Chapter 93 - Bacterial meningitis

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Abstract

Bacterial meningitis is a neurologic emergency. Vaccination against common pathogens has decreased the burden of disease. Early diagnosis and rapid initiation of empiric antimicrobial and adjunctive therapy are vital. Therapy should be initiated as soon as blood cultures have been obtained, preceding any imaging studies. Clinical signs suggestive of bacterial meningitis include fever, headache, meningismus, and an altered level of consciousness but signs may be scarce in children, in the elderly, and in meningococcal disease. Host genetic factors are major determinants of susceptibility to meningococcal and pneumococcal disease. Dexamethasone therapy has been implemented as adjunctive treatment of adults with pneumococcal meningitis. Adequate and prompt treatment of bacterial meningitis is critical to outcome. In this chapter we review the epidemiology, pathophysiology, and management of bacterial meningitis.

Introduction

Community-acquired bacterial meningitis continues to exact a heavy toll, even in developed countries. It is a neurologic emergency and the patients require immediate evaluation and treatment. The incidence of bacterial meningitis is about five cases per 100 000 adults per year in developed countries and may be 10 times higher in less developed countries (van de Beek et al., 2006a, Brouwer et al., 2010a). The predominant causative pathogens in adults are Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus), which are responsible for about 80% of all cases (van de Beek et al., 2006a, Brouwer et al., 2010a).

Section snippets

Epidemiology

The incidence of acute bacterial meningitis is 5–10/100 000 persons per year in high income countries, resulting in 15 000–25 000 cases in the US annually (Durand et al., 1993, Hsu et al., 2009, Brouwer et al., 2010a). Vaccination strategies have substantially changed the epidemiology of community-acquired bacterial meningitis during the past two decades (Whitney et al., 2003, Hsu et al., 2009, Brouwer et al., 2010a). The routine vaccination of children against Haemophilus influenzae type B has

Genetics

Host genetic factors are major determinants of susceptibility to infectious diseases. The cause of these differences in susceptibility are single base-pair variations, also known as single-nucleotide polymorphisms (SNPs), in genes controlling the host response to microbes. Patients with recurrent or familial meningitis or sepsis due to S. pneumoniae or N. meningitidis are often found to have rare mutations that cause a substantial increase in susceptibility to infection (Brouwer et al., 2009).

Pathophysiology and pathology

Specific bacterial virulence factors for meningeal pathogens include specialized surface components that are crucial for adherence to the nasopharyngeal epithelium, the evasion of local host defense mechanisms, and subsequent invasion of the bloodstream (Scheld et al., 2002). In pneumococcal disease, presence of the polymeric immunoglobulin A receptor on human mucosa, which binds to a major pneumococcal adhesin, CbpA, correlates with the ability of pneumococci to invade the mucosal barrier.

Community-acquired bacterial meningitis

Early diagnosis and rapid initiation of appropriate therapy are vital in the treatment of patients with bacterial meningitis. A recent study provided a systematic assessment of the sequence and development of early symptoms in children and adolescents with meningococcal disease (encompassing the spectrum of disease from sepsis to meningitis) before admission to the hospital (Thompson et al., 2006). Classic symptoms of rash, meningismus, and impaired consciousness develop late in the prehospital

Management

Given the high mortality of acute bacterial meningitis, starting treatment and completing the diagnostic process should be carried out simultaneously in most cases (Fig. 93.2) (van de Beek et al., 2006a). The first step is to evaluate vital functions, obtain two sets of blood cultures, and blood tests which typically should not take more than 1 or 2 minutes. At the same time, the severity of the patient’s condition and the level of suspicion for the presence of bacterial meningitis should be

Outcome

Community-acquired bacterial meningitis in adults is a severe disease with high fatality and morbidity rates. Meningitis caused by S. pneumoniae has the highest case fatality rate, reported from 19% to 37% (van de Beek et al., 2006a, Weisfelt et al., 2006c, Brouwer et al., 2010a). Whereas neurologic complications are the leading cause of death in younger patients, elderly patients die predominantly from systemic complications. Of those who survive, up to 50% develop long-term neurologic

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