RESUMEN
OBJECTIVE: Pneumonia is considered a focus of infection in patients presenting with community-acquired bacterial meningitis but the impact on disease course is unclear. The aim was to study presenting characteristics, clinical course and outcome of meningitis patients with co-existing pneumonia on admission. METHODS: We evaluated adult patients with community-acquired bacterial meningitis with pneumonia on admission in a nationwide, prospective cohort performed from March 2006 to June 2017. We performed logistic regression analysis to identify clinical characteristics predictive of pneumonia on admission, and to quantify the effect of pneumonia on outcome. RESULTS: Pneumonia was diagnosed on admission in 315 of 1852 (17%) bacterial meningitis episodes and confirmed by chest X-ray in 256 of 308 (83%) episodes. Streptococcus pneumoniae was the causative organism in 256 of 315 episodes (81%). Pneumonia on admission was associated with advanced age (OR 1.03 per year increase, 95% CI 1.02-1.04, p < 0.001), alcoholism (OR 1.96, 95% CI 1.23-3.14, p 0.004), cancer (OR 1.54, 95% CI 1.12-2.13, p 0.008), absence of otitis or sinusitis (OR 0.44, 95% CI 0.32-0.59, p < 0.001) and S. pneumoniae (OR 2.14, 95% CI 1.55-2.95, p < 0.001) in the multivariate analysis. An unfavourable outcome defined as a score of 1-4 on the Glasgow Outcome Scale was observed in 172 (55%) episodes and 87 patients (28%) died. Pneumonia on admission was independently associated with unfavourable outcome and mortality in the multivariate analysis (OR 1.48, 95% CI 1.12-1.96; p 0.005). CONCLUSION: Pneumonia on admission in bacterial meningitis is a frequent coexisting infection and is independently associated with unfavourable outcome and mortality.
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Infecciones Comunitarias Adquiridas/microbiología , Meningitis Bacterianas/complicaciones , Neumonía/microbiología , Anciano , Antibacterianos/uso terapéutico , Femenino , Humanos , Modelos Logísticos , Masculino , Meningitis Bacterianas/líquido cefalorraquídeo , Meningitis Bacterianas/tratamiento farmacológico , Persona de Mediana Edad , Países Bajos , Neumonía/diagnóstico por imagen , Estudios Prospectivos , Radiografía , Factores de RiesgoRESUMEN
OBJECTIVES: Current information on rates and dynamics of meningococcal carriage is essential for public health policy. This study aimed to determine meningococcal carriage prevalence, its risk factors and duration in the Netherlands, where meningococcal C vaccine coverage is >90%. Several methods to identify serogroups of meningococcal carriage isolates among adolescent and young adults were compared. METHODS: Oropharyngeal swabs were collected from 1715 participants 13-23 years of age in 2013-2014; 300 were prospectively followed over 8 months. Cultured isolates were characterized by Ouchterlony, real-time (rt-) PCR or whole-genome sequencing (WGS). Direct swabs were assessed by rt-PCR. Questionnaires on environmental factors and behaviour were also obtained. RESULTS: A meningococcal isolate was identified in 270/1715 (16%) participants by culture. Of MenB isolates identified by whole genome sequencing, 37/72 (51%) were correctly serogrouped by Ouchterlony, 46/51 (90%) by rt-PCR of cultured isolates, and 39/51 (76%) by rt-PCR directly on swabs. A sharp increase in carriage was observed before the age of 15 years. The age-related association disappeared after correction for smoking, level of education, frequent attendance to crowded social venues, kissing in the previous week and alcohol consumption. Three participants carried the same strain identified at three consecutive visits in an 8-month period. In these isolates, progressively acquired mutations were observed. CONCLUSIONS: Whole genome sequencing of culture isolates was the most sensitive method for serogroup identification. Based upon results of this study and risk of meningococcal disease, an adolescent meningococcal vaccination might include children before the age of 15 years to confer individual protection and potentially to establish herd protection.
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Portador Sano/epidemiología , Infecciones Meningocócicas/epidemiología , Neisseria meningitidis/aislamiento & purificación , Orofaringe/microbiología , Adolescente , Portador Sano/microbiología , Estudios Transversales , Femenino , Humanos , Estudios Longitudinales , Masculino , Infecciones Meningocócicas/microbiología , Neisseria meningitidis/clasificación , Países Bajos/epidemiología , Prevalencia , Estudios Prospectivos , Reacción en Cadena en Tiempo Real de la Polimerasa , Factores de Riesgo , Serogrupo , Serotipificación , Encuestas y Cuestionarios , Factores de Tiempo , Secuenciación Completa del Genoma , Adulto JovenRESUMEN
OBJECTIVES: To investigate sex-based differences in clinical features, causative pathogens, outcome and treatment of adult community-acquired meningitis. METHODS: From January 2006 to July 2014, we prospectively investigated sex-based differences in clinical features, causative pathogens, outcome and treatment of adult community-acquired meningitis in a nationwide cohort study in the Netherlands. Sex was analysed along with known predictors of unfavourable outcome using logistic regression. RESULTS: We evaluated 1412 episodes of meningitis, 707 (50%) in men. Men more often presented with a history of remote head injury (41/667 (6%) versus 14/658 (2%) women, p 0.0002) or alcoholism (61/652 (9%) versus 21/660 (3%) women, p <0.0001). Neck stiffness was less common in men (453/651 (70%) versus 524/671 (78%) women, p 0.0004). Despite greater illness severity, women were less likely to receive treatment in an intensive care unit (odds ratio (OR) 0.72, 95% CI 0.58-0.89, p 0.003) or mechanical ventilation (OR 0.67, 95% CI 0.54-0.85, p 0.001). Women exhibited higher serum inflammatory parameters than men (median C-reactive protein 211 versus 171, p 0.0001; median erythrocyte sedimentation rate 48 versus 33, p <0.0001). Corticosteroids improved prognosis in both sexes, but absolute risk reduction was higher in women (20% versus 15%, p 0.001), although we found no significant interaction between sex and dexamethasone (p 0.38). In the multivariable analysis, male sex was an independent predictor of unfavourable outcome (OR 1.34, 95% CI 1.03-1.75, p 0.03) and death (OR 1.47, 95% CI 1.04-2.07, p 0.03). CONCLUSIONS: Our findings show sex-based differences in adults with community-acquired bacterial meningitis. Male sex is an independent risk factor for adverse outcome. It is possible that sex-based differences in immune reaction could determine a distinct response to corticosteroids.
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Infecciones Comunitarias Adquiridas/epidemiología , Meningitis Bacterianas/epidemiología , Adolescente , Adulto , Anciano , Antibacterianos/uso terapéutico , Biomarcadores , Infecciones Comunitarias Adquiridas/diagnóstico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/microbiología , Comorbilidad , Femenino , Humanos , Masculino , Meningitis Bacterianas/diagnóstico , Meningitis Bacterianas/tratamiento farmacológico , Meningitis Bacterianas/microbiología , Persona de Mediana Edad , Países Bajos/epidemiología , Oportunidad Relativa , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Factores Sexuales , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: To study the impact of an evidence-based guideline on the management of community-acquired bacterial meningitis. METHODS: We performed an interrupted time series analysis in a prospective nationwide cohort study from 2006 to 2015. The guideline stresses the importance of cranial imaging before lumbar puncture (LP) in selected patients based on clinical criteria, and early treatment with amoxicillin and a third-generation cephalosporin for adults with suspected community-acquired bacterial meningitis. The guideline was published in April 2013. RESULTS: We included 1326 episodes before and 210 episodes after guideline introduction. Cranial imaging was performed before LP in 497 (84%) of 591 episodes with clinical criteria warranting computed tomography (CT). The guideline did not improve this (increase of 2%; 95% confidence interval (CI), -15 to 19). Without these criteria, imaging before LP occurred in 606 (67%) of 900 episodes, also without effect of the guideline (increase of 1%; 95% CI, -25 to 28). The estimate of effect of the guideline for treatment with the recommended antibiotic regimen was an increase of 19.5% (95% CI, 13.5 to 25.5), and there was a trend towards more frequent initiation of treatment before CT. There was no association between delay in antibiotic treatment due to imaging before LP and unfavourable outcome (odds ratio, 1.14; 95% CI 0.86 to 1.52). CONCLUSIONS: Cranial imaging is performed before LP in the majority of patients with bacterial meningitis, irrespective of guideline indications. The guideline introduction was associated with a trend towards early initiation of treatment before imaging and with increased adherence to antibiotic policy.
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Amoxicilina/administración & dosificación , Encéfalo/diagnóstico por imagen , Cefalosporinas/administración & dosificación , Meningitis Bacterianas/tratamiento farmacológico , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Adolescente , Adulto , Anciano , Amoxicilina/uso terapéutico , Infecciones Comunitarias Adquiridas/diagnóstico por imagen , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Infecciones Comunitarias Adquiridas/patología , Manejo de la Enfermedad , Medicina Basada en la Evidencia , Humanos , Análisis de Series de Tiempo Interrumpido , Meningitis Bacterianas/diagnóstico por imagen , Meningitis Bacterianas/patología , Persona de Mediana Edad , Países Bajos , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Punción Espinal/estadística & datos numéricos , Tomografía Computarizada por Rayos X/métodos , Adulto JovenRESUMEN
Requests to place an unborn child under formal supervision was made in the course of two pregnancies. The first woman was 27 years old, she had a history of schizophrenia, forensic psychiatric care, and a personality disorder with impulsive aggressive behaviour. The second patient was 36 years old. She had a bipolar disorder due to which her firstborn had been placed in foster care. In the first case, formal supervision for the unborn child ensued. In the second case the request was initially denied, but due to the disordered domestic situation was granted ten days after birth. Prior to birth, a relevant risk assessment based on maternal characteristics can be made. In the Netherlands it is possible to place a foetus under formal supervision after 24 weeks gestation. This may prevent hospitalization of a healthy newborn in an unhealthy environment which is poor in stimuli. It also prevents the stressful situation that may arise when parents threaten to take their newborn child from the hospital, pending the inquiry into the domestic situation.