Review Article

3

Diagnosis and Management of Adult Bacterial Meningitis
Wen-Neng Chang and Chen-Hsien Lu

Abstract- The early use of appropriate antibiotic therapy is one of the important and explicit steps in the
management of potentially fatal adult acute bacterial meningitis (ABM). Changing epidemiology of ABM,
especially with regards to the change of the relative frequency of causative pathogens, has been noted in a
serial of studies in Taiwan. This change may influence the choice of initial empiric antibiotic treament. In
this review, the authors will discuss the epidemiologic trend, diagnosis and management of ABM in Taiwan.
For a better understanding, the clinical and laboratory data of 204 adult ABM cases diagnosed at Chang
Gung Memorial Hospital-Kaohsiung, collected over a period of 8 years (1999-2006), were included for
analysis. This review may help first-line, primary-care neurologists have a better view on handling this criti-
cal central nervous system infection.

Key Words: Adult, Acute bacterial meningitis, Diagnosis, Epidemiologic trend, Management

Acta Neurol Taiwan 2009;18:3-13

INTRODUCTION fatal disease.
In adult ABM patients, little is known about the
Acute bacterial meningitis (ABM) in adults is a seri- exact timeframe between the initial onset of symptoms
ous infectious disease of the central nervous system and first visit with a neurologist. Patients in a postneuro-
(CNS)(1,2). Despite the availability of effective antibiotics surgical state, in that they have had a preceding event
and the advent of new antibiotics, adult ABM remains a such as a brain condition, may have overlapping signs
disease of high mortality and morbidity. A delay in early and symptoms of meningitis and this results in a greater
appropriate antibiotic treatment has been associated diff iculty in making a proper ABM diagnosis.
with worse outcomes. For this critical issue, neurologists Meanwhile, although acute meningitis is usually caused
are often called on to “ rule out” ABM, therefore, a by bacteria or viruses, some pathogens of chronic
dilemma exist for neurologists who need to accurately meningitis such as fungi may have similar clinical pre-
diagnose patients with ABM and then rapidly administer sentations. The following two cases are clinical exam-
appropriate management (antbiotics, adjunctive steroid ples of common and uncommon acute meningitis.
and/or neurosurgical procedures) for this potentially Case 1, a 38-year-old man, presented to the emer-

From the Department of Neurology, Chang Gung Memorial Reprint requests and correspondence to: Wen-Neng Chang
Hospital-Kaohsiung Medical Center, Chang Gung University MD. Department of Neurology, Chang Gung Memorial
College of Medicine, Kaohsiung, Taiwan. Hospital-Kaohsiung, No. 123, Ta Pei Road, Niao Sung Hsiang,
Received December 3, 2008. Kaohsiung Hsien 833, Taiwan.
Revised and Accepted December 5, 2008. E-mail: cwenneng@ms19.hinet.net

Acta Neurologica Taiwanica Vol 18 No 1 March 2009

total protein (TP) 714. and Enterobacter spp. Cultures of CSF. This change may influence the ABM as the second most common Gram-negative ABM. mode of con- Except for the presence of neck stiffness. present to the ER with a chief the most common. pneumoniae is still (DM) and liver cirrhosis. Escherichia (E.3% of monomicrobial ABM. Case 2. His past history was unremarkable. other freguent Gram-negative pathogens. Under the and the time period of study. from those reported in western countries(1-5.22). The same is true for both Streptococcus 103/mm 3) and purulent CSF profile including WBC pneumoniae and Neisseria meningitidis infections in 1485/mm3 (neutrophil 90%). blood and cerebrospinal influenzae type b has nearly been eliminated in many fluid (CSF) studies were performed and the results developed countries since routine childhood vaccination revealed peripheral leukocytosis (WBC 21.9% (46/185) of complaint of headache and fever for one day and altered monomicrobial infection. respectively for adult ABM of a monomicrobial infection.22-25). all other neuro. Leptomeningeal enhc. dure during the therapeutic course. metastatic infection is also common in this specific adult For these clinical problems. this patient received intravenous 75) and 19 mixed infections. pneumoniae.) spp. Acinetobacter (A. are the Kaohsiung. Our previous study(34) showed that Acinetobacter meningntis accounted One of the important issues that the neurologists for 3. pneumoniae meningitis study showed leukocytosis (WBC 550/ mm3). respectively. fever and ABM is influenced by several factors including age. diagnosed at Chang Gung Memorial Hospital Pseudomonas (P. 185 of gram (CT) study. accounting for 2006) were included for analysis.0% (13/185).) spp. choice of initial empiric antibiotic treatment(1) which is The emergence of Acinetobacter infection and the fre- an important strategy for a successful treatment of adult quent multiple antibiotic resistant feature of Acta Neurologica Taiwanica Vol 18 No 1 March 2009 . a 56-year-old man with diabetes mellitus Among the implicated pathogens. accounting for 24.5% (12/185) and 3. glucose 94 is usually a spontaneous.6 Ű was initiated(17). Brain MRI study revealed previous studies of adult ABM in Taiwan(22-24). The prevalence rate of implicated pathogens of Kaohsiung with a chief complaint of headache. Furthermore. The leading implicated ceftriaxone (2 gm Q12 hr) therapy and a drainage for Gram-negative and Gram-positive pathogens were K. the clinical data of 204 adult ABM cases. (7/185).27-33). 11. For these (Gram-negative infection 110. pneumoniae and staphylococcal species. status of vaccination.4% (21/185). liver abscess. The listed relative frequency of imaging (MRI) study and multiple liver abscesses were implicated pathogens of adult ABM is quite different detected on both abdominal echo and computed tomo. K. K. these 204 cases involved monomicrobial infection ed from liver abscess grew K. glucose < 5 mg/dL.3 mg/dL. Compared leptomeningeal enhancement and hydrocephalus. this review article will ABM in Taiwan(26) and usually requires a drainage proce- focus on the diagnosis and management of adult ABM. pre- vomiting for 5 days. collected over a period of 8 years (1999. CSF with other adult ABM cases. ceding medical and/or surgical conditions. A CSF cryptococcal antigen and most of these cases involve DM and/or liver disease detection revealed a positive result (1:512)..4 gency room (ER) of Chang Gung Memorial Hospital. but its incidence has have to face is the changing epidemiologic trend of adult increased markedly and has replaced Pseudomonas ABM in recent years(1-16). They are all frequent pathogens of ABM IMPLICATED PATHOGENS patients with a posneurosurgical state(1. This finding is consistent with consciousness for half day. 7. Table 1 shows the implicated pathogens of the 204 nacement was detected on brain magnetic resonance enrolled ABM cases. For example. Hemophilius impression of acute meningitis. geographic distribution. Gram-positive infection infectious problems.8% ratory data of these patients are shown in Tables 1-5. ABM. 6. Concomitant septic was treated with amphotericin B and fluconazole.) coli. and some regions of the world(18-21). logic examinations revealed normal results. This patient as the underlying conditions(1. traction. The clinical and labo. community-acquired infection mg/dL and TP 75 mg/dL. blood and pus aspirat.

especially in those with an inser. The emergence of 3rd. 58. baumannii strain have resulted in increased gitis cases therapeutic difficulty(28.29). s/p EVD 32 tion of an intracranial device such as ventriculo-peri.and 4th.P shunt 32 postneurosurgcial state. Causative pathogens of 204 adult bacterial meningitis cases Gram-negative pathogens Gram-positive pathogens Mixed infection Klebsiella pneumoniae (46) Coagulase-negative staphylococci (24) (19) Acinetobacter species (21) Staphylococcus aureus (20) Escherichia coli (13) Viridans streptococci (8) Pseudomonas species (12) Streptococcus pneumonia (7) Enterobacter species (7) Enterococcus species (7) Proteus mirabilis (3) Others streptococci (3) Neisseria meningitidis (2) Corybacterium species (3) Salmonella species (2) Listeria monocytogenes (2) Fusobacterium necleatum (1) Micrococcus (1) Sphingomonas paucimobilis (1) Serratia marcescens (1) Citrobacter diversus (1) Acinetobacter strains such as the emergence of pan-drug Table 2. 5 Table 1.3% (19/204) of our study group. Preceding neurosurgical conditions of 120 acute spp. Diaetes mellitus 36 20 tion accounted for 9. Liver disease 14 2 This type of infection is usually seen in patients with a Alcoholism 14 4 postneurosurgical state (35) and its incidence did not Chronic otitis media 5 1 change when compared with the incidence of mixed Intravenous drug abuser 5 0 infections in our previous study(34). coli. EVD: external of adult ABM are methicillin-resistant(36-38) and may also ventricular device. s/p craniectomy 19 toneal shunt and extra-ventricular device (36-38). Table Systemic lupus erythematosis 1 1 1 shows a marked increase in the incidence of staphylo. craniectomy. V-P: ventriculoperitoneal. and Enterobacter spp. Adult staphylo. End state renal disease 6 0 With regards to the Gram-positive pathogens. Pseudomonas spp. Underlying conditions of 204 adult bacterial menin- resistant A. is also n = 84 n = 120 a therapeutic challenge of adult ABM(30-33). ICH: intracerebral hemorrhage Acta Neurologica Taiwanica Vol 18 No 1 March 2009 . Postneurosurgical conditions Case number coccal infection is frequently noted in patients with a s/p V. Head trauma 28 cal state as their preceding event (Tables 2 and 3. Traumatic ICH s/p EVD.8% (44/185) of the implicated bacterial meningitis cases pathogens of the monomicrobial ABM.8%. Staphylococcal Table 3. Spontaneous Post-neurosurgical generation cephalosporin-resistant strains in implicated form form E. accounted for 23. The Spontaneous ICH s/p craniotomy s/p EVD 6 increase of staphylococcal infection can be explained by Head trauma s/p craniotomy 6 the increased number of patients with a post-neurosurgi. V-P shunt 25 120/204). Most of the implicated staphylococcal strains s/p: post-state. Mixed infec. Malignancy 6 10 coccal infection and a decrease in the incidence of Streptococcus pneumoniae infection when compared with the data of our previous report(34).

Acta Neurologica Taiwanica Vol 18 No 1 March 2009 .0) Altered consciousness 56 (66. in Taiwan(37-41).5) 8 ( 6.7) 68 (57. tory. community.7) Bacteremia 33 (39.22). Therefore. of the adult ABM patients(43) which may tell us that cer- cination in Taiwan in this decrease needs further clarifi.5) HHNK or DKA 5 ( 6. the ficity for the diagnosis of ABM. Patient history and clinical presentations together to form a clinical impression.6) 3 ( 2.4) 102 (85. mised. but its incidence has decreased sign.0) Multiple septic abscess 3 ( 3. the lack of a fever response with nosocomial infection.42). All of these findings may disclose that tions including fever.7) Brain abscess 13 (15. altered consciousness) is present in 99% our study group. headahce.7) 11 ( 9.3) 23 (19. trends of adult ABM(1. but it can be explained partially by the above-mentioned essential elements (fever. meningismus.34).1) 32 (26. tain aspects of history and physical examination can be cation.7) Hydrocephalus 12 (14. The exact cause of this decrease Despite this poor correlative state. or in a partially-treated state. at least one of the is not clear.6) 15 (12. increasing incidence in recent years suggests the evi. DKA: diabetic ketoacidosis. As shown in Table 4. headahce. 178/204) which is consistent with the findings of with classic oxacillin resistance.4) 0 ( 0. However. Brudzinski’s sign. post-neurosurgical adult ABM in meningismus. The findings of especially in those with spontaneous. Streptococcus can be seen in patients who are elderly. especially in patients other reports(2. but should combine a number of historical and physical examination findings A.6 cause a therapeutic challenge in the choice of initial meningitis begins with an evaluation of the clinical his- empiric antibiotics in adult patients with postneurosurgi. The contribution of pneumococcal vac. Clinical manifestations of 204 acute bacterial meningitis cases Spontaneous meningitis Post-neurosurgical meningitis n = 84 (%) n = 120 (%) Fever 76 (90.22.0) 3 ( 2. and despite the in-hospital isolation procedures for patients altered consciousness have a poor sensitivity and speci- with methicillin-resistant staphylococcal infection. fever is the most common finding of adult ABM cases dence of rapid dissemination of staphylococcal strains (87.2) Seizure 27 (32.2) Liver abscess 7 ( 8. physical examinations including skin rash. The approach to a patient suspected of having acute Table 4. immunocompro- pneumonia is an important leading pathogen of ABM.5) Infections endocarditis 2 ( 2.3) 78 (65. the clinical course and classic presenta- cal meningitis. used to highten suspicion of meningitis even if they can- not alone rule out the diagnosis.3) 0 ( 0. and impaired jolt recently in our comparative studies of epidemiologic acceleration testing are also non-specific for ABM. increase in nosocomial.0) HHNK: hyperosmolar hyperglycemic non-ketoacidosis. However. Kerning’s acquired infection(2.5.0) Septic shock 9 (10.34. neurologists EVALUATION OF SUSPECTED ADULT should not rely on any single clinical feature or single BACTERIAL MENINGITIS physical test for ABM diagnosis. meningismus.5) Cerebral infarction 3 ( 3.

level. The great cases(1. Although we owing to a perception that this is a standard of care. an immunocompromised state.54.morphonuclear cells) is the most Despite advances in medical science.49. or moderate to severe impairment of conscious. 5%-19% of patients still have a CSF reported. a cranial imaging study should be performed moment is a complex function of the blood glucose before LP in order to avoid cerebral herniation(46). cranial CT scan is used for the evaluation an important local issue due to the high incidence and of patients with suspected ABM in most institutions.a level many implicated pathogens in 60% to 90% of ABM would consider predictive for viral disease.22. when the blood glucose level is of great Cranial CT and MRI studies in adult patients with diagnostic importance. for at least 4 hours(52). inner ear infec.49) and can certainly help to make the diagno. Therefore. overlapping CSF lactate concentrations seen in different dural effusion. both Gram’s stain and culture may indicate WBC count less than 100 WBC/mm3. waiting and performing this procedure may delay tic issue. Actually be kept in mind while managing this critical CNS infec- the diagnostic sensitivity of CSF should not be demi.4 or < 2. A variable time is increased intracranial pressure or focal neurologic required before the CSF glucose level reaches a steady- deficit. it has been reported that a CSF lac- each different neuroimaging finding.5 mmol/l if no simutaneous cultures and appropriate empiric antibiotic therapy initi. For nostic test. is generally nonspecific in meningitis (51) because the ment.2. However.47). with treatment antibiotic therapy(45). mastoiditis. CSF analysis is important diagnostic f inding (1. It has become also worth noting that partial antibiotic treatment may common practice to perform cranial CT before perform. abscess. Among CSF profiles. Thus.55). tate concentration determination was found to be superi- peutic strategy should be considered. how. sinusitis). CSF analysis is the cornerstone of diagnosis and In ABM.34. Therefore. C.15.36-38). fractures. Although 90% of the cornerstone of ABM diagnosis and the identification patients will have a greater than 100 WBC /mm3 in CSF of infectious agents in ABM remains highly dependent study and about 60% have a greater than 1000 on it. Therefore. hydrocephalus. The study of lactate levels in CSF tion. patients identified as remaining elevated for 10 days or more(48. However.48. we must keep in mind that patients with the following conditions: new-onset changes in the blood glucose level are reflected in paral- seizures. a different thera. But in reading the glucose level data. signs of lel changes in the CSF glucose level. state equilibrium(52). CSF protein level is nished by delaying the LP by 1 or 2 hours after initiating the most resistant to rapid change. the problem of staphylococcal Unless the capabilities and accessibility of MRI can contamination of CSF samples should be emphasized as be expanded. leptomeningeal enhance. 7 B. when ated before undergoing a cranial CT study. epidural or sub. It is patients before lumbar puncture (LP). In Taiwan. the CSF glucose level at any ness. blood glucose level is determined(1. Neuroimaging study also plays a crucial role in sis of ABM with a high specificity if contamination can diagnosis and therapeutic decision-making be excluded. cerebral edema. rise of staphylococcal ABM among postneurosurgical Cranial imaging can be considered as a way to evaluate adults(36-38). the diagnosis of such infections for signs of brain shift as a precaution in selected should be defined in a very strict manner(1.51). do not have exact data regarding this important therapeu- ever. or to the glucose ratio for the diagnosis of bacterial meningitis following surgery(53).2.50). tious disease. Although different sensitivity rates have been WBC/mm3(1-3. alter CSF characteristics and may also decrease the diag- ing LP in patients with suspected bacterial meningitis.43. Glucose high risk of brain herniation should have blood drawn for ratio is usually < 0. vasculitis and vascular events meningitis have limited the value of the assay as a diag- such as cerebral infarct and venous thrombosis(1. the partially treated state of adult ABM should the start of appropriate antimicrobial therapy(44). variability of CSF WBC count is also shown in the 204 Acta Neurologica Taiwanica Vol 18 No 1 March 2009 . purulent CSF feature (leukocytosis with management of bacterial meningitis predominant poly. CSF and blood glucose should be ABM may also reveal the following findings: skull obtained simutaneously with the patient in a fasting state pathology (operation wound. nostic yield of Gram’s stain and cultures.2).

53 Malignancy 8 8 0.815 0.085 0.094 Peripheral blood study Thrombocytopenia 4 4 Bacteremia 25 31 Leukocytosis 45 89 Laboratory data at the time of admission Glucose (mmol/L) 2.445 0.3 0.495 0.446Ų1.02 9.38 Intravenous drug abuser 2 3 0.03Ų3.8Ų2.492Ų1.913 0.013 Gender Female 16 43 0. CI: confidence interval.8 Table 5.256Ų1.676Ų2.216 0 Hydrocephalus 26 64 1.752 0.679 0.063 GCS: Glasgow coma score.1Ų14 51.187 0.37 0.742 0.9 0. Acta Neurologica Taiwanica Vol 18 No 1 March 2009 .001 White cell count (Ű106/L) 23472Ų100597 2503Ų5689 0.385Ų1.244Ų0.47 0.165 0.883 0.028Ų7.008 Postneurosurgical meningitis 29 91 GCS at the time of admission 8.01 0.7Ų8.65 End-stage renal disease 5 1 0.059 0.16 3.884 Liver cirrhosis 9 8 0. DKA: diabetic ketoacidosis.95 0.497 DKA/HHNK 3 5 0.184 0.268Ų0.17Ų0.85 0.453 0.252 0.023 Nosocomial acquired 22 72 Types of infection Spontaneous meningitis 35 49 0.95 3.8Ų17.174Ų3.842 0.028Ų7.111Ų4.363 0.446 0.619 0.299Ų1.073 Seizure 20 39 0.472 Chronic otitis media 3 3 0.152Ų1.9Ų4.694 0.453 0.388Ų9.497Ų2. HHNK: hyperosmolar hyperglycemic nonketotic coma.87Ų2.753 0.821 0.404 Male 48 97 Clinical feature Fever 55 123 1.703 Disturbed consciousness 45 80 0.06Ų2.242 0.012 Systemic lupus erythematosus 1 1 0.65Ų7.014 Underlying diseases Diabetes mellitus 18 38 0. OR: odds ratio.061 0. Prognostic factors of 204 adult bacterial meningitis cases Fatal group Non-fatal group OR 95 % CI P-Value (N = 64) (N = 140) Age at meningitis (year) 58.109 0.77 0.002 Lactate (mmol/L) 13.708 CSF leakage 2 8 1.424 0.97Ų7.4 9.363 0.1Ų0.284 Total Protein (g/L) 5.728 Infectious endocarditis 1 1 0.3 0.231 0.136Ų1.952 0.53 Acquisition of infection Community acquired 42 68 0.62 Septic shock 17 3 0.879 0.45 Alcoholism 7 11 0.269 0.563 0.4Ų4.

ABM (65) and this may influence the choice of initial Excessive inflammation contributes to the pathogen- appropriate empiric antibiotics(1).29. most of the implicated pathogens of as hydrocephalus and focal suppuration.24. 9 enrolled cases (Table 5). at this moment.58). and 3) use of postneurosurgical ABM patients can have better cover- anti-inflammatory therapy. therefore. the early use 3. 2) application more appropriate for this specific group of patients.56). In Gram-positive adult ABM. antibiotic regimen should be adjusted further by the But no bacterial disease has undergone a more dramatic results of pathogen identification and antibiotic suscepti- change in epidemiology during the past decade than bility test. Because of these practical problems.32-38). ABM. especially in those with a postneurosurgical state ter delineation.51.25. because of different epidemiologic trends. anti-inflammatory drugs have ABM must consider the most likely pathogens involved. There is no doubt that reducing mortality and mor. In and DNA sequencing has an even higher diagnostic rate Taiwan. age. Neurologists should rely 4.59-61) id plus ceftazidime or cefepime or meropenem would be include 1) use of appropriate antibiotic(s). there is also a on combinations of CSF findings to accurately predict marked increase in staphylococcal infection in ABM. mandating the use of bacteri. the value of this genetic study in the initial empiric antibiotic to cover all types of adult ABM diagnosis needs further large-scale study for a bet. In Gram-negative adult ABM. There is an increase in incidence of postneurosur. In ABM diagnosis. it is uncertain gical ABM whether all adults with ABM benefit from treatment 2. important epi.15. ceftriaxone can only cidal antimicrobial in the treatment of ABM is required be choosen as one of the initial empirical antibiotics in (62-64) . ini- tial empiric antibiotics including vancomycin or linezol- The main therapeutic strategies of adult ABM(1. Other antibiotic therapy such as the use of ampi- Since host immune response is incapable of control. knowing the epidemiologic trend of ABM is revealed that early treatment with dexamethasone signif- important for antibiotic choice(1). Use of broad-range real-time PCR spectrum coverage of the implicated pathogens. there is no single variable cal state that can reliably rule out ABM. groups of adult ABM. should be also considered(59). there is a marked of dexamethasone (dexamethasone given before or with increase of Acinetobacter meningitis and this is the first dose of antibiotic and then very 6 hours for 4 Acta Neurologica Taiwanica Vol 18 No 1 March 2009 . Empiric therapy of esis of ABM. Therefore. community-acquired ABM patients without an immuno- bidity of ABM is critically dependent on rapid diagnosis compromoised and/or postneurosurgical state. as the preceding event because in this group of adult ABM.71. the present. important therapeutic potential. it would be inappropriate to use ceftriaxone as of ABM(57. especially in those with communi- demiologic trends of ABM in Taiwan are as follows: ty-acquired Streptococcus pneumoniae infection(66-70). Therfore. pneumoniae is still the most common implicat. According to a hospi. Bacterial DNA detection that one considers the events preceding ABM when mak- by polymerase chain reaction for common pathogens in ing the choice of initial. With of neurosurgical procedures for certain conditions such this combination. At present there is ed pathogen of overall adult ABM no related data from Taiwan and therefore. cillin in old-aged and/or immunocompromised patients ling infection in the CNS.16. it is essential ence of false-positive results(51).30. icantly reduces mortality and morbidity from some tal-based study(1. in the setting of an noted especially in patients with a postneurosurgi- elevated WBC count in CSF. empiric antibiotics with a broad- CSF is available(51. most of the patients have methicillin-resistant MANAGEMENT OF BACTERIAL staphylococcal infection or multiple antibiotic resistant MENINGITIS Gram-negative infection. So far. But 1. and clinical trials have Therefore. K.72). The final and on the timely initiation of appropriate anticiotics. In Taiwan. bacterial antigen study with patients with a postneurosurgical state and most of latex agglutination test is not routinely recommended them are methicillin-resistant strains because of its wide-range of susceptibilities and the pres. with adjunctive dexamethasone(66.

Changing epidemi- cially first-line primary-care neurologists. Stefanoff P. Schortgen F.59:241-51. et al. A 20-year overview. In their study. thus far. Acute bacterial protein. Khawnnimit B. Ayaz C. tional results were quite controversial(75. Lawlor DA. 3. 50. Gjini AB. et al. in relation to becaue any change may influence the choice of initially human immunodeficiency virus serostatus. Adult communi- several factors(1. As shown in Table 5.328:21-8. bacterial meningitis in adults. 12. use of dexamethasone may signifi. Bjönsson OM. 5. Geater A.22). Jonsdottir KE. the epidemiologic opportunistic pathogens associated with meningitis in trends of adult ABM should be examined frequently adults in Bangui. providing that van. the early use of 9. Bernede C. Bekondi C. The therapeutic result of ABM can be influenced by 6. Geyik MF. Sigurdardottir B. Acute comycin concentrations in the CSF because its penetra. et al. to have a bet. 2006.77).43:632-6. 11. N Engl On the other hand. Int J Infect Dis empiric antibiotic greatly. A review of 493 episodes.36:15-22. Kyaw MH. rial meningitis in adults. There have been clincal studies con. Bacterial meningitis in appropriate antibiotics still the most consistent positive Hong Kong: 10-years’ experience. Meningitis and encephalitis in CONCLUSIONS Poland in 2003. Weber DJ. 2005. Chayakul P. Clin Neurol Neurosurg prognostic factor. Trop Med Public Health 2004. Adults with spontaneous aerobic Gram-negative bacillary meningitis admitted to the intensive care unit.107:366-70. Huang CR. when treating adult ABM patients.10:387-95. et al. Tong PY. et al.22. The changing epi- trations of vancomycin in CSF may be obained when demiology of bacterial meningitis and invasive non-menin- concomitant steroids are used. Central African Republic. Singapore Different prognostic factors were reported in the litera.34:289-98. Thomas R. Jones IG. Bouadma L.. Ng KC. Chang WN.2. the potential ty acquired bacterial meningitis in a Singaporean teaching prognostic factors of the 204 ABM adults were many. A seven-year overview (1993-2000). The therapeutic strategies dis. Rosinska M.74). et al. Georges S. serial CSF 14-3-3 7. et al. acquired adult ABM(78). This concern is primarily related to the high incidence of postneurosurgical conditions as the 1. appropriate concen.10 days) (60) in adult ABM should be considered with a REFERENCES degree of caution.76). pital-based study. but the observa. According to 166:231-4. Chan YC. Epidemiology of bac- patients who survived had nearly cleared their 14-3-3 terial meningitis in France in 2002. Przegl Epidemiol 2005. inflammation(73.157:425-30. Lu CH. Acut bacterial menin- ducted regarding this therapeutic issue. Stuart JM. Infection 2008. et al. Arch tion into the CNS is largely dependent on meningeal Intern Med 1997. espe. Southeast Asian J of value in predicting the outcome of community. Epidemiol Infect 2006. the study results of Richard et al. Med J 2002. Hosoglu S. Changing epidemiol- preceding event and high incidence of DM as the the ogy of adult bacterial meningitis in southern Taiwan: a hos- underlying condition among the adult ABM patients(1. Wilder-Smith A. Durand ML. ture(1. Scand J Infect Dis 2002. gitis in adults: analysis of 218 episodes. However. most of the ABM 8. 13. Clin Microbiol Infect Acta Neurologica Taiwanica Vol 18 No 1 March 2009 . et al. check-ups can be meningitis in adults: a 20 year review. Primary and For a better theraspeutic result.(76). 10.134:567-9. 88.54:945- protein from CSF before discharge. et al. hospital. Hui AC. especially the gamma isoform. Rev Prat 2004. J Med 1993. As reported by Lu. Ong BK. Laurent E. gitic bacterial disease in scotland during the period 1983- comycin dosage is “adequate”. Passone N. Perrocheau A. cantly decrease the achievement of therapeutic van. Ir J Med Sci 1997. a more close 2. If early dexamethasone therapy is used. agement. ology of bacterial meningitis among adults in England and ter understanding of adult ABM in Taiwan and its man.35:886-92. 4. Calderwood SB. Wales 1991-2002.22). et al. Christie P. cussed in this review article may help neurologists. Acute bacte- monitoring of metabolic derangment should be arranged.

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