveillance network and examining references of identified papers. The review included all studies with at least 10 cases in which outcomes were compared between treated and untreated groups. MAIN OUTCOME MEASURE: Subsequent cases of meningococcal disease 1-30 days after onset of disease in the index patient. RESULTS: Four observational studies and one small trial met the inclusion criteria. Meta-analysis of studies on chemoprophylaxis given to household contacts showed a significant reduction in risk (risk ratio 0.11, 95% confidence interval 0.02 to 0.58). The number needed to treat to prevent a case was estimated as 218 (121 to 1135). Primary outcome data were not available in studies of chemoprophylaxis given to the index patient: when prophylaxis had not been given, rate of carriage after discharge from hospital was estimated as 3% (0 to 6), probably an underestimate of the true rate. No studies of chemoprophylaxis in day care settings were identified that met the inclusion criteria. CONCLUSION: There have been no high quality experimental trials looking at control policies for meningococcal disease. The best available evidence is from retrospective studies. The risk of meningococcal disease in household contacts of a patient can be reduced by an estimated 89% if they take antibiotics known to eradicate meningococcal carriage. Chemoprophylaxis should be recommended for the index patient and all household contacts.