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Outcome of penicillin-nonsusceptible Streptococcus pneumoniae meningitis: a nested case-control study
James D Kellner1, David W Scheifele, Scott A Halperin
1Canadian Paediatric Society, Ottawa, Ontario, Canada.
Background:
There are few data comparing the clinical features, management and outcome of penicillin-nonsusceptible (PNSP) meningitis patients with penicillin-susceptible (PSSP) meningitis patients.
Methods:
We performed a retrospective, nested case-control study comparing cases with PNSP meningitis with controls with PSSP meningitis obtained from the Immunization Monitoring Program, Active (IMPACT) cross-Canada surveillance study of invasive infections.
Results:
There were 30 PNSP meningitis cases (10.1% of total) and 45 PSSP meningitis controls from 6 centers obtained from 297 meningitis cases in the IMPACT database from 1991 through 1999. Vancomycin was used for empiric therapy in no cases and controls in 1991 to 1993 and in all cases in 1999. A third generation cephalosporin was used in 93.3% of confirmed PNSP cases, and 70.0% also received vancomycin and/or rifampin. Penicillin was used in 66.7% of confirmed PSSP cases. PNSP cases were more likely than PSSP controls to have a second lumbar puncture (odds ratio, 4.1; P= 0.01). PNSP cases were treated with intravenous antibiotics for an average of 15.6 days compared with 12.3 days for controls ( P= 0.04). Among PNSP cases, those patients who did not receive empiric vancomycin were treated with intravenous antibiotics for an average of 18.5 days compared with 12.0 days for those who did receive empiric vancomycin ( P= 0.04). The overall mortality was 5.3%, and 36.6% of survivors had >or=1 neurologic sequelae, including 19.7% with hearing loss. In multivariate statistical models, PNSP was not a risk factor for intensive care unit admission or neurologic sequelae.
Conclusions:
Management of suspected bacterial meningitis and confirmed meningitis in Canadian children changed in the past decade. Treatment of PNSP meningitis is significantly different from that for PSSP meningitis. These changes have occurred in response to the emergence of PNSP in Canada. Neurologic sequelae remain common after meningitis, but there are no differences between PNSP cases and PSSP cases.
Insights
Penicillin-nonsusceptible (PNSP) meningitis requires different treatment than penicillin-susceptible (PSSP) meningitis, with longer antibiotic courses. However, PNSP meningitis does not increase the risk of intensive care unit admission or long-term neurologic sequelae.
Area of Science:
- Pediatrics
- Infectious Diseases
- Clinical Microbiology
Background:
- Limited data exist comparing clinical features, management, and outcomes of penicillin-nonsusceptible (PNSP) versus penicillin-susceptible (PSSP) bacterial meningitis.
- The emergence of PNSP necessitates understanding its impact on pediatric meningitis cases.
Purpose of the Study:
- To compare clinical features, management strategies, and outcomes between pediatric patients with PNSP meningitis and those with PSSP meningitis.
- To evaluate changes in meningitis management in response to increasing PNSP rates.
Main Methods:
- A retrospective, nested case-control study was conducted using data from the Immunization Monitoring Program, Active (IMPACT) surveillance study.
- PNSP meningitis cases were compared with PSSP meningitis controls from 297 invasive bacterial meningitis cases diagnosed between 1991 and 1999.
Main Results:
- PNSP meningitis cases (10.1%) required longer intravenous antibiotic treatment (15.6 days vs. 12.3 days) compared to PSSP cases.
- Empiric vancomycin use increased significantly for PNSP meningitis cases over the study period.
- No significant difference in intensive care unit admission or neurologic sequelae was observed between PNSP and PSSP meningitis groups, despite higher rates of second lumbar punctures in PNSP cases.
Conclusions:
- Management strategies for bacterial meningitis in Canadian children have evolved due to the rise of PNSP.
- Treatment for PNSP meningitis differs significantly from PSSP meningitis, particularly in antibiotic selection and duration.
- Neurologic sequelae remain a common complication of meningitis, with similar rates observed in both PNSP and PSSP cases.