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Early versus late diagnosis in community-acquired bacterial meningitis: a retrospective cohort study
J Bodilsen1, C T Brandt2, A Sharew3
1Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark.
Insights
Late diagnosis of community-acquired bacterial meningitis (CABM) is common, often with non-infectious initial diagnoses. This delay increases mortality, highlighting the need for vigilance in elderly patients and those with pneumonia.
Area of Science:
- Infectious Diseases
- Clinical Medicine
- Epidemiology
Background:
- Community-acquired bacterial meningitis (CABM) poses a significant diagnostic challenge.
- Timely diagnosis and treatment are crucial for improving patient outcomes in CABM.
Purpose of the Study:
- To investigate the clinical characteristics of patients with delayed diagnosis of CABM.
- To determine the outcomes associated with late diagnosis of CABM.
- To identify predictors of delayed diagnosis and in-hospital mortality in CABM patients.
Main Methods:
- A retrospective chart review was conducted on adult patients diagnosed with CABM across three Danish centers from 1998 to 2014.
- Patients were classified into early or late diagnosis groups based on initial diagnostic and treatment considerations.
- Modified Poisson regression analysis was employed to assess predictors of late diagnosis and in-hospital mortality.
Main Results:
- 32% of CABM patients (113/358) received a late diagnosis, frequently with initial non-infectious misdiagnoses (72%).
- Late diagnosis was associated with older age (>65 years), absence of neck stiffness, and concurrent pneumonia.
- Patients with late diagnosis exhibited a significantly higher in-hospital mortality rate (36% vs. 18%, adjusted RR 1.7).
Conclusions:
- Late diagnosis of CABM is prevalent and linked to suboptimal patient management and increased mortality.
- The absence of classic symptoms like neck stiffness should not exclude CABM, particularly in elderly patients or those with pneumonia.
- Enhanced clinical suspicion and prompt diagnostic workup are essential for improving CABM outcomes.
Objectives:
To examine clinical characteristics and outcome of patients with late diagnosis of community-acquired bacterial meningitis (CABM).
Methods:
We conducted a chart review of all adults with proven CABM in three centres in Denmark from 1998 through to 2014. Patients were categorized as early diagnosis of CABM immediately on admission, or late diagnosis if CABM was not listed in referral or admission records and neither lumbar puncture nor antibiotic therapy for meningitis was considered immediately on admission. We used modified Poisson regression analysis to compute adjusted relative risks with 95% CIs for predictors of late diagnosis and in-hospital mortality.
Results:
A total of 113/358 (32%) patients were categorized as late diagnosis demonstrating a variety of tentative diagnoses of which 81/113 (72%) were non-infectious. We observed several statistically significant baseline differences (p <0.05) in patients with late versus early diagnosis including age >65 years (56/113, 50% versus 67/245, 27%), neck stiffness (35/97, 36% versus 183/234, 78%), concomitant pneumonia (26/113, 23% versus 26/245, 11%), and meningococcal meningitis (6/113, 5% versus 52/245, 21%). These variables remained statistically significant in multivariate analysis. Moreover, late diagnosis was associated with increased in-hospital mortality (41/113, 36% versus 43/245, 18%; adjusted relative risk 1.7, 95% CI 1.2-2.5).
Conclusions:
Late diagnosis of CABM was common and patients were admitted with mostly non-infectious diagnoses. Absence of neck stiffness did not rule out CABM and special attention should be given to patients with pneumonia and the elderly. Late diagnosis was associated with incorrect patient management and increased mortality.
