Hearing loss in adults surviving pneumococcal meningitis is associated with otitis and pneumococcal serotype.

We assessed the incidence of hearing loss and its relationship with clinical characteristics and pneumococcal serotypes in adults surviving pneumococcal meningitis. We analysed hearing loss in 531 adults surviving pneumococcal meningitis included in two prospective nationwide cohort studies performed from April 1998 through to October 2002 and March 2006 through to January 2009. Hearing loss was evaluated on admission and discharge for all patients. Severe hearing loss was assessed by pure tone average on audiology and corrected for age, or by the combination of hearing loss on discharge and a score on the Glasgow Outcome Scale below 5, which could not be explained by other neurological sequelae. A total of 531 episodes of pneumococcal meningitis with non-lethal outcome were included. Predisposing conditions for pneumococcal meningitis were present in the majority of patients (64%), most commonly otitis (36%). Hearing loss was present at discharge in 116 patients (22%) and was classified as mild in 53% and severe in 47%. Hearing loss was related to otitis (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.66-4.02; p < 0.001) and inversely related to serotype 23 F infection (OR, 0.36; 95% CI, 0.13-0.98; p = 0.025), but not with parameters of disease severity or indicators of cerebrospinal fluid inflammation severity. Meningitis due to pneumococcal serotype 3 was associated with the highest rate of hearing loss. Hearing loss frequently complicates pneumococcal meningitis. Risk factors for hearing loss were infection with pneumococcal serotype 23 F and otitis, but not disease severity. Otitis and resulting perilympathic inflammation contribute to meningitis-associated hearing loss.

Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis.

BACKGROUND: In this nationwide prospective cohort study, we evaluated the implementation of adjunctive dexamethasone therapy in Dutch adults with pneumococcal meningitis. METHODS: From March 2006 through January 2009, all Dutch patients over 16 years old with community-acquired pneumococcal meningitis were prospectively evaluated. Outcome was classified as unfavorable (defined by a Glasgow Outcome Scale score of 1 to 4 points at discharge) or favorable (a score of 5). Clinical characteristics and outcome were compared with a similar nationwide cohort of 352 patients with pneumococcal meningitis from a previous period before guidelines recommended dexamethasone therapy (1998-2002). A multivariable prognostic model was used to adjust for differences in case mix between the 2 cohorts. RESULTS: We evaluated 357 episodes with pneumococcal meningitis in 2006-2009. Characteristics on admission were comparable with the earlier cohort (1998-2002). Dexamethasone was started with or before the first dose of antibiotics in 84% of episodes in 2006-2009 and 3% in 1998-2002. At discharge, unfavorable outcome was present in 39% in 2006-2009 and 50% in 1998-2002 (odds ratio [OR] 0.63; 95% confidence interval [CI] 0.46-0.86; p = 0.002). Rates of death (20% vs 30%; p = 0.001) and hearing loss (12% vs 22%; p = 0.001) were lower in 2006-2009. Differences in outcome remained after adjusting for differences in case mix between cohorts. CONCLUSIONS: Dexamethasone therapy has been implemented on a large scale as adjunctive treatment of adults with pneumococcal meningitis in the Netherlands. The prognosis of pneumococcal meningitis on a national level has substantially improved after the introduction of adjunctive dexamethasone therapy. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that dexamethasone (10 mg IV, given every 6 hours for 4 days started before or with the first dose of parenteral antibiotics) reduced the proportion of patients with unfavorable outcomes (Glasgow Outcome Scale score of 1 to 4) in the 2006-2009 cohort, as compared to the 1998-2002 cohort (39% vs 50%; OR 0.63; 95% CI 0.46-0.86; p = 0.002). Mortality rate (20% vs 30%; absolute risk difference 10%; 95% CI 4%-17%; p = 0.001) was also lower in 2006-2009.

Community-acquired Haemophilus influenzae meningitis in adults.

Haemophilus influenzae is an uncommon cause of bacterial meningitis in adults. This report describes a prospective evaluation of 16 episodes of community-acquired H. influenzae meningitis in a nationwide study on bacterial meningitis. Predisposing conditions were present in eight (50%) of the 16 episodes; the most common predisposing conditions were otitis or sinusitis (five episodes; 31%) and remote neurosurgery or head trauma (three episodes; 19%). One (6%) episode was fatal and hearing loss occurred in four (25%) episodes. It was concluded that H. influenzae meningitis in adults is a disease with a rather benign clinical course and a relatively good prognosis compared with pneumococcal meningitis.

Hyponatraemia in adults with community-acquired bacterial meningitis.

BACKGROUND: Hyponatraemia in adults with bacterial meningitis has been described as a common complication, but its true prevalence and clinical importance are unknown. AIM: To investigate the prevalence, clinical characteristics and consequences of hyponatraemia in bacterial meningitis in adults. DESIGN: Nationwide observational cohort study. METHODS: We prospectively assessed the prevalence and clinical characteristics of hyponatraemia among 696 adults with community-acquired bacterial meningitis. Symptoms and signs on admission, blood and CSF test results, radiological examinations and complications during admission were recorded. RESULTS: Sodium levels were determined at admission in 685/696 episodes of bacterial meningitis (98%). Hyponatraemia (<135 mmol/l) was seen in 208/685 (30%) and was classified as severe (<130 mmol/l) in 38 (6%). Hyponatraemia developed during admission in an additional 53 episodes. Hyponatraemia was not associated with an increase in symptoms, with complications or with unfavourable outcome. Treatment for hyponatraemia was initiated in 16% of episodes, but did not influence its duration. DISCUSSION: Hyponatraemia appears both common and benign in adults with bacterial meningitis. In cases of severe hyponatraemia, we suggest the use of fluid maintenance therapy.