Bacterial Meningitis

Abstract

Bacterial meningitis is bacterial infection of the cerebrospinal fluid within the subarachnoid space. It can be broadly divided into acute or chronic meningitis and community‐acquired or healthcare‐associated (nosocomial) meningitis. Each entity is associated with a particular pattern of infecting organisms, presentation, management and outcome. Acute bacterial meningitis is the commonest and, arguably, the most important. The epidemiology of acute bacterial meningitis is evolving worldwide, primarily driven by changing immunisation schedules. A wide variety of organisms have been associated with acute bacterial meningitis, but the majority of cases are caused by a handful of organisms (Streptococcus pneumoniae, Neisseria menigitidis, Group B streptococcus, Haemophilus influenzae and Listeria monocytogenes). Chronic bacterial meningitis is less common and is usually caused by Mycobacterium tuberculosis. Bacterial meningitis is a medical emergency requiring prompt diagnosis and treatment as mortality approaches 100% if left untreated. Even with treatment there is a significant mortality rate and long‐term neurological sequelae are common.

Key Concepts:

  • The frequency and aetiology of bacterial meningitis varies according to multiple factors but most importantly patient age, geographical region and social setting.

  • The incidence and commonest aetiological agents of bacterial meningitis have altered over the last two decades with the introduction of Hib, pneumococcal and menigococcal vaccines.

  • The triad of fever, meningitis and altered mental state is not universally present but the absence of any of these features usually excludes a diagnosis of meningitis.

  • Early antibiotics administration is crucial to achieving a good outcome.

  • CSF examination is the most valuable diagnostic investigation.

  • Empiric treatment for tuberculous meningitis should be commenced on clinical suspicion alone and should not wait for microbiological confirmation.

  • Coadministration of glucocorticoids with antituberculous therapy reduces both morbidity and mortality from TBM.

Keywords: bacterial meningitis; chronic; acute; pneumococcus; meningococcus; tuberculosis

Figure 1.

Pneumococcal meningitis. Brain tissue and subarachnoid space showing congested blood vessels, neutrophil polymorphs and cellular debris within the subarachnoid space.

Figure 2.

Pneumococcal meningitis. High‐power view of the surface of the brain. The leptomeninges are inflamed and yellow pus is evident beneath them.

Figure 3.

Pneumococcal meningitis. Gram stain of cerebrospinal fluid showing neutrophil polymorphs and Gram‐positive diplococci (pneumococci).

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References

Attia J, Hatala R, Cook DJ and Wong JG (1999) The rational clinical examination. Does the adult patient have acute meningitis? Journal of the American Medical Association 282: 175–181.

Bilukha OO, Rosenstein N and National Center for Infectious Disease, Centers for Disease Control and Prevention (2005) Prevention and control of meningococcal disease. Recommendations of the advisory committee on Immunisation Practices. MMWR Recommendation Report 54(RR‐7): 1–21.

Blumberg HM, Burman WJ, Chaisson RE et al. (2003) American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. American Journal of Respiratory and Critical Care Medicine 167: 603–662.

Bonadio WA (1992) The cerebrospinal fluid: physiological aspects and alterations associated with bacterial meningitis. Paediatric Infectious Diseases Journal 11: 423–432.

Booy R and Kroll S (1998) Bacterial meningitis and meningococcal infection. Current Opinions in Paediatrics 10: 13–18.

Bouza E, García de la Torre M, Parras F et al. (1987) Brucellar meningitis. Reviews of Infectious Diseases 9(4): 810–822.

Brouwer MC, McIntyre P, de Gans J, Prasad K and van de Beek D (2010) Corticosteroids for acute bacterial meningitis. Cochrane Database Systematic Reviews 8(9): CD004405.

De Gans J and van de Beek D (2002) European dexamthasone in Adult Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. New England Journal of Medicine 347: 1549–1556.

Ellner JJ and Bennett JE (1976) Chronic meningitis. Medicine (Baltimore) 55: 341.

Gray SJ, Trotter CL, Ramsay ME et al. (2006) Epidemiology of meningococcal disease in England and Wales 1993/94 to 2003/04: contribution and experience of the meningococcal Reference Unit. Journal of Medical Microbiology 55: 887–896.

Halperin JJ (2011) Neurologic manifestations of Lyme disease. Current Infectious Disease Reports April 12 (Epub).

Hildebrand J and Aoun M (2003) Chronic meningitis: still a diagnostic challenge. Journal of Neurology 250(6): 653–660.

Hinman AR (1967) Tuberculous meningitis at Cleveland Metropolitan General Hospital 1959 to 1963. American Review of Respiratory Disease 95(4): 670–673.

Kameshwar P and Singh Mamta B (2008) Corticosteroids for managing tuberculous meningitis. Cochrane Database Systematic Reviews (1): CD002244.

Kanegaye JT, Soliemanzadeh P and Bradley JS (2001) Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery cerebrospinal fluid pathogens after parentral antibiotic treatment. Pediatrics 108: 1169–1174.

Kaufman BA (1997) Infections in cerebrospinal fluid shunts. In: Scheld WM, Whitley RJ and Durack DT (eds) Infections of the central nervous system, 2nd edn, pp. 555–577. Philadelphia: Lippincott‐Raven.

Kent SJ, Crowe SM, Yung A et al. (1993) Tuberculous meningitis: a 30‐year review. Clinical Infectious Diseases 17: 987–994.

Khatami A and Pollard AJ (2010) The epidemiology of meningococcal disease and the impact of vaccines. Expert Reviews in Vaccines 9: 285–298.

Kim KS (2010) Acute bacterial meningitis in infants and children. Lancet Infectious Diseases 10: 32–42.

Marra CM (2004) Neurosyphilis. Current Neurology and Neuroscience Reports 4(6): 435–440.

Marton KI and Gean AD (1986) The spinal tap: a new look at an old test. Annals of Internal Medicine 104: 840–848.

National Institute for Health and Clinical Excellence (NICE) (2011) Clinical Diagnosis and Management of Tuberculosis, and Measures for its Prevention and Control. Clinical Guideline117. London: National Institute for Health and Clinical Excellence.

Nguyen TH, Tran TH, Thwaites G et al. (2007) Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. New England Journal of Medicine 357: 2431–2440.

Nigrovic LE, Kuppermann N and Malley R Bacterial meningitis Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (2008) Children with bacterial meningitis presenting to the emergency department during the pneumococcal vaccine era. Academy of Emergency Medicine 15: 522–528.

Ozateş M, Kemaloglu S, Gürkan F et al. (2000) CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiology 41(1): 13.

Pai M, Flores LL, Pai N et al. (2003) Diagnostic accuracy of nucleic acid amplification tests for tuberculous meningitis: a systematic review and meta‐analysis. Lancet Infectious Diseases 3: 633–643.

Patel VB, Padayatchi N, Bhigjee AI et al. (2004) Multidrug‐resistant tuberculous meningitis in KwaZulu‐Natal, South Africa. Clinical Infectious Diseases 38: 851–856.

Quagliarello V and Scheld WM (1992) Bacterial meningitis: pathogenesis, pathophysiology and progress. New England Journal of Medicine 327: 864–872.

Rich AR and McCordock HA (1933) Pathogenesis of tuberculous meningitis. Bulletin of the Johns Hopkins Hospital 52: 5–37.

Scarborough M, Gordon SB, Whitty CJ et al. (2007) Corticosteroids for bacterial meningitis in adults in sub‐Sarahran Africa. New England Journal of Medicine 357: 2441–2450.

Schuchat A (1999) Group B streptococcus. Lancet 353: 51–56.

Schuchat A, Robinson K, Wenger JD et al. (1997) Bacterial meningitis in the United States in 1995. Active surveillance team. New England Journal of Medicine 337(14): 970–976.

Thigpen MC, Whitney CG, Messonnier NE et al. (2011) Bacterial meningitis in the United States, 1998–2007. New England Journal of Medicine 364: 2016–2025.

Thwaites G, Chau TTH, Mai NTH et al. (2000) Tuberculous meningitis. Journal of Neurology Neurosurgery & Psychiatry 68: 289–299.

Thwaites GE, Chau TT and Farrar JJ (2004) Improving the bacteriological diagnosis of tuberculous meningitis. Journal of Clinical Microbiology 42: 378–379.

Thwaites GE, Lan NT, Dung NH et al. (2005) Effect of antituberculosis drug resistance on response to treatment and outcome in adults with tuberculous meningitis. Journal of Infectious Diseases 192: 79–88.

Tsai CJ, Griffin MR, Nuorti JP and Grijalva CG (2008) Changing epidemiology of pneumococcal meningitis after the introduction of pneumococcal conjugate vaccine in the United States. Clinical Infectious Diseases 46: 1664–1672.

Tunkel A and Scheld WM (1995) Acute bacterial meningitis. Lancet 346: 1675–1680.

Tunkel AR, Hartmann BJ, Kaplan SL et al. (2004) Practical guidelines for the management of bacterial meningitis. Clinical Infectious Diseases 39: 1267–1284.

Van de Beek D, de Gans J, Spanjaard L et al. (2004) Clinical features and prognostic factors in adults with bacterial meningitis. New England Journal of Medicine 351(18): 1849–1859. Erratum in: (2005) New England Journal of Medicine 352(9): 950.

Wenger JD, Hightower AW, Facklam RR et al. (1990) Bacterial meningitis in the United States, 1986: report of multistate surveillance study. Journal of Infectious Diseases 162: 1316–1323.

Wertheim HF, Nghia HD, Taylor W and Schultsz C (2009) Streptococcus suis: an emerging human pathogen. Clinical Infectious Diseases 48: 617–625.

Whalen CM, Hockin JC, Ryan A and Ashton F (1995) The changing epidemiology of invasive meningococcal disease in Canada, 1985 through 1992. Emergence of a virulent clone of Neisseria meningitidis. Journal of the American Medical Association 273: 390–394.

Further Reading

Ginsberg DK (2008) Chronic and recurrent meningitis. Practical Neurology 8: 348–361.

Kay R, Cheng AF and Tse CY (1995) Streptococcus suis infection in Hong Kong. Quarterly Journal of Medicine 88: 39–47.

Lambert PL (1991) Infections of the Central Nervous System. Philadelphia: BC Decker.

Robbins JB, Towne DW, Gotschlich EC and Schneerson R (1997) Love's labours lost: failure to implement mass vaccination against group A meningococcal meningitis in sub‐saharan Africa. Lancet 350: 880–882.

Roos KL, Tunkel AR and Scheld WM (2004) Acute bacterial mennigitis. In: Scheld WM, Whitley RJ and Marra CM (eds) Infections of the Central Nervous System, 3rd edn, pp. 347–422. Philadelphia: Lippincott‐Raven.

Smith A (2004) Neonatal meningitis. In: Scheld WM, Whitley RJ and Marra CM (eds) Infections of the Central Nervous System, pp. 313–334. Philadelphia: Lippincott‐Raven.

Whitney CG, Farley MM, Hadler J et al. (2003) Decline in invasive pneumococcal disease after the introduction of protein‐polysaccharide conjugate vaccine. New England Journal of Medicine 348: 1737–1746.

Zuger A and Lowy FD (1997) Tuberculosis. In: Scheld WM, Whitley RJ and Durack DT (eds) Infections of the Central Nervous System. pp. 417–443. Philadelphia: Lippincott‐Raven Publishers.

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How to Cite close
Hemsley, Carolyn, and McGregor, Alastair(Nov 2011) Bacterial Meningitis. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0002220.pub2]