November 2000
TORONTO - Although neonatal bacterial meningitis mortality is declining, adverse outcome has remained steady at approximately 30% of survivors. Presence of seizures, seizure duration >72 hours, coma, hypotension, respiratory distress, markedly elevated cerebrospinal fluid protein, hypoglycorrhachia, leukopenia and thrombocytopenia have all been associated with severe adverse outcomes.
Researchers here attempted to construct objective, user-friendly guides to the prognosis of meningitis at a number of points during the course of the illness. They found that physicians should be able to make fairly accurate outcome predictions within 12 hours of hospital admission.
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Researchers found the main associations with adverse outcome were CSF:blood glucose ratio of <0.5, hypotension, presence of coma, presence of seizures, use of inotropes, need for ventilation, number of anticonvulsants used, leukopenia and abnormal neurological examination on discharge. Adverse outcomes were not related to the causative organism.
At 12 hours postadmission, researchers found that independent predictors of adverse outcome were presence of seizures, presence of coma, need for ventilation and leukopenia.
At 24 hours, independent predictors were seizure duration of longer than 12 hours, presence of coma and the need for ventilatory support. At 48 hours, 96 hours and at time of discharge, the independent predictors were seizure duration and presence of coma.
"The prognosis of bacterial meningitis, without seizures, or with a period of seizures of <12 hours duration, is quite good," said Max Perlman, MB, BS, of the division of neonatology at the Hospital for Sick Children here. "The difference between the average duration of symptoms of infants with good outcomes (29 hours) and the average duration of symptoms of infants with adverse outcomes (38 hours), although not statistically significant, is clinically significant."
Researchers studied infants between the ages of 1 and 28 days who were admitted through the emergency department or referred from other hospitals to the Hospital for Sick Children between 1979 and 1998. For inclusion in the study infants had to have a diagnosis of bacterial meningitis confirmed by CSF culture and have had a gestational age of at least 35 weeks at birth. Infants were excluded if they had coexisting intrapartum asphyxia, major congenital abnormalities, any congenital central nervous system anomalies, known syndromes, genetic conditions or chromosomal abnormalities.
Of 228 charts reviewed, researchers found 101 cases that fulfilled eligibility criteria. Mean gestational age at birth for those included was 38.3 weeks, and mean age at diagnosis was 10.8 days. Mean duration of symptoms prior to hospital admission was 31 hours.
Forty-six infants were admitted from 1979 to 1988, and 55 were admitted between 1989 and 1998. Age at admission, symptom duration, presence of seizures, coma, use of inotropes, hypotension and duration of ventilation were similar during both periods. However, researchers did notice a trend toward decreased incidence of streptococcal meningitis from 1989 to 1998.
The mortality rates were 17.4% from 1979 to 1988 and 9% from 1989 to 1998. The adverse outcome rates were 23.9% from 1979 to 1988 and 25.5% from 1989 to 1998.
Thirteen infants died, four while on life support, and seven when it was discontinued. Two infants died at 8 and 26 weeks of age due to meningitis complications. Twelve infants had adverse outcomes at age 12 months, mostly multiple neurological disabilities. Four additional infants had mild neurological or developmental delay at age 12 months.
Follow-up past age 12 months showed two other children with adverse outcomes. One child had moderate disability, and another had severe disability. Follow-up information was available for 27 children at school age. Twenty-six percent of children had moderate-to-severe disabilities, and 15% had isolated learning disabilities.
For more information:
- Klinger G, Chin CN, Beyene J, et al. Predicting the outcome of neonatal bacterial meningitis. Pediatrics. 2000;106(3):477-482.
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