Acta Pædiatrica ISSN 0803-5253 REGULAR ARTICLE A 15-year retrospective analysis of prognostic factors in childhood bacterial meningitis Liang Yi Justin Wee ([email protected])1, Raymond Reinaldo Tanugroho1, Koh Cheng Thoon2,3,4, Chia Yin Chong2,3,4, Chew Thye Choong3,4,5, Subramania Krishnamoorthy1, Matthias Maiwald4,6,7, Nancy Wen Sim Tee4,6, Natalie Woon Hui Tan2,3,4 1.Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore City, Singapore 2.Infectious Disease Service, Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore City, Singapore 3.Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore 4.Duke-National University of Singapore Graduate Medical School, Singapore City, Singapore 5.Neurology Service, Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore City, Singapore 6.Department of Pathology and Laboratory Medicine, KK Women’s and Children’s Hospital, Singapore City, Singapore 7.Department of Microbiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore Keywords Bacterial meningitis, Disease severity, Paediatric, Prognostic factors, Sequelae ABSTRACT Aim: This retrospective chart review aimed to identify factors in childhood bacterial Correspondence Dr Liang Yi Justin Wee, Department of Paediatrics, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore. Tel: (+65) 6225 5554 | Fax: (+65) 6394 2488| Email: [email protected] Methods: The study included 112 episodes of microbiologically confirmed bacterial Received 7 May 2015; revised 6 August 2015; accepted 23 September 2015. DOI:10.1111/apa.13228 meningitis that predicted disease severity and long-term outcome. meningitis in children aged three days to 15 years who were admitted to a Singapore hospital from 1998 to 2013. Results: The mortality rate was 6%, and 44% required intensive care unit (ICU) admission. Predictive factors associated with ICU admission included pneumococcal meningitis, with an odds ratio (OR) of 5.2 and 95% confidence interval (CI) of 1.5–18.2, leukopenia (OR 5.6, 95% CI 1.7–17.9) and a cerebrospinal fluid (CSF):serum glucose ratio <0.25 (OR 4.5, 95% CI 1.4–14.4). An initial CSF white blood cell count >1000/mm3 (OR 0.26, 95% CI 0.086–0.76) was negatively associated with ICU admission. Five years after meningitis, 32% had residual sequelae, and the associated prognostic factors were Haemophilus influenzae type b (Hib) meningitis (OR 29.5, 95% CI 2–429), seizures during their inpatient stay (OR 10.6, 95% CI 1.9–60.2) and septic shock (OR 8.4, 95% CI 1.1–62.1). Conclusion: As mortality was low in this bacterial meningitis study, ICU admission was used as a marker of disease severity. These findings underscore the importance of the pneumococcal and Hib meningitis vaccines. INTRODUCTION Bacterial meningitis can have potentially devastating consequences, especially in infancy and childhood. Compared to viral or aseptic meningitis, it carries a higher risk of mortality and morbidity if left untreated (1). Globally, the risk of long-term disabling sequelae from bacterial meningitis has been estimated at around 20% (2,3). The negative health impact from childhood bacterial meningitis persists even into adulthood, as it is associated with lower educational achievement and less economic self-sufficiency in adult life (4). During the last two decades, vaccines against Haemophilus influenzae type b (Hib), Streptococcus pneumoniae and Neisseria meningitidis have been introduced. Abbreviations CSF, Cerebrospinal fluid; CI, Confidence interval; GBS, Group B Streptococcus; GCS, Glasgow Coma Scale; Hib, Haemophilus influenzae type b; ICU, Intensive care unit; IQR, Interquartile range; OR, Odds ratio; PCR, Polymerase chain reaction. e22 They have been shown to reduce the incidence of invasive disease, including meningitis, due to these organisms (5–7). In Singapore, the pneumococcal vaccine was added to the national childhood immunisation schedule in 2009, followed by the Hib vaccine in 2013. However, prior to the official addition of the Hib vaccine Key Notes This study aimed to identify factors that predicted disease severity and long-term outcome in cases of microbiologically confirmed childhood bacterial meningitis from 1998 to 2013. These factors include pneumococcal and Haemophilus influenzae type b meningitis, which are vaccinepreventable diseases. ICU admission can be used as a marker of disease severity in place of the mortality rate in settings where there is relatively low mortality from bacterial meningitis. ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 Prognostic factors in bacterial meningitis Wee et al. into the national childhood immunisation schedule, there was already wide uptake of this vaccine from 2005 onwards, with national Hib vaccine coverage reaching >80% during the period 2004–2012 (8). Conversely, pneumococcal vaccine coverage in Singapore was only an estimated 60% in 2012 (9). Current mortality rates from childhood acute bacterial meningitis range between 5 and 10%, even in developed regions (10–12). This is a reduction compared to the period before such vaccines were introduced, when mortality rates were upwards of 15% (13). As such, the number of children who succumb to meningitis has been reduced. However, it has been reported that more than 40% of children with bacterial meningitis are still admitted to the intensive care unit (ICU) (14), resulting in higher medical costs and increased length of hospital stay. Therefore, the aims of this study were to identify predictive factors at initial presentation associated with subsequent ICU admission, as well as prognostic factors for the development of long-term sequelae in children afflicted with bacterial meningitis in Singapore over a 15-year period. Conventionally, most studies relating to disease severity in childhood bacterial meningitis have focused on factors affecting the mortality rate. However, in light of the decreasing mortality due to meningitis, we decided to use the requirement for ICU admission as a marker of disease severity in place of the mortality rate. MATERIALS AND METHODS We conducted a retrospective study of children under 18 years of age who were admitted with acute bacterial meningitis to the Department of Paediatrics of KK Women’s and Children’s Hospital, Singapore, between January 1998 and May 2013. It is the largest paediatric tertiary hospital in Singapore with more than 350 paediatric beds and 175 000 attendances at its children’s emergency department per year. Cases were selected on the basis of positive identification of the causative organism from cerebrospinal fluid (CSF), via either bacterial culture, latex-based antigen detection or polymerase chain reaction (PCR). A list of all patients meeting the above criteria was obtained from the hospital’s infection control unit, based on data from the microbiology laboratory. Subsequently, the medical records of these cases were reviewed to confirm that they had clinical and laboratory parameters consistent with a diagnosis of acute bacterial meningitis and were eligible for inclusion into the study. Children who had previous neurosurgical instrumentation or skull fracture were excluded from the analysis. Altered mental state on initial physical examination was defined as irritability, a Glasgow Coma Scale (GCS) score of less than eight, a decrease in the GCS score by two or more points from the baseline or an inability to sense or respond to outside stimuli. Tachycardia and hypotension were defined according to age-appropriate normal values. Respiratory distress was defined as increased respiratory rate beyond age-appropriate normal values, chest wall retractions, grunting or nasal flaring. Cut-off points for anaemia and leukopenia were taken from the age-specific haematological reference ranges used in the hospital laboratory. All patients who had survived meningitis were followed up by a paediatric neurologist or infectious disease physician. Their records were reviewed for the presence or absence of any long-term complications at six months, one year, two years and five years after the acute episode of meningitis. The long-term complications were as follows: sensorineural hearing loss diagnosed by a comprehensive audiologic assessment by an otolaryngologist, cortical blindness, developmental delay or learning difficulties assessed by the attending paediatrician at follow-up, cerebral palsy or other persistent neuromotor deficits, hydrocephalus, epilepsy and feeding difficulty requiring assisted feeding via a nasogastric tube or gastrostomy. If a case had one or more of these on follow-up, that case was assessed to have residual sequelae at that time point. Cases who were lost to follow-up, who died or who had not reached that particular time point by May 2013, when the study was concluded, were excluded from the analysis of these longterm complications. Data were analysed using the SPSS v17.0 software (IBM, Armonk, New York, USA). Differences between categorical variables were analysed for statistical significance using the chi-square test. Variables with p values of <0.25 on univariate analysis were selected for multivariate analysis via binary logistic regression using the forward conditional method to identify factors that predicted disease severity and development of sequelae. p values of <0.05 were considered to be statistically significant. The study was approved by the SingHealth Centralised Institutional Review Board. RESULTS Initially, 121 cases of childhood bacterial meningitis were identified from data provided by the microbiology laboratory. After review, two cases were excluded as they had prior neurosurgical intervention and seven cases were excluded as their medical records were incomplete or unavailable. A final total of 112 meningitis cases were included in the study, as shown in Figure 1. Demographics A total of 109 patients whose ages ranged from three days to 15 years were included. However, a total of 112 episodes of meningitis were analysed as three patients had recurrent meningitis. The median age was 0.33 years, with an interquartile range (IQR) of 0.08–1.92 years. We noted that 59 cases (53%) were male, 63 (56%) were of Chinese ethnicity, 29 (26%) were of Malay ethnicity, 13 (12%) were of Indian ethnicity, and the remaining seven cases (6%) were from other ethnic groups. This matched the proportion of each ethnic group under the age of 15 in Singapore’s population in 2014 (15). With regard to age, 32 cases (29%) were neonates up to one month of ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 e23 Prognostic factors in bacterial meningitis Wee et al. Progress during hospitalisation Of the 112 cases, seven (6%) were given intravenous dexamethasone. The most common acute complications were 44 (39%) cases of seizures requiring antiepileptic drugs, 28 (25%) cases of subdural empyema and 21 (19%) cases of septic shock. Other complications included 16 (14%) cases of syndrome of inappropriate antidiuretic hormone secretion, 14 (15%) cases of cerebral oedema and three (3%) cases of disseminated intravascular coagulation. Haemodialysis for acute renal failure was required in three of the cases (3%). ICU admission was required in 49 (44%) cases, and the median length of ICU stay was 6 days (IQR 3–9 days). Figure 1 Number of cases remaining in study population at each time point. age, 47 (42%) were infants between one month and one year of age, and the remaining 33 cases (29%) were children aged one year and above. Four cases had preexisting comorbidities of hypogammaglobulinaemia, biliary atresia complicated by hypersplenism and pancytopenia, acute lymphocytic leukaemia and a congenital defect of the oval window. Prior to admission, 21 cases (19%) were given treatment with oral antibiotics. The median length of hospital stay was 21 days (IQR 13–28). Causative organisms The causative organisms involved are shown in Table 1. Group B streptococci (GBS; Streptococcus agalactiae) and Escherichia coli were more common in neonates, whereas in children aged one year and above, encapsulated bacteria such as Hib, Streptococcus pneumoniae and Neisseria meningitidis made up the vast majority of cases. In the first half of the study period (1998–2004), 12 (24%) of the 51 cases were due to Hib, compared with four (6%) of the 61 cases from 2005 to 2013. This was a significantly higher proportion with an odds ratio (OR) of 4.3 and a 95% confidence interval (CI) of 1.3–14.5. The proportion of cases due to Streptococcus pneumoniae between 2009 and 2013, after the pneumococcal vaccine was introduced into Singapore’s national childhood immunisation schedule, remained nearly the same at seven (19%) of the 36 cases during that period compared with 15 (20%) of the 76 cases previously. Three patients had recurrent meningitis. One child with no known comorbidities had two episodes of group B Salmonella meningitis. Another child with no known comorbidities had two episodes of group D Salmonella meningitis. The patient with congenital defect of the oval window had pneumococcal meningitis first and then this was followed by Hib meningitis. The defect was subsequently repaired. e24 Outcomes We found that seven (6%) of the 112 cases succumbed to meningitis and one other case died of an unrelated cause, which was an idiosyncratic drug reaction. Of these seven, the causative organisms were two cases of Streptococcus pneumoniae, two cases of GBS and one case each of Escherichia coli, Streptococcus pyogenes and Klebsiella pneumoniae. Table 2 shows the number of cases who were still being followed up, as well as the number of cases suffering from specific complications at each time point. Five years after meningitis, 23 (32%) of the 73 cases still had residual sequelae. All three patients with recurrent meningitis were readmitted after completing the full course of antibiotic therapy for the first episode of meningitis and had not been discharged against medical advice. Two of these patients did not complete five years of follow-up after meningitis, while the third had no residual sequelae five years after meningitis. Prognostic factors As previously mentioned, due to the small number of cases who succumbed to meningitis, the requirement for ICU admission was used instead of mortality as an indicator of disease severity. In the first half of the study period (1998– Table 1 Causative organisms in the study population (n = 112) Organism Group B Streptococcus Streptococcus pneumoniae Haemophilus influenzae type b Escherichia coli Neisseria meningitidis Salmonella species Other Gram-positive bacteria1 Other Gram-negative bacteria2 Number (%) 23 22 16 15 12 9 9 6 (21) (20) (14) (13) (11) (8) (8) (5) 1 Other Gram-positive bacteria included Streptococcus bovis (three cases), Streptococcus milleri (two cases), Listeria monocytogenes (two cases), Enterococcus faecalis (one case) and Streptococcus pyogenes (one case). 2 Other Gram-negative bacteria included Klebsiella pneumoniae (two cases), Pseudomonas aeruginosa (one case), Morganella morganii (one case), Proteus mirabilis (one case) and Edwardsiella tarda (one case). ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 Prognostic factors in bacterial meningitis Wee et al. Table 2 Progress at outpatient follow-up Percentage (number of patients) Time point Total number still on follow up Residual sequelae present Complications Developmental delay or learning difficulties Epilepsy on antiepileptic drugs Cerebral palsy or other neuromotor deficits Sensorineural hearing loss Hydrocephalus/shunt placement Requirement for assisted feeding Cortical blindness Six months One year Two years Five years 93 44% (41) 86 36% (31) 81 36% (29) 73 32% (23) 30% 22% 17% 11% 10% 8% 4% 27% 15% 17% 8% 8% 5% 5% 27% 15% 17% 8% 9% 5% 5% 26% 16% 19% 5% 10% 4% 6% (28) (20) (16) (12) (9) (7) (4) 2004), 26 (47%) of the 55 cases required ICU admission, which was not significantly different from the second half of the study period (2005–2013) when 23 (40%) of the 57 cases required ICU admission (OR 1.3, 95% CI 0.63–2.8). All clinically relevant predictive factors with regard to ICU admission are listed in Table 3. Multivariate analysis showed that risk factors associated with ICU admission included pneumococcus as the causative organism (OR 5.2, 95% CI 1.5–18.2), leukopenia on initial blood count (OR 5.6, 95% CI 1.7–17.9) and a CSF:serum glucose ratio <0.25 (OR 4.5, 95% CI 1.4–14.4). A CSF white blood cell count > 1000/mm3 (OR 0.26, 95% CI 0.086–0.76) was found to be negatively associated with a requirement for ICU admission. Five years after meningitis, 19 (59%) of the 32 cases who required ICU admission had residual sequelae, compared to only four (10%) of the 41 cases who did not (OR 13.5, 95% CI 3.9–47.2). During the first half of the study period (1998–2004), 17 (47%) of the 36 cases had residual sequelae five years after meningitis, compared to the second half of the study period (2005–2013) when six (16%) of 37 cases had residual sequelae (OR 4.6, 95% CI 1.6–13.8). All clinically relevant prognostic factors with regard to residual sequelae five years after meningitis are listed in Table 4. Multivariate analysis showed that risk factors associated with residual sequelae five years after meningitis include Hib as the causative organism (OR 29.5, 95% CI 2–429), seizures during inpatient stay requiring antiepileptic drugs (OR 10.6, 95% CI 1.9–60.2) and septic shock (OR 8.4, 95% CI 1.1–62.1). We looked at the feasibility of examining the prognostic factors for patients in the neonatal period as a subgroup. This showed that 14 (44%) of the 32 neonatal cases were admitted to ICU and five (20%) of the 25 neonatal cases for which data were available had residual sequelae after five years of follow-up. However, due to the small number of neonatal patients (n = 32), we did not analyse the prognostic factors for neonates and nonneonates separately. (23) (13) (15) (9) (7) (4) (4) (22) (12) (14) (9) (7) (4) (4) (19) (12) (14) (6) (7) (3) (4) DISCUSSION The rates of mortality and development of long-term sequelae in our study population, which were 6% and 32% respectively, were comparable to similar statistics from other developed countries (2,3,10–12). The microbiological profile of the study cases was similar to that observed in other developed countries. In South Korea, an analysis of 402 cases of childhood bacterial meningitis, of which 29.9% were neonates, showed GBS to be the most common causative organism (24.6%), followed by Streptococcus pneumoniae (22.6%) and Haemophilus influenzae (16.7%) (10). Organisms associated with the genitourinary tract such as GBS and Escherichia coli were implicated by other studies in the majority of neonatal meningitis cases (16). In our study, pneumococcus as the causative organism, leukopenia on initial blood count and a CSF:serum glucose ratio <0.25 were found to be factors predictive of increased disease severity, as indicated by the need for ICU admission, whereas a high CSF white blood cell count (>1000/mm3) was found to be associated with a lower likelihood of requiring ICU admission. A similar study from Taiwan concluded that pneumococcal meningitis had the highest mortality rate, whereas Hib meningitis was associated with the highest rate of sequelae (17). Leukopenia is reflective of severe sepsis, and lower peripheral blood and CSF white blood cell counts may indicate inadequacy of the immune response. Chao et al. (18) found an association between low CSF white blood cell counts and higher mortality in pneumococcal meningitis. Nigrovic et al. (19) found that pretreatment with parenteral antibiotics prior to lumbar puncture did not change CSF white blood cell counts, but was associated with higher CSF glucose and lower CSF protein levels. Hence, a lower CSF white blood cell count may be a useful predictor of disease severity in established bacterial meningitis regardless of whether parenteral antibiotics were administered before the lumbar puncture. Lower glucose levels in the CSF have been associated with increased inflammation and cytokine levels (20) and have been shown to return to normal sooner in patients receiving ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 e25 Prognostic factors in bacterial meningitis Wee et al. Table 3 Predictive factors for ICU admission Factor Male gender Age Up to one month Between one month and one year One year and above Causative organism Streptococcus pneumoniae Hib GBS History Fever ≥48 hours prior to presentation Initial laboratory tests Anaemia Leukopenia Thrombocytopenia CRP > 100 mg/mL Bacteraemia CSF white blood cell count > 1000/mm3 CSF:serum glucose ratio <0.25 CSF protein > 1 g/L CSF Gram stain positive Prevalence in study population (%) Univariate OR (95% CI) p-value Multivariate OR1 (95% CI) p-value 53 0.44 (0.21–0.95) 0.038 – 0.41 29 42 29 1.0 (0.45–2.3) 0.70 (0.33–1.5) 1.5 (0.65–3.3) 1 0.44 0.41 Not done Not done Not done 20 14 21 2.8 (1.0–7.2) 1.3 (0.47–3.9) 0.64 (0.25–1.7) 0.054 0.6 0.48 5.2 (1.5–18.2) Not done Not done 54 1.45 (0.68–3.2) 0.34 Not done 28 24 16 44 74 38 66 78 53 1.3 3.7 1.1 1.7 4.3 0.40 3.6 4.9 1.6 0.67 0.007 1 0.18 0.003 0.044 0.009 0.005 0.25 Not done 5.6 (1.7–17.9) Not done – – 0.26 (0.086–0.76) 4.5 (1.4–14.4) – Not done (0.55–2.9) (1.5–9.2) (0.38–2.9) (0.82–3.7) (1.6–11.6) (0.18–0.92) (1.4–9.5) (1.5–15.5) (0.78–3.5) 0.009 0.004 0.79 0.20 0.014 0.01 0.08 1 The odds ratio (OR) for significant risk factors after multivariate analysis was indicated as the multivariate OR. anti-inflammatory medications such as dexamethasone (21). The inflammatory response in bacterial meningitis has been implicated in the pathogenesis of meningitisassociated brain injury and neuronal death, via the release of potentially cytotoxic agents such as reactive oxygen species and proteolytic enzymes by leucocytes recruited during the inflammatory response (22). Increased central nervous system inflammation, which can be indicated by a low CSF glucose level, would therefore be expected to result in a higher risk of neurological complications and a higher likelihood of being admitted to the ICU. Prognostic factors for the development of long-term sequelae of bacterial meningitis were found to be the development of seizures or septic shock while in hospital and Hib as the causative organism. Hib is known to cause a high rate of sequelae in children with acute bacterial meningitis (17). In a meta-analysis of prognostic studies, the median risk of at least one major long-term complication was 9.5% in Hib meningitis (2). The decrease in the likelihood of residual sequelae in the second half of the study was likely to have been due to the significant reduction in the incidence of Hib meningitis during the same period. Repeated seizures are known to cause neuronal cell death via excessive neuronal activation (23), and there is evidence that markers of neuronal injury are present after even a single seizure (24). Therefore, it is not surprising that seizures during the course of meningitis are associated with the subsequent development of sequelae. Septic shock is the result of an excessive immune response to the offending organism in meningitis (25) and, as e26 previously mentioned, the meningitis-associated brain injury associated with the inflammatory response can result in long-term neurological sequelae. Another mechanism by which septic shock causes neuronal damage is cerebral hypoperfusion, which will result in ischaemic injury. Merkelbach et al. (26) found that meningitis patients with decreased cerebral arterial blood flow velocity and cerebral arterial narrowing, which denotes a low perfusion state, had worse neurological outcomes. In light of this, we suggest that treatment of children with bacterial meningitis should focus on reducing the frequency and duration of seizures and maintaining cerebral perfusion as these are most strongly associated with the future development of neurological sequelae. Previous large epidemiological studies or meta-analyses found significant prognostic factors for neurological sequelae to be prolonged fever for more than seven days prior to admission, the absence of petechiae, a low CSF white blood cell count, a CSF glucose <40 mg/dL (2.22 mmol/L) and positive blood cultures for bacteria (27–29). Predictors of mortality were found to be shock, severe respiratory distress and a low peripheral white blood cell count (28,30). Coma, seizures and a high CSF protein level have been reported to predict both mortality and neurological sequelae (27–30). In our study, very few cases presented with prolonged fever or petechial rash, and this was probably due to the easy access to tertiary-level care in Singapore. Factors which are themselves criteria for ICU admission, such as coma or seizures, were excluded from the analysis of predictive factors relating to disease severity. Other than these, many ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 Prognostic factors in bacterial meningitis Wee et al. Table 4 Prognostic factors for residual sequelae five years after meningitis Factor Male gender Age Up to one month Between one month and one year One year and above Causative organism Streptococcus pneumoniae Hib GBS History Fever ≥48 hours prior to presentation Drowsiness, lethargy or irritability Initial physical examination Altered mental state Tachycardia or hypotension Respiratory distress Initial laboratory tests Anaemia Leukopenia Thrombocytopenia CRP > 100 mg/mL Bacteraemia CSF white blood cell count > 1000/mm3 CSF:serum glucose ratio <0.25 CSF protein > 1 g/L CSF Gram stain positive Complications during inpatient stay Subdural empyema Seizures requiring antiepileptic drugs Septic shock SIADH1 Prevalence in study population (%) Univariate OR (95% CI) p-value Multivariate OR (95% CI) p-value 53 0.37 (0.13–1.1) 0.079 – 0.41 29 42 29 0.42 (0.13–1.3) 1.5 (0.56–4.1) 1.6 (0.50–5.2) 0.185 0.456 0.535 – Not done Not done 0.051 20 14 21 2.1 (0.64–7.4) 6.9 (1.5–29.7) 0.41 (0.12–1.39) 0.323 0.009 0.174 Not done 29.5 (2.0–429) – 54 57 1.9 (0.67–5.4) 0.87 (0.32–2.4) 0.304 0.803 Not done Not done 51 45 26 1.5 (0.56–4.13) 0.84 (0.31–2.3) 3.8 (1.3–11.0) 0.457 0.804 0.016 Not done Not done – 28 24 16 44 74 38 66 78 53 2.0 2.0 1.7 2.1 4.5 0.64 4.2 0.38 0.90 (0.68–6.1) (0.68–5.7) (0.48–6.1) (0.78–5.8) (0.93–21.7) (0.21–2.0) (1.1–16.9) (0.10–1.5) (0.33–2.4) 0.25 0.27 0.5 0.20 0.072 0.59 0.042 0.23 1 Not Not Not – – Not – – Not 25 39 19 14 1.5 9.3 7.4 3.2 (0.52–4.4) (2.9–29.7) (2.0–27.7) (0.77–13.3) 0.58 <0.001 0.002 0.13 0.013 0.25 0.074 done done done 0.28 0.45 done 0.33 0.55 done Not done 10.6 (1.9–60.2) 8.4 (1.1–62.1) – 0.008 0.036 0.70 1 Syndrome of inappropriate antidiuretic hormone secretion. of the predictive and prognostic factors that we identified have also been found in previous studies of childhood bacterial meningitis, and this further supports their validity. Our study had some limitations. Relatively strict inclusion criteria were applied, requiring positive identification of bacteria from the CSF. While the purpose of this was to exclude aseptic or viral meningitis cases from the analysis, as PCR or other confirmatory tests for viral meningitis were not available during the early part of the study period, this would have excluded cases of probable bacterial meningitis for which no pathogen was found in the CSF. In addition, it is likely that patients with true bacterial meningitis who had been pretreated with antibiotics before hospital admission were missed. However, the advantage of these strict criteria is that the conclusions drawn from this study are likely to be more representative of childhood bacterial meningitis, as meningitis in all study cases was confirmed to be bacterial in origin. Other limitations relate to the follow-up period. Five years after meningitis, 23 (22%) of the 104 cases who survived had defaulted on their follow-up and hence were not included in the analysis. However, the incidence of most prognostic factors was similar between those patients who were still being followed up and those who were lost to follow-up five years after meningitis. Of all the prognostic factors analysed, the only factors with a significant difference in frequency between these two groups were tachycardia or hypotension on initial examination, which was more common in the group that was still being followed up (OR 2.6, 95% CI 1.1–6.4), age over one year, which was more common in the group lost to follow-up (OR 0.29, 95% CI 0.12–0.72), and GBS as the causative organism, for which all affected patients were still on follow-up five years after meningitis. Additionally, the presence of developmental delay or learning difficulties was based on the attending physician’s assessment at follow-up, with formal developmental assessment not being routinely carried out. Therefore, minor neurological sequelae might have gone unnoticed, especially in infants and preschoolers where learning difficulties are less easily detectable. This was likely to have been the reason why the percentage of cases in the neonatal age group with residual sequelae five years after meningitis (20%) was lower than for the study population as a whole. ©2015 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2016 105, pp. e22–e29 e27 Prognostic factors in bacterial meningitis Wee et al. Further research could focus on the longer-term follow-up of childhood meningitis survivors into adulthood, to be able to detect more subtle degrees of neurological sequelae and their impact, if any, on occupational and social function. 5. 6. CONCLUSIONS This study represents the experience of a single large medical centre in a developed, multi-ethnic Asian country over a long time period of 15 years, with a study population of patients who all had microbiologically confirmed bacterial meningitis. Furthermore, 70% of the initial cases had completed an extended follow-up period of five years. In view of the small number of cases who succumbed to meningitis, we used the requirement for ICU admission as a marker of disease severity, which becomes more relevant than raw mortality in settings with a low overall incidence of bacterial meningitis. We found that predictive factors for increased severity of childhood acute bacterial meningitis, necessitating ICU admission, included pneumococcus as the causative organism, leukopenia on initial blood count and a CSF:serum glucose ratio <0.25. Patients with a CSF white blood cell count >1000/mm3 were less likely to require ICU admission. Recognition of these common clinical and laboratory parameters, possibly as part of a severity score, can allow for better allocation of resources by identifying patients who may need closer monitoring or warrant more aggressive treatment. Prognostic factors for residual sequelae five years after meningitis include Hib as the causative organism, seizures during the child’s inpatient stay and septic shock. Knowledge of these factors would help to identify those patients who may need more intensive outpatient rehabilitation. It is also important to note that both pneumococcal and Hib meningitis are vaccine-preventable diseases, further underscoring the importance of vaccination against these organisms. 7. 8. 9. 10. 11. 12. 13. 14. CONFLICTS OF INTEREST The authors have no competing interests to declare. 15. FUNDING No funding was received for this study from any organisation. 16. 17. References 1. Lee BE, Davies HD. Aseptic meningitis. Curr Opin Infect Dis 2007; 20: 272–7. 2. 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