Outcome in Patients With Bacterial Meningitis Presenting With A Minimal Glasgow Coma Scale Score

OUTCOME IN PATIENTS WITH
BACTERIAL MENINGITIS PRESENTING

WITH A MINIMAL
GLASGOW COMA SCALE SCORE
Oleh :
dr. Yuki Fitria Maatisya
Pembimbing :
dr. Yusril Sp.S
Bacterial Meningitis
Bacterial meningitis is a serious and life-threatening
disease.
Streptococcus pneumoniae and Neisseria meningitidis
are the predominant causative pathogens of this
disease in adults causing 80%85% of all cases, with
high associated morbidity and mortality rates.
Many patients with bacterial meningitis present with
an abnormal conscious state, and 15%20% of patients
are comatose upon presentation.
Bacterial Meningitis &

GCS
Glasgow Coma Scale, is a strong predictor for poor disease

outcome in bacterial meningitis.
Abnormal conscious caused by a complex interaction
between severe brain inflammation, raised intracranial
pressure (ICP), and resulting complications such as
hydrocephalus, cerebral (micro) infarctions, or epileptic
seizures
We
analyzed
the
incidence,
clinical
characteristics,
complications, and outcome of patients with bacterial

meningitis presenting with a minimal Glasgow Coma Scale
score.
Methode
Prospective nation wide observational cohort
study in the Netherlands
Included :
Excluded:
episodes of community
negative CSF cultures, hospital
acquired
bacterial
meningitis confirmed by
culture of CSF in adults.
acquired
meningitis,
neurosurgical device, or who

underwent
neurosurgical
operation within 1 month before

bacterial meningitis onset.
Methode
Informed consent was obtained from all participating
patients or, in case of decreased consciousness, from their
legally authorized representatives.
Clinical data, including specific queries about the Glasgow
Coma Scale score on admission, had been prospectively
collected by means of an online case record form.
The Glasgow Coma Scale grades coma severity according
to 3 categories of responsiveness: eye opening, motor
responses, and verbal responses, with scores ranging from
3 to 15.
Methode
All
patients
underwent
neurologic
examination
performed by a neurologist, and outcome was graded

according to the Glasgow Outcome Scale.
A favorable outcome was defined as a score of 5 and
an unfavorable outcome as a score of 14.
Standard protocol approvals, registrations, and patient
consents. The study was approved by the ethics
committee
of
the
Academic
Amsterdam, the Netherlands.
Medical
Center,
RESULTS
From 2006 to 2012, 1,083 episodes of communityacquired bacterial meningitis were included in the cohort.
Thirty of 1,083 patients (3%) presented with a Glasgow
Coma Scale score of 3 on admission (figure 1).
Fifteen patients (50%) were female and the median age
was 65 years (interquartile range 4976 years; table 1).
Fifteen patients (50%) had one or more predisposing
conditions
for
bacterial
meningitis,
consisting
of
otitis/sinusitis in 8, immunocompromised state in 6, and

pneumonia in 2.
Figure 1 Distribution of scores on Glasgow Coma Scale for

adults presenting
with community-acquired bacterial meningitis
Table 1 Clinical characteristics of 30 patients with bacterial meningitis

presenting with a minimal coma scorea
Table 1 Clinical characteristics of 30 patients with bacterial meningitis

presenting with a minimal coma score
RESULT
Cranial CT on admission was performed in 27 of 30
patients (90%) and was abnormal in 67% .
In 22 of 30 patients (73%), the minimal Glasgow Coma
Scale score could be explained either by complications
resulting
from
the
meningitis
(seizures
in
10,
hydrocephalus in 5, and cerebral edema in 7) or by

sedative medication (5 patients).
In the other 8 patients, the minimal score on the Glasgow
Coma Scale was explained by a direct effect of the
meningitis (defined as a combination of severe brain
inflammation and raised ICP).
Figure 2 Spectrum of abnormal CT scanning of patients with

bacterial meningitis presenting with a minimal Glasgow Coma
Scale score
RESULT
Twenty-nine of the 30 patients (97%) had at least one
individual CSF finding predictive of bacterial meningitis
(glucose level ,34 mg/dL [1.9 mmol/L], ratio of CSF
glucose to blood glucose < 0.23, protein level > 220
mg/dL, or leukocyte count > 2,000/mm3).
Ten of 27 patients (37%) had a CSF leukocyte count
below 1,000 cells/mm3, which has previously been
associated with poor outcome
RESULT
CSF cultures grew S pneumoniae in 26 patients (87%)
and
Haemophilus
influenzae,
Salmonella
enterica,
Streptococcus pyogenes, and Staphylococcus aureus in

1 patient each.
Initial
antibiotic
treatment
was
microbiologically
adequate in all patients and 25 of 29 patients (86%)

received adjunctive dexamethasone on admission. The
clinical characteristics, results of cranial imaging, and
CSF analysis were similar when considering only
patients who did not receive sedative medication
RESULT
The
majority
of
patients
(87%)
developed
complications during the clinical course.

Systemic complications consisted of respiratory failure
(15 of 25 [60%]), pneumonia (6 of 26 [23%]), and
hyponatremia (4 of 27 [15%]).
Neurologic complications consisted of seizures (7 of

30 [23%]), hearing impairment (4 of 30 [13%]),
cerebral infarction (3 of 30 [10%]), and subdural
empyema (2 of 30 [7%]).
Table 2 Complications and outcome of 30 patients with bacterial

meningitis
Table 2 Complications and outcome of 30 patients with bacterial

meningitis
RESULT
The causes of death in the 18 deceased patients were as follows:
extensive neurologic damage due to meningitis (6 patients),
acute brain herniation shown on cranial imaging (4 patients),
withdrawal of care because of poor neurologic prognosis (2
patients; care was withdrawn 2 and 3 days after admission),
multiorgan failure or septic shock (2 patients each), and
cardiac arrest or delayed cerebral thrombosis (1 patient each).
Autopsy was performed in 3 patients showing severe brain
damage in all patients.
In 1 patient venous sinus thrombosis was identified that was
not diagnosed prior to autopsy.
DISCUSSION
A
small
minority
of
patients
with
community-acquired
bacterial meningitis presents with a minimal score on the

Glasgow Coma Scale (3%).
Although the majority of these patients had an unfavorable
outcome (77%) and many patients died (60%), the number of
patients who recovered completely was substantial
Neuroimaging showed that 1 out of 4 patients with bacterial
meningitis presenting with a minimal score on the Glasgow
Coma
Scale
have
cerebral
abnormalities
such
as
hydrocephalus or subdural empyema, which may require

emergency neurosurgery.
DISCUSSION
Early
identification
treatment
of
and
these
subsequent
complications
neurosurgical
may
improve
prognosis.
Cranial imaging should precede lumbar puncture in all
patients with a minimal Glasgow Coma Scale score to
rule out space-occupying lesions causing brain shift.
Antibiotic
therapy
and
adjunctive
dexamethasone
therapy if indicated should be started before sending

the patient to the imaging room.
Table 3 Clinical characteristics of patients with bacterial meningitis

presenting
with a minimal coma score with good outcome and with poor outcome
CONCLUSION
Patients
with
community-acquired
bacterial
meningitis rarely present with a minimal score on

the Glasgow Coma Scale, but this condition is
associated with high rates of morbidity and
mortality.
However, 1 out of 5 of these severely ill patients
will make a full recovery, stressing the continued
need for aggressive supportive care.
CRITICAL APPRAISAL
VALIDITAS
1
Apakah seluruh sampel yang dikumpulkan berada pada fase awal

penyakit?
Apakah follow up terhadap sampel lama dan lengkap?
Apakah kriteria keluaran klinis dilakukan secara blinding?
Jika ditemukan faktor-faktor lain yang berpengaruh apakah faktor
YA
YA
TIDAK
tersebut akan dianalisis dan dijadikan faktor prognosis baru?
YA
IMPORTANCE
1
Bagaimana survival rate dan median survival?
Bagaimana confidence interval?
ADA
DATA TIDAK
DITAMPILKAN
APPLICABILITY
Apakah karakteristik pasien di kota/negara kita berbeda sehingga

studi ini tidak bisa diterapkan?
YA
THANK
YOU

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OUTCOME IN PATIENTS WITH

BACTERIAL MENINGITIS PRESENTING

Bacterial Meningitis &

Glasgow Coma Scale, is a strong predictor for poor disease

complications, and outcome of patients with bacterial

negative CSF cultures, hospital

neurosurgical device, or who

operation within 1 month before

performed by a neurologist, and outcome was graded

Amsterdam, the Netherlands.

otitis/sinusitis in 8, immunocompromised state in 6, and

Figure 1 Distribution of scores on Glasgow Coma Scale for

Table 1 Clinical characteristics of 30 patients with bacterial meningitis

Table 1 Clinical characteristics of 30 patients with bacterial meningitis

hydrocephalus in 5, and cerebral edema in 7) or by

Figure 2 Spectrum of abnormal CT scanning of patients with

Streptococcus pyogenes, and Staphylococcus aureus in

adequate in all patients and 25 of 29 patients (86%)

complications during the clinical course.

Neurologic complications consisted of seizures (7 of

Table 2 Complications and outcome of 30 patients with bacterial

Table 2 Complications and outcome of 30 patients with bacterial

bacterial meningitis presents with a minimal score on the

hydrocephalus or subdural empyema, which may require

therapy if indicated should be started before sending

Table 3 Clinical characteristics of patients with bacterial meningitis

meningitis rarely present with a minimal score on

Apakah seluruh sampel yang dikumpulkan berada pada fase awal

Apakah follow up terhadap sampel lama dan lengkap?

Apakah kriteria keluaran klinis dilakukan secara blinding?

Jika ditemukan faktor-faktor lain yang berpengaruh apakah faktor

tersebut akan dianalisis dan dijadikan faktor prognosis baru?

Bagaimana survival rate dan median survival?

Bagaimana confidence interval?

Apakah karakteristik pasien di kota/negara kita berbeda sehingga

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