====== Bacterial meningitis in neurosurgery======

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Bacterial meningitis is a serious infection characterized by inflammation of the meninges, the protective membranes that cover the brain and spinal cord. It is primarily caused by bacteria and can lead to severe illness or even death if not promptly treated. Bacterial meningitis is a medical emergency and requires immediate medical attention. Here are some important points about bacterial meningitis:

Causes: Bacterial meningitis is most commonly caused by several types of bacteria, including:

Neisseria meningitidis (meningococcus): Common cause of outbreaks, particularly in crowded settings like college dorms.
Streptococcus pneumoniae (pneumococcus): A major cause of community-acquired bacterial meningitis.
Haemophilus influenzae type b (Hib): Less common due to widespread vaccination against Hib.
Listeria monocytogenes: More likely to affect pregnant women, newborns, the elderly, and people with weakened immune systems.
Transmission: Bacterial meningitis is typically transmitted through respiratory secretions (e.g., through coughing, sneezing) from an infected person. Close contact with an infected individual can increase the risk of transmission.

Symptoms: Common symptoms of bacterial meningitis include:

Fever
Severe headache
Stiff neck (neck pain and rigidity)
Nausea and vomiting
Sensitivity to light (photophobia)
Confusion or altered mental status
Seizures
Rash (in some cases, particularly with meningococcal meningitis)
Diagnosis: Diagnosis of bacterial meningitis involves a combination of clinical evaluation, analysis of cerebrospinal fluid (CSF) obtained via lumbar puncture (spinal tap), and blood tests. CSF analysis is critical for confirming the presence of the infection and identifying the specific bacteria causing the meningitis.

Treatment: Bacterial meningitis is a medical emergency, and immediate treatment is essential. Treatment typically involves hospitalization and intravenous (IV) antibiotics to target the specific bacteria causing the infection. The choice of antibiotics may be adjusted based on the results of bacterial culture and susceptibility testing.

Complications: Bacterial meningitis can lead to severe complications, including brain damage, hearing loss, neurological deficits, and death if not treated promptly.

Prevention: Several vaccines are available to prevent some of the most common causes of bacterial meningitis, such as the meningococcal, pneumococcal, and Hib vaccines. Vaccination is a key preventive measure, especially for individuals at higher risk.

Close Contacts: Individuals who have been in close contact with someone diagnosed with bacterial meningitis, especially if the cause is a vaccine-preventable bacterium, may be given prophylactic antibiotics to reduce the risk of transmission.

Prognosis: The prognosis for bacterial meningitis depends on various factors, including the specific bacteria involved, the timeliness of treatment, the patient's overall health, and the presence of complications. Prompt diagnosis and appropriate treatment improve the chances of a favorable outcome.

Bacterial meningitis is a serious and potentially life-threatening condition that requires immediate medical intervention. Timely vaccination and awareness of the signs and symptoms can help reduce the risk and improve outcomes for individuals at risk of this infection.

===== Classification =====

see [[Nosocomial bacterial meningitis]].
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The most common organisms causing [[meningitis]] were non-lactose fermenting [[Gram negative bacteria]] followed by [[Pseudomonas aeruginosa]] and [[Klebsiella]] species. 
((Srinivas D, Veena Kumari HB, Somanna S, Bhagavatula I, Anandappa CB. The
incidence of postoperative meningitis in neurosurgery: an institutional
experience. Neurol India. 2011 Mar-Apr;59(2):195-8. doi: 10.4103/0028-3886.79136.
PubMed PMID: 21483116.
)).

[[Gram negative bacteria]] organisms are the most common causative [[pathogen]]s of postoperative [[meningitis]].

see [[Acinetobacter baumannii meningitis]].

see [[Pneumococcal meningitis]].

[[Stenotrophomonas maltophilia meningitis]]
====Score====
see [[Bacterial Meningitis Score]].

====Treatment====
Bacterial [[meningitis]] is a medical emergency needing quick and timely diagnosis.

Early neuro-intensive care using [[intracranial pressure]] ICP-targeted therapy, mainly [[cerebrospinal fluid drainage]], reduces mortality and improves the overall outcome in adult patients with acute bacterial meningitis (ABM) and severely impaired mental status on admission
((Glimåker M, Johansson B, Halldorsdottir H, Wanecek M, Elmi-Terander A, Ghatan 
PH, Lindquist L, Bellander BM. Neuro-intensive treatment targeting intracranial
hypertension improves outcome in severe bacterial meningitis: an
intervention-control study. PLoS One. 2014 Mar 25;9(3):e91976. doi:
10.1371/journal.pone.0091976. eCollection 2014. PubMed PMID: 24667767; PubMed
Central PMCID: PMC3965390.
)).

===== Outcome =====

Performing [[follow-up]] [[cerebrospinal fluid culture]]s has been demonstrated to lower mortality rates in Post-neurosurgical patients suffering from Gram-negative bacterial meningitis/[[encephalitis]]. The higher mortality rate observed in patients with persistent gram-negative bacterial meningitis/encephalitis suggests that performing [[follow-up]] [[cerebrospinal fluid culture]]s is a crucial component of proper patient [[care]] and management, and is therefore recommended for use by clinicians as a [[standard practice]]. This finding underscores the significance of consistent implementation of [[follow-up]] [[cerebrospinal fluid culture]]s in the management and prognosis of patients with Post-neurosurgical [[infection]]s
((Sun J, Shi Y, Ding Y, Wang S, Qian L, Luan X, Li G, Chen Y, Li X, Lv H, Zheng G, Zhang G. Effect of Follow-Up [[Cerebrospinal Fluid Culture]]s in Post-Neurosurgical Patients' Outcome with Gram-Negative [[Bacterial Meningitis]]/Encephalitis. Infect Drug Resist. 2023 Sep 22;16:6285-6295. doi: 10.2147/IDR.S425799. PMID: 37771842; PMCID: PMC10522782.))

===== Complications =====
[[Intracranial subdural empyema]] (SDE) and [[cerebrovascular accident]] (CVA) are uncommon life-threatening complications of bacterial [[meningitis]], which require urgent evacuation to prevent adverse outcomes. Clinicians must be vigilant of the onset of focal [[neurologic deficit]]s or [[seizure]] activity to establish the diagnosis of SDE
((Dakkak M, Cullinane WR Jr, Ramoutar VR. Subdural Empyema Complicating
Bacterial Meningitis: A Challenging Diagnosis in a Patient with Polysubstance
Abuse. Case Rep Med. 2015;2015:931819. doi: 10.1155/2015/931819. Epub 2015 Oct
12. PubMed PMID: 26543484; PubMed Central PMCID: PMC4620381.
)).
----
[[Symptomatic chronic extra-axial fluid collections in children]]

===== Case series =====

Ten consecutive patients with severe [[streptococcus]] [[meningitis]] were included in a [[prospective]] [[cohort study]] from the [[Odense]] University Hospital. [[Intracranial pressure]], [[brain tissue oxygen tension]] ([[PbtO2]] ), and energy metabolism (intracerebral [[microdialysis]]) were continuously monitored in nine patients. A cerebral lactate/pyruvate (LP) ratio <30 was considered indicating normal oxidative metabolism, LP ratio >30 simultaneously with pyruvate below lower normal level (70 µmol/L) was interpreted as biochemical indication of ischemia, and LP ratio >30 simultaneously with a normal or increased level of pyruvate was interpreted as mitochondrial dysfunction. The biochemical variables were compared with PbtO2 simultaneously monitored within the same cerebral region.

In two cases, the [[LP ratio]] was normal during the whole study period and the simultaneously monitored PbtO2 was 18 ± 6 mm Hg. In six cases, interpreted as mitochondrial dysfunction, the simultaneously monitored PbtO2 was 20 ± 6 mm Hg and without correlation with the LP ratio. In one patient, exhibiting a pattern interpreted as ischemia, PbtO2 decreased below 10 mm Hg and a correlation between LP and PbtO2 was observed.

This study demonstrated that compromised cerebral energy metabolism, evidenced by increased LP ratio, was common in patients with severe bacterial meningitis while not related to insufficient tissue oxygenation
((Larsen L, Nielsen TH, Nordström CH, Andersen AB, Schierbeck J, Schulz MK,
Poulsen FR. Patterns of cerebral tissue oxygen tension and cytoplasmic redox
state in bacterial meningitis. Acta Anaesthesiol Scand. 2018 Oct 17. doi:
10.1111/aas.13278. [Epub ahead of print] PubMed PMID: 30328110.
)).
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Yin et al. from the Department of Neurotrauma, General Hospital of Chinese People's Armed Police Force, No. 69 Yongding Road, Haidian District, [[Beijing]], China, conducted a retrospective analysis of 46 patients who attended General Hospital of Chinese People's Armed Police Force in [[Beijing]], China, from January 1, 2014 to April 30, 2016. The CSF leukocyte, polykaryocyte, protein and glucose had been tested when their antibiotic treatments were empirically stopped. Between the non-relapse and relapse groups, Wilcoxon Rank Sum test was used to compare the differences of CSF leukocyte and polykaryocyte, and t-test was applied to contrast the distinctions of CSF protein and glucose, then, the thresholds of significant items were estimated by ROC curve.

The CSF leukocyte counts in non-relapse group are 23.72 ± 14.12/mm3, which are statistically less than the relapse group's (47.00 ± 1.00/mm3, P = 0.014), so does the CSF polykaryocyte counts (1.74 ± 4.84/mm3 &4.67 ± 1.15/mm3, P = 0.012). Between the two groups, the AUCs of leucocyte and polykaryocyte are 0.926 (95% CI = 0.845-1.0, P = 0.014) and 0.884 (95%CI = 0.786-0.982, P = 0.028), respectively. Their critical values are 44/mm3 (sensitivity = 1, specificity = 0.907) and 3/mm3 (sensitivity = 1, specificity = 0.837). Conversely, CSF protein and glucose have no statistic differences between the two groups.

Both CSF leukocyte and polykaryocyte can satisfactorily indicate whether the post-neurosurgical bacterial meningitis has completely been cured, 0-44/mm3 is recommended as the reference range of CSF leukocyte, and the CSF polykaryocyte' s is 0-3/mm3
((Yin L, Han Y, Miao G, Jiang L, Xie S, Liu B. CSF leukocyte, polykaryocyte,
protein and glucose: Their cut-offs of judging whether post-neurosurgical
bacterial meningitis has been cured. Clin Neurol Neurosurg. 2018 Sep
19;174:198-202. doi: 10.1016/j.clineuro.2018.09.023. [Epub ahead of print] PubMed
PMID: 30273842.
)).

===2017===
A [[retrospective study]] was conducted at Hamad General Hospital between January 1, 2009, and December 31, 2013.

Khan et al. identified 117 episodes of acute bacterial meningitis in 110 patients. Their mean age was 26.4 ± 22.3 years (range: 2-74) and 81 (69.2%) of them were male patients. Fifty-nine episodes (50.4%) were [[community acquired infection]] and fever was the most frequent symptom (94%), whereas neurosurgery is the most common underlying condition. Coagulase-negative staphylococci were the most common causative agent, of which 95% were oxacillin-resistant, while 63.3% of Acinetobacter spp. showed resistance to meropenem. The in-[[Hospital mortality]] was 14 (12%). Only the presence of underlying diseases, hypotension, and inappropriate treatment were found to be independent predictors of mortality.

Acute bacterial meningitis predominantly affected adults and [[Coagulase negative staphylococcus]] species were the common causative agent in Qatar with majority [[Nosocomial infection]]s. More than 90% of all implicated coagulase-negative staphylococci strains were [[oxacillin]]-resistant
((Khan FY, Abu-Khattab M, Almaslamani EA, Hassan AA, Mohamed SF, Elbuzdi AA,
Elmaki NY, Anand D, Sanjay D. Acute Bacterial Meningitis in Qatar: A
Hospital-Based Study from 2009 to 2013. Biomed Res Int. 2017;2017:2975610. doi:
10.1155/2017/2975610. Epub 2017 Jul 13. PubMed PMID: 28785577; PubMed Central
PMCID: PMC5530415.
)).