The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Community-Acquired Bacterial Meningitis: Risk Stratification for Adverse Clinical Outcome and Effect of Antibiotic Timing

Steven I. Aronin, MD; Peter Peduzzi, PhD; and Vincent J. Quagliarello, MD
[+] Article, Author, and Disclosure Information

From Waterbury Hospital, Waterbury, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; and Yale University School of Medicine, New Haven, Connecticut. Acknowledgments: The authors thank Lucy Tomaso and Rita Rossi for manuscript preparation. Grant Support: In part by Roche Pharmaceuticals. Dr. Quagliarello is supported by the Donaghue Medical Research Foundation. Requests for Reprints: Vincent Quagliarello, MD, 800 LCI, Yale University School of Medicine, New Haven, CT 06510. Current Author Addresses: Dr. Aronin: Waterbury Hospital, 64 Robbins Street, Waterbury, CT 06721. Dr. Peduzzi: Cooperative Studies Program, Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516. Dr. Quagliarello: 800 LCI, Yale University School of Medicine, New Haven, CT 06510.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(11_Part_1):862-869. doi:10.7326/0003-4819-129-11_Part_1-199812010-00004
Text Size: A A A

Background: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults.

Objective: To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome.

Design: Retrospective cohort study; patients were divided into derivation and validation samples.

Setting: Four hospitals in Connecticut.

Patients: 269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department.

Measurements: Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge).

Results: For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21%) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P = 0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P = 0.008) or intermediate risk (P = 0.003) at arrival in the emergency department to high risk before administration of antibiotics.

Conclusions: In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.