Morbidity and Mortality

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Morbidity and Mortality

• By
• James Yost, MD, MS, MBA
• PGY 2
• Emory Family Medicine

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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

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Gram-Negative Bacillary Meningitis

• Background Continued
• Two age groups are affected
• Neonates/infants
• Adults
• community-acquired meningitis
• nosocomial meningitis

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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

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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

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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

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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

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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)

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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

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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

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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

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E. Coli Meningitis

• Clinical History
• head trauma
• neurosurgery
• debilitated patients
• elderly people
• alcoholics
• diabetics
• cancer
• immunosuppressive state

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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

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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

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E. Coli Meningitis

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

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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.

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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

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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

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Bartholin's Gland

• The two Bartholin's glands secrete mucus to
  provide moisture for the vulva
• Cysts and abscesses are the most common disorders

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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.

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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 bartholins gland has
  not been found.

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• Thank You