Elizabeth Aguilera

Clinical Characteristics and Predictors of Adverse Outcome in Adult and Pediatric Patients With Healthcare-Associated Ventriculitis and Meningitis.

Background. Healthcare-associated meningitis or ventriculitis is a serious and life-threatening complication of invasive neurosurgical procedures or penetrating head trauma. Methods. We performed a retrospective study of adults and children with the diagnosis of healthcare-associated meningitis or ventriculitis, as defined by the 2015 Centers of Disease Control and Prevention case definition, at 2 large tertiary care hospitals in Houston, Texas from July 2003 to November 2014. Patients were identified by infection control practitioners and by screening cerebrospinal fluid samples sent to the central laboratory. We collected data on demographics, clinical presentations, laboratory results, imaging studies, treatments, and outcomes. Results. A total of 215 patients were included (166 adults and 49 children). A positive cerebrospinal fluid culture was seen in 106 (49%) patients, with the majority of the etiologies being Staphylococcus and Gram-negative rods. An adverse clinical outcome was seen in 167 patients (77.7%) and was defined as death in 20 patients (9.3%), persistent vegetative state in 31 patients (14.4%), severe disability in 77 patients (35.8%), or moderate disability in 39 patients (18.1%). On logistic regression analysis, age >45 years (adjusted odds ratio [OR], 6.47; 95% confidence interval [CI], 2.31–18.11; P ≤ .001), abnormal neurological exam (adjusted OR, 3.04; 95% CI, 1.27–7.29; P = .013), and mechanical ventilation (adjusted OR, 5.34; 95% CI, 1.51–18.92; P = .01) were associated with an adverse outcome. Conclusions. Healthcare-associated meningitis or ventriculitis is associated with significant morbidity and mortality.

Use of Testing for West Nile Virus and Other Arboviruses.

For patients with meningitis and encephalitis, testing for these viruses is underutilized.

Aseptic meningitis in adults and children: Diagnostic and management challenges.

BACKGROUND Aseptic meningitis represents a common diagnostic and management dilemma to clinicians. OBJECTIVES To compare the clinical epidemiology, diagnostic evaluations, management, and outcomes between adults and children with aseptic meningitis. STUDY DESIGN We conducted a retrospective study from January 2005 through September 2010 at 9 Memorial Hermann Hospitals in Houston, TX. Patients age≥2months who presented with community-acquired aseptic meningitis with a CSF white blood cell count >5cells/mm3 and a negative Gram stain and cultures were enrolled. Patients with a positive cryptococcal antigen, positive blood cultures, intracranial masses, brain abscesses, or encephalitis were excluded. RESULTS A total of 509 patients were included; 404 were adults and 105 were children. Adults were most likely to be female, Caucasian, immunosuppressed, have meningeal symptoms (headache, nausea, stiff neck, photophobia) and have a higher CSF protein (P <0.05). In contrast, children were more likely to have respiratory symptoms, fever, and leukocytosis (P <0.05). In 410 (81%) patients, the etiologies remained unknown. Adults were more likely to be tested for and to have Herpes simplex virus and West Nile virus while children were more likely to be tested for and to have Enterovirus (P <0.001). The majority of patients were admitted (96.5%) with children receiving antibiotic therapy more frequently (P <0.001) and adults receiving more antiviral therapy (P=0.001). A total of 384 patients (75%) underwent head CT scans and 125 (25%) MRI scans; all were normal except for meningeal enhancement. All patients had a good clinical outcome at discharge. DISCUSSION Aseptic meningitis in adults and children represent a management challenge as etiologies remained unknown for the majority of patients due to underutilization of currently available diagnostic techniques.

The clinical significance of neutrophilic pleocytosis in cerebrospinal fluid in patients with viral central nervous system infections

BACKGROUND Viral central nervous system (CNS) infections are typically characterized by a cerebrospinal fluid (CSF) lymphocytic pleocytosis. A CSF neutrophilic pleocytosis presentation has been described, but its prognostic and clinical significance is unknown. The objectives of this study were to (1) compare the clinical and laboratory characteristics of viral CNS infections with a CSF neutrophilic pleocytosis to those with a lymphocytic pleocytosis, and (2) evaluate factors associated with an adverse clinical outcome. METHODS A retrospective study of patients with confirmed viral CNS infections was conducted. The patients were divided into those with CSF neutrophilic pleocytosis and those with CSF lymphocytic pleocytosis. Clinical findings and outcomes were compared between the two groups. RESULTS Of the 182 patients included in the study, 45 (24.7%) had CSF neutrophilic pleocytosis. Enterovirus infections were the cause of 64% of neutrophil-predominant CSF and 33% of lymphocyte-predominant CSF (p<0.001), while herpes infections were the cause of 46% of lymphocytic pleocytosis and 20% of neutrophilic pleocytosis (p=0.003). Moreover, neutrophilic pleocytosis was seen more commonly in younger patients (p=0.001), patients with respiratory symptoms (p=0.04), and patients with higher CSF white cell counts (p=0.004). Twenty-nine patients had an adverse clinical outcome (15.9%); the only predictor independently associated with an adverse clinical outcome on multivariable logistic regression analysis was an encephalitis presentation (p=0.01). CONCLUSIONS The results of a study exploring the association between CSF neutrophilic pleocytosis and clinical and prognostic significance are presented here. This study suggests that CSF neutrophilic pleocytosis is not associated with higher adverse clinical outcomes.

Detection of NH1N1 influenza virus in nonrespiratory sites among children.

Among 20 children admitted with laboratory-confirmed influenza, viral RNA was detected in respiratory secretion, stool and blood in 19, 5 and 1 children, respectively. Gastrointestinal symptoms were common but were not associated with viral RNA in stool. nH1N1 viremia was detected, for the first time, in an immunocompetent child.

Risk Classification for Enteroviral Infection in Children With Meningitis and Negative Gram Stain

Objectives Enterovirus is the most common cause of aseptic meningitis in children. This study aimed at identifying baseline variables associated with a positive cerebrospinal fluid (CSF) Enterovirus polymerase chain reaction (PCR) to aid clinicians in targeting patients who could be tested and treated as outpatients. Methods We performed a retrospective review of children (2 months to 17 years old) admitted to the Childrens Memorial Hermann Hospital in Houston, TX, between January 2005 and December 2010 with symptoms of meningitis, CSF white cell count of greater than 5 cells/mm3, and a negative CSF Gram stain, who had a CSF Enterovirus PCR. Results One hundred thirty-seven children were reviewed; median age was 4.7 (0.1–17.1) years, and 79 (58%) were male. Fifty patients (37%) had positive CSF Enterovirus PCR. Only 13 (15%) of the Enterovirus PCR-negative patients had an identifiable etiology. All patients were hospitalized. The mean hospital stay for patients with Enterovirus was 2.9 days; 88% received empiric antibiotics. Rates of antibiotic administration were not different between PCR-positive and PCR-negative groups (P > 0.05). All patients with Enterovirus had a favorable clinical outcome. A predictive model was created using 3 baseline variables independently associated with a positive Enterovirus PCR (P < 0.05): May to November presentation, CSF protein of less than 100 mg/dL, and absence of focal neurologic signs. The model classified patients into 2 risk categories for a positive Enterovirus PCR (low risk, 0% [0/17 patients]; high risk, 42% [50/120 patients]; P < 0.001). Conclusions Our predictive model can be used to identify children for whom Enterovirus PCR testing is warranted. Such testing could avoid unnecessary hospitalization and antibiotic administration.

843Enhancing Pathogen Identification Using a Comprehensive PCR System in Adult and Pediatric Patients with Meningitis and a Negative Gram Stain

System in Adult and Pediatric Patients with Meningitis and a Negative Gram Stain Susan Wootton, MD; Elizabeth Aguilera, MD; Lucrecia Salazar, MD; Andrew Hemmert, PhD; Rodrigo Hasbun, MD, MPH; Pediatrics, University of Texas Health Science Center, Houston, TX; Division of Infectious Diseases, University of Texas Medical School at Houston, Houston, TX; BioFire Diagnostics, LLC, Salt Lake City, UT; University of Texas Health Science Center at Houston, Houston, TX

CSF HSV PCR testing in adults and children with meningitis and encephalitis

Abstract Background Herpes simplex virus (HSV) is a common treatable cause of meningitis and encephalitis. Delayed antiviral therapy is associated with worse clinical outcomes in HSV encephalitis. Objectives To determine the utilization of a cerebrospinal fluid (CSF) HSV polymerase chain reaction (PCR) and identify predictors for a positive HSV PCR result. Methods A retrospective review of 751 adults and children with meningitis and encephalitis at 9 hospitals in Houston TX from January 1 2005 to December 31 2010. Results Of 751 patients, 331 (44%) underwent CSF HSV PCR testing. Adults were more commonly tested than children (84% vs. 69%, P <0.0001). Additionally, patients with more comorbidities and clinical findings of encephalitis (e.g., altered mental status, focal neurological findings, seizures) were more commonly tested for HSV (P <0.001). Patients tested for HSV were also more likely to be evaluated for West Nile Virus, receive empiric acyclovir and have worse outcomes (P < 0.001). In total, 48 of 331 (14.5%) patients tested had a positive CSF HSV PCR. Predictors for a positive CSF HSV PCR on logistic regression analysis were stiff neck (odds ratio [OR], 2.181 [1.090–4.366]; P = 0.028, lymphocytic pleocytosis >50% lymphocytes (OR, 6.187 [1.412–27.11] P = 0.016, and CSF protein > 100mg/dl (OR, 3.279 [1.105–9.731] P = 0.032. Conclusion CSF HSV PCR is underutilized in community acquired meningitis and encephalitis and is done more frequently in adults and in those with an encephalitis presentation. Disclosures R. Hasbun, Biomeriaux: Consultant, Consulting fee Biofire: Speaker’s Bureau, Speaker honorarium Merck: Speaker’s Bureau, Speaker honorarium Pfizer: Speaker’s Bureau, Speaker honorarium Medicine’s Co: Speaker’s Bureau, Speaker honorarium