Predictors for neurological complications of bacterial meningitis in adults in a limited-resource country

Objective: A prospective analysis of prognostic factors for neurological complications of bacterial meningitis in adults. Methods: This prospective study enrolled 46 adults older than 16 years of age, treated for bacterial meningitis during the period of 1/1/2009 through 12/31/2010 at the Infectious Diseases Clinic in Prishtinë. Adults are categorized into specific age groups: >16–26 years of age (10 patients), >26–60 years of age (25 patients) and >60 years of age (11 patients). Eighteen relevant predictors were chosen to analyze their association with the incidence of neurological complications. p values less than 0.05 were considered statistically significant. Results: Of the 46 adults treated for bacterial meningitis, neurological complications developed in 17 patients (37%) and the overall mortality rate was 13% (6 death cases). Observed neurological complications in adults were: cerebral abscess (n = 7), cerebral edema (n = 4), hemiparesis (n = 3), recurrent seizures (n = 2), thrombosis sinus cavernosus (n = 1), paresis nervus facialis (n = 1) and decerebration (n = 1). The etiology of bacterial meningitis cases was proven by CSF cultures and Gram stain in 33/46 cases (72%): 13 meningococci, 7 Gram-negative bacilli, 7 pneumococci, and 2 staphylococci isolates were found. In adults, no statistical differences in the occurrence of neurological complications were identified concerning age groups (p = 0.41). Adults >60 years of age had a greater risk for unfavorable outcome. Neurological complications developed more frequently in patients who were infected with Gram-negative bacilli (6/7). Factors found to be associated with increased risk for development of neurological complications were the presence of focal neurological deficit on admission, previous treatment with antibiotics and altered mental state at admission, especially coma (p < 0.05). Half of patients (48%) have been treated with antibiotics prior to admission and 86% of them with parenteral therapy. On admission, 50% of patients had altered mental state, 26% were in coma and 13% had focal neurologic abnormalities. Duration of illness >48 h, seizures prior to admission, initial therapy with one antibiotic, dexamethasone use, resistance of pathogens to antimicrobics, community-acquired infection, initial pleocytosis >5000 cells/mm3, turbid CSF after 48 h, low CSF/blood glucose ratio <0.20, increased proteinorrhachia, male gender, rural location, the presence of comorbidity and primary focus of infection were not associated with increased risk for the development of neurological complications. Seizures prior to admission manifesed 20% of patients, primary focus of infection was found in 85% and the presence of comorbidity in 57% of patients. The initial therapy with two antibiotics was given in 63% and dexamethasone was used in 89% of patients. All the patients except 3, had community acquired infection. Conclusions: The severity of clinical presentation at admission involving the presence of focal neurologic deficit, altered mental state, especially coma, and infection with Gram negative-bacilli have been identified as the strongest predictors for neurological complications of bacterial meningitis in adults and may be of value in selecting patients for more intensive care and treatment.