By

James Yost, MD, MS, MBA

PGY 2

Emory Family Medicinepsp.about.com

Background

1805 Meningitis was originally recognized and was virtually 100 percent fatal.1892 Gram-negative meningitis was first recognized1930s and 40sCases were described resulting from abortion, genitourinary manipulation, and spinal anesthesia1950s and 60sRecognized as an occasional complication of injuries and neurosurgical procedures

Background Continued

Two age groups are affectedNeonates/infantsAdultscommunity-acquired meningitisnosocomial meningitis

Epidemiology

Frequency

Gram-negative bacilli account for 1.5 4.3% of all cases of meningitis

E. coli and Klebsiella account for more than 50-70% of cases of gram-negative bacillary meningitisThere was an inverse relationship with age with E. coli74% E. coli in neonates10% E. coli and 40% Klebsiella in adults

Epidemiology

Frequency

Neonatal and infant meningitisGram-negative bacilli are the fifth most common cause accounting for 3.6% of all cases 40.3% of all Gram-negative bacilli cases occur in this age group53% of those were caused by E. coli

Community-acquired gram-negative meningitis accounting for only 9 of 253 episodes (3.6%) in a report from the United States

Epidemiology

Frequency ContinuedNosocomial acquired gram-negative meningitis33-69% of bacterial meningitis are believed to nosocomial36 to 50% of cases occurred after neurosurgical procedures

Associated bacteremiaNeonates and infants were 55%Community-acquired gram-negative meningitis were 58%Nosocomial were 43%

Epidemiology

Mortality/Morbidity

The mortality rate of untreated disease approaches 100 percent.The mortality in adults and children with gram-negative meningitis has ranged from 40 to 80%E. coli meningitis has a mortality rate from 50 to 90%, in patients in a coma or with bacteremiaTransient or permanent neurologic morbidity occurred in 21 to 28% of survivors

Epidemiology

Mortality/Morbidity ContinuedThree baseline clinical features were independently associated with an adverse outcome (defined as in-hospital death or neurologic deficit at discharge):hypotension, altered mental status, and seizures

9% adverse outcome had no clinical risk factors33% adverse outcome had intermediate risk (one clinical factor)57% adverse outcome had high risk (two or three clinical factors)

Epidemiology

Risk FactorsIn a report of 197 cases of nosocomial meningitis, the major risk factors were:neurosurgery or head trauma within the past montha neurosurgical devicea CSF leak. These accounted for 75 percent of casesVaginal birth and the hands of health care workersImmunocompromised states for community-acquired

Pathophysiology

The CSF is normally deficient in immunoglobulins The development of bacterial meningitis progresses through four interconnected phases Bacterial invasion of the host with subsequent infection of the CNS Bacterial multiplication and induction of inflammation in the subarachnoid and ventricular space Progression of inflammation with associated pathophysiologic alterations Development of neuronal damage

Pathophysiology Continued

E. coli have two mechanisms that aid in the pathogenesis of meningitisK1 capsular polysaccharidebacterial capsule Similar to those of S. pneumoniae, N. meningitidis, and Haemophilus influenzae Can assist the organism in evading host defensesS fimbriae Facilitates CSF entry particularly at the choroid plexus

Clinical Historyhead trauma neurosurgerydebilitated patients

elderly peoplealcoholicsdiabeticscancer immunosuppressive state

Clinical History Continued

Most cases of postoperative gram-negative meningitis occur 10 or more days after surgeryRange of 1-20 daysThe time interval is similar in infants, with a mean of 5.5 days following surgery Range 1 to 15 days

Causes

Neonatal E. coli meningitis acquired during or soon after deliveryvaginal flora of the mother the hands of hospital personnel Nosocomial E. coli meningitis neurosurgery head trauma within the past montha neurosurgical deviceCSF leaktemporary epidural catheterstunneled intraspinal catheter systems

Causes Continued

Community-acquired meningitisAny Immunosuppressed stateAlcohol-induced cirrhosisDiabetesMalignancySplenectomyglucocorticoid therapyInstrumentation of the urinary tract

Treatment for the Adult

Vancomycin to cefotaxime or ceftriaxone as empiric treatment until culture and susceptibility results are available Dexamethasone is 0.15 mg/kg every six hours suspected pneumococcal meningitis and a Glasgow coma scale score of 8 to 11 should be continued for four days if the Gram stain reveals organisms consistent with S. pneumoniae should be discontinued if the gram stain and/or cultures reveal another pathogen If using steroids, use Rifampin in place of Vanc.

Complications

Ventriculitis Subdural effusion Brain abscess Syndrome of inappropriate antidiuretic hormone secretion Hydrocephalus Seizure disorder Spastic paralysis Mental retardation Hearing deficit Metastatic septic abscesses Acute disseminated encephalomyelitis

Prognosis

In virtually all studies, one of the most important factors predicting survival is the state of consciousness at the time of admission.In a large series from Massachusetts, patients who were unresponsive or responsive only to pain had a 49 percent mortality rate compared to 16 percent for those who were alert or only lethargic

The two Bartholin's glands secrete mucus to provide moisture for the vulva

Cysts and abscesses are the most common disorders

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Bartholin's Gland Cyst

Chronic inflammation can obstruct the orifice of the Bartholin's gland ductleads to cystic dilatation of the duct

Bartholin's Gland Abscess

Result of a polymicrobial infectionThe predominant aerobic and facultative bacteria are Escherichia coli and N. gonorrhea The most common anaerobic bacteria are Bacteroides species.

E. coli meningitis is a very rare disease with a very high mortality rate.Most common causes in adults were from neurosurgical procedures, trauma or urinary tract manipulationIn a literature search from 1966 to the present, a case of E. coli meningitis resulting from incision and drainage of a bartholins gland has not been found.

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