Morbidity and Mortality

1. Morbidity and Mortality By James Yost, MD, MS, MBA PGY 2 Emory Family Medicine psp.about.com

2. Gram-Negative Bacillary Meningitis • Background • 1805 • Meningitis was originally recognized and was virtually 100 percent fatal. • 1892 • Gram-negative meningitis was first recognized • 1930s and 40s • Cases were described resulting from abortion, genitourinary manipulation, and spinal anesthesia • 1950s and 60s • Recognized as an occasional complication of injuries and neurosurgical procedures

3. Gram-Negative Bacillary Meningitis • Background Continued • Two age groups are affected • Neonates/infants • Adults • community-acquired meningitis • nosocomial meningitis

4. Gram-Negative Bacillary Meningitis • Epidemiology • Frequency • Gram-negative bacilli account for 1.5 – 4.3% of all cases of meningitis • E. coli and Klebsiella account for more than 50-70% of cases of gram-negative bacillary meningitis • There was an inverse relationship with age with E. coli • 74% E. coli in neonates • 10% E. coli and 40% Klebsiella in adults

5. Gram-Negative Bacillary Meningitis • Epidemiology • Frequency • Neonatal and infant meningitis • Gram-negative bacilli are the fifth most common cause accounting for 3.6% of all cases • 40.3% of all Gram-negative bacilli cases occur in this age group • 53% of those were caused by E. coli • Community-acquired gram-negative meningitis • accounting for only 9 of 253 episodes (3.6%) in a report from the United States

6. Gram-Negative Bacillary Meningitis • Epidemiology • Frequency Continued • Nosocomial acquired gram-negative meningitis • 33-69% of bacterial meningitis are believed to nosocomial • 36 to 50% of cases occurred after neurosurgical procedures • Associated bacteremia • Neonates and infants were 55% • Community-acquired gram-negative meningitis were 58% • Nosocomial were 43%

7. Gram-Negative Bacillary Meningitis • Epidemiology • Mortality/Morbidity • The mortality rate of untreated disease approaches 100 percent. • The mortality in adults and children with gram-negative meningitis has ranged from 40 to 80% • E. coli meningitis has a mortality rate from 50 to 90%, in patients in a coma or with bacteremia • Transient or permanent neurologic morbidity occurred in 21 to 28% of survivors

8. Gram-Negative Bacillary Meningitis • Epidemiology • Mortality/Morbidity Continued • Three baseline clinical features were independently associated with an adverse outcome (defined as in-hospital death or neurologic deficit at discharge): • hypotension, altered mental status, and seizures • 9% adverse outcome had no clinical risk factors • 33% adverse outcome had intermediate risk (one clinical factor) • 57% adverse outcome had high risk (two or three clinical factors)

9. Gram-Negative Bacillary Meningitis • Epidemiology • Risk Factors • In a report of 197 cases of nosocomial meningitis, the major risk factors were: • neurosurgery or head trauma within the past month • a neurosurgical device • a CSF leak. • These accounted for 75 percent of cases • Vaginal birth and the hands of health care workers • Immunocompromised states for community-acquired

10. Gram-Negative Bacillary Meningitis • Pathophysiology • The CSF is normally deficient in immunoglobulins • The development of bacterial meningitis progresses through four interconnected phases • Bacterial invasion of the host with subsequent infection of the CNS • Bacterial multiplication and induction of inflammation in the subarachnoid and ventricular space • Progression of inflammation with associated pathophysiologic alterations • Development of neuronal damage

11. E. coli Meningitis • Pathophysiology Continued • E. coli have two mechanisms that aid in the pathogenesis of meningitis • K1 capsular polysaccharide • bacterial capsule • Similar to those of S. pneumoniae, N. meningitidis, and Haemophilus influenzae • Can assist the organism in evading host defenses • S fimbriae • Facilitates CSF entry particularly at the choroid plexus

12. E. Coli Meningitis • Clinical History • head trauma • neurosurgery • debilitated patients • elderly people • alcoholics • diabetics • cancer • immunosuppressive state

13. E. Coli Meningitis • Clinical History Continued • Most cases of postoperative gram-negative meningitis occur 10 or more days after surgery • Range of 1-20 days • The time interval is similar in infants, with a mean of 5.5 days following surgery • Range 1 to 15 days

14. E. Coli Meningitis • Causes • Neonatal E. coli meningitis • acquired during or soon after delivery • vaginal flora of the mother • the hands of hospital personnel • Nosocomial E. coli meningitis • neurosurgery • head trauma within the past month • a neurosurgical device • CSF leak • temporary epidural catheters • tunneled intraspinal catheter systems

15. E. Coli Meningitis • Causes Continued • Community-acquired meningitis • Any Immunosuppressed state • Alcohol-induced cirrhosis • Diabetes • Malignancy • Splenectomy • glucocorticoid therapy • Instrumentation of the urinary tract

16. E. Coli Meningitis • Treatment for the Adult • Vancomycin to cefotaxime or ceftriaxone as empiric treatment until culture and susceptibility results are available • Dexamethasone is 0.15 mg/kg every six hours • suspected pneumococcal meningitis and a Glasgow coma scale score of 8 to 11 • should be continued for four days if the Gram stain reveals organisms consistent with S. pneumoniae • should be discontinued if the gram stain and/or cultures reveal another pathogen • If using steroids, use Rifampin in place of Vanc.

17. E. Coli Meningitis • Complications • Ventriculitis • Subdural effusion • Brain abscess • Syndrome of inappropriate antidiuretic hormone secretion • Hydrocephalus • Seizure disorder • Spastic paralysis • Mental retardation • Hearing deficit • Metastatic septic abscesses • Acute disseminated encephalomyelitis

18. E. Coli Meningitis • Prognosis • In virtually all studies, one of the most important factors predicting survival is the state of consciousness at the time of admission. • In a large series from Massachusetts, patients who were unresponsive or responsive only to pain had a 49 percent mortality rate compared to 16 percent for those who were alert or only lethargic

19. Bartholin's Gland • The two Bartholin's glands secrete mucus to provide moisture for the vulva • Cysts and abscesses are the most common disorders www.aafp.org www.aafp.org

20. Bartholin's Gland • Bartholin's Gland Cyst • Chronic inflammation can obstruct the orifice of the Bartholin's gland duct • leads to cystic dilatation of the duct • Bartholin's Gland Abscess • Result of a polymicrobial infection • The predominant aerobic and facultative bacteria are Escherichia coli and N. gonorrhea • The most common anaerobic bacteria are Bacteroides species.

21. Conclusion • E. coli meningitis is a very rare disease with a very high mortality rate. • Most common causes in adults were from neurosurgical procedures, trauma or urinary tract manipulation • In a literature search from 1966 to the present, a case of E. coli meningitis resulting from incision and drainage of a bartholin’s gland has not been found.

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