Si. Aronin et al., Community-acquired bacterial meningitis: Risk stratification for adverse clinical outcome and effect of antibiotic timing, ANN INT MED, 129(11), 1998, pp. 862-869
Citations number
49
Categorie Soggetti
General & Internal Medicine","Medical Research General Topics
Background: Community-acquired bacterial meningitis causes substantial morb
idity and mortality in adults.
Objective: To create and test a prognostic model for persons with community
-acquired bacterial meningitis and to determine whether antibiotic timing i
nfluences clinical outcome.
Design: Retrospective cohort study; patients were divided into derivation a
nd validation samples.
Setting: Four hospitals in Connecticut.
Patients: 269 persons who, between 1970 and 1995, had community-acquired ba
cterial meningitis microbiologically proven by a lumbar puncture done withi
n 24 hours of presentation in the emergency department.
Measurements: Baseline clinical and laboratory features and times of arriva
l in the emergency department, performance of lumbar puncture, and administ
ration of antibiotics. The target end point was the development of an adver
se clinical outcome (death or neurologic deficit at discharge).
Results: For the total group, the hospital mortality rate was 27%. Fifty-si
x of 269 patients (21%) developed a neurologic deficit, and in 9% the neuro
logic deficit persisted at discharge. Three baseline clinical features (hyp
otension, altered mental status, and seizures) were independently associate
d with adverse clinical outcome and were used to create a prognostic model
from the derivation sample. The prediction accuracy of the model was determ
ined by using the concordance index (c-index). For both the derivation samp
le (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-inde
x, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome s
ignificantly better than chance. For the total group, the model stratified
patients into three prognostic stages: low risk for adverse clinical outcom
e (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; sta
ge III) (P = 0.001). Adverse clinical outcome was more common for patients
in whom the prognostic stage advanced from low risk (P = 0.008) or intermed
iate risk (P = 0.003) at arrival in the emergency department to high risk b
efore administration of antibiotics.
Conclusions: In persons with community-acquired bacterial meningitis, three
baseline clinical features of disease severity predicted adverse clinical
outcome and stratified patients into three stages of prognostic severity. D
elay in therapy after arrival in the emergency department was associated wi
th adverse clinical outcome when the patient's condition advanced to the hi
ghest stage of prognostic severity before the initial antibiotic dose was g
iven.