Ping-Yu Lee

Adult spinal epidural abscess: clinical features and prognostic factors.

Twenty-nine adult patients with spinal epidural abscess (SEA), aged 31-73 years, have been identified over a period of 8 years. The 29 SEA patients included 21 men and eight women with a mean age of 54 years. Initial diagnosis of SEA was made in only 17% of our patients and another 48% of patients were initially suggested of having infection or mass of the spine. Spinal pain and fever were the two most common clinical features shared among our patients. The two most common pathogens were Staphylococcus aureus and Mycobacterium tuberculosis, which were found in 62% of patients. Twenty-seven patients received surgical intervention and antibiotic treatment for SEAs, one of which succumbed to meningitis. Two patients without neurological abnormalities received conservative treatment alone and survived. The number of patients, which showed improvement of symptoms, included all seven patients with neck/back pain without neurologic deficits, all 15 patients with paraparesis, 10 of 13 patients with bladder/bowel dysfunction with or without motor deficits, and none of the five with plegia. Preoperative plegia was identified as a poor prognostic factor, and patients with SEA continue to show high rates of morbidity and mortality. Thus, in order to improve the therapeutic outcome of patients with SEA, early diagnosis and management are mandatory to treat the patients before the deterioration of neurologic deficit occurs.

Community-acquired bacterial meningitis in adults: the epidemiology, timing of appropriate antimicrobial therapy, and prognostic factors

Between January 1986 and December 1999, 109 adult patients with culture-proven community-acquired bacterial meningitis were identified at Kaohsiung Chang Gung Memorial Hospital. To compare changes over time, the appearance of disease among our patients was divided into two equal time periods: an earlier time period (1986-1992) and a later time period (1993-1999). In this study, there was a decreasing proportion of community-acquired bacterial meningitis compared with nosocomial bacterial meningitis in adult patients in recent years. Its proportion declined dramatically from 81% in the earlier 7 years to 37% in the later 7 years. Of the pathogens, Klebsiella (K.) pneumoniae was the most frequently implicated pathogen, followed by Viridans (V.) streptococci, Streptococcus pneumoniae, and Staphylococcus aureus. Other rare organisms including Acinetobacter baumannii, Salmonella Group B and D, Proteus mirabilis, Group B, D, and non-A, non-B and non-D streptococci, and coagulase-negative staphylococci emerged during the second period. There was a decrease in the mortality rate from 44% in the first to 34% in the second time period, but the overall mortality rate remained high. Of the implicated pathogens, patients infected with V. streptococci had a consistently favorable prognosis, while a dramatic decrease in the mortality rate of those infected with K. pneumoniae was seen in recent years. In the multiple logistic regression analysis, only the presence of septic shock and seizures was independently associated with mortality. The timing of appropriate antimicrobial therapy, as defined by consciousness level, was a major determinant of survival and neurological outcomes for patients with community-acquired bacterial meningitis, and the first dose of an appropriate antibiotic should be administrated before a patients consciousness deteriorates to a Glasgow coma scale score lower than 10.

Bacterial meningitis in infants: the epidemiology, clinical features, and prognostic factors.

This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.

Community-acquired spontaneous bacterial meningitis in adult diabetic patients: an analysis of clinical characteristics and prognostic factors.

Abstract.Background: We analyzed the clinical characteristics and prognostic factors of community-acquired spontaneous bacterial meningitis (CASBM) in adult diabetic patients. Patients and Methods: Over a period of 15 years, 47 adult diabetic patients with CASBM were identified. The clinical characteristics, laboratory data and therapeutic outcome of these 47 patients were statistically analyzed. Results: The 47 patients were 31 men and 16 women, aged 22 to 79 years, and they accounted for 38.5% (47/122) of our adult patients with culture-proven CASBM. The most common causative pathogen was Klebsiella pneumoniae (n = 32), followed by pathogens of the streptococcal species (n = 6). Besides classic manifestations of bacterial meningitis, bacteremia and focal suppuration, especially liver abscess, were common features in this group of patients. Liver cirrhosis and/or alcoholism were the other frequent underlying conditions. 27 patients survived in the course of therapy. The prognostic factors with statistical significance were glucose ratio and cerebrospinal fluid (CSF) white blood cell (WBC) count. Conclusion: This study showed the high incidence of diabetes mellitus (DM) among the adult patients with CASBM in Taiwan. K. pneumoniae was the most frequent causative pathogen. Bacteremia and focal suppuration, especially liver abscess, were common findings. The values of glucose ratio and CSF WBC count had a statistically significant influence on the prognosis of our patients.

Brain abscess caused by aerobic Gram-negative bacilli: clinical features and therapeutic outcomes

Thirty-three patients (24 males and nine females) with brain abscesses resulting from infection by aerobic Gram-negative bacilli were identified at Kaohsiung Chang Gung Memorial Hospital over a period of 14 years. Of these, 23 cases developed spontaneously, with the remaining ten postneurosurgery. The organisms most frequently involved were Klebsiella (K.) pneumoniae, Pseudomonas aeruginosa, Escherichia coli and Proteus species and included some rare pathogens, such as Salmonella and Enterobacter species, K. oxytoca, Vibrio and Morganella morganii. Apart from one exception, the locations of the abscess were supratentorial. Twenty-four patients presented with a single abscess, while nine revealed multiple abscesses, with 26 treated surgically and seven with antibiotics exclusively. In total, seven patients died, representing an overall mortality rate of 21%. This study demonstrates that brain abscesses associated with neurosurgical procedures are not rare, accounting for 30% of cases in this study, with K. pneumoniae, Proteus and Enterobacter species the most prevalent of the revealed pathogens. Further, Proteus species were the most prevalent pathogens demonstrated for cases of both otogenic and polymicrobial infections. If brain abscesses are diagnosed for diabetic patients or have a gas-forming appearance, a diagnosis of K. pneumoniae infection should be considered, with particular attention paid to detection of other metastatic septic abscesses. In light of the high mortality rate, early treatment is essential to maximize the chances of survival.

Adult Acinetobacter Meningitis and Its Comparison with Non-acinetobacter Gram-negative Bacterial Meningitis

Between January 1999 and December 2003, 81 cases of single pathogen-related culture-proven Gram-negative adult bacterial meningitis were identified at Chang Gung Memorial Hospital-Kaohsiung. Of these 81 cases, Acinetobacter infection was found in 13 cases. Clinical and laboratory data of these Acinetobacter meningitis patients were studied and were compared with those of other 68 non-Acinetobacter Gram-negative bacterial meningitis (GNBM) patients. Of the 13 implicated Acinetobacter strains, A. baumannii was the most common (12), and the other was A. lwoffii (1). Eleven of these 13 cases were due to a post-neurosurgical infection. The results of the antibiotic susceptibility test of the 13 Acinetobacter strains from cerebrospinal fluid included ceftriaxone, (1/13, 8%), ciprofloaxin (6/13, 46%), ceftazidime (6/13, 46%), cefepime (7/13, 54%), ampicillin-subtactam (7/13, 54%), imipenem (12/13, 92%) and meropenem (12/13, 92%). One strain with pan-drug resistant A. baumannii (PDRAB) emerged in 2003. A statistically significant difference between Acinetobacter meningitis and non-Acinetobacter GNBM included hydrocephalus and ceftazidime-resistance. A mortality rate was 30% (4/13), and 7 of the other 9 survivals had severe neurologic deficits. The emergence of Acinetobacter infections in adult post-neurosurgical infections, multiple antibiotic resistant characteristics, and the emergence of PDRAB strain remained a challenge of the initial management of this specific meningitis. Use of carbapenem, especially meropenem, could be considered as one of the initial empiric antibiotics chosen for the management of adult post-neurosurgical meningitis.

Neonatal bacterial meningitis in southern Taiwan.

To determine the epidemiologic trends, prognostic factors, and therapeutic results of neonatal bacterial meningitis, 60 neonatal patients with culture-proven neonatal bacterial meningitis were enrolled in this study. To compare changes over time, the appearance of disease among the patients was divided into two equal periods (1986-1993 and 1994-2001). Group B streptococci were the most common causative pathogens, accounting for approximately 32% of the episodes. Escherichia coli, the next most common pathogen, was more frequently observed in the second period. Seventy-seven percent of gram-negative bacilli isolates were resistant to ampicillin. Moreover, oxacillin-resistant Staphylococcus and ampicillin-resistant group B streptococci strains occurred in the second periods as late-onset neonatal bacterial meningitis. The overall mortality rates for the first and second study period were 17% and 8%, respectively. However, if individuals with poor outcomes were taken into account, 38% of patients were considered treatment failures. Significant prognostic factors included the presence of seizures, thrombocytopenia, and high cerebrospinal fluid protein and low cerebrospinal fluid glucose concentration. Although the mortality rate was significantly reduced in the second period, there has been increasing incidence of the emergence of resistant strains presenting a therapeutic challenge. The presentation in neonatal bacterial meningitis might be nonspecific, and blood culture results were negative in 45% of the episodes. Early diagnosis, choice of appropriate antibiotics, and correction of metabolic derangement are essential to improving outcomes.

High Incidence of Gram-Negative Bacillary Infection and High Mortality in Adult Patients with Bacterial Meningitis and Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is a relatively rare neoplasm in most parts of the world. In two large-series studies of adult bacterial meningitis in Western populations, NPC was not mentioned as an underlying condition [1, 2]. Although the incidence of NPC is relatively high in Taiwan [3], there is limited data on the incidence of NPC in patients with bacterial meningitis in this country [4, 5]. Moreover, the clinical characteristics of bacterial meningitis in adult NPC patients have rarely been reported in the literature [6, 7, 8]. Thus, we conducted the present study to retrospectively determine the incidence of NPC among adult patients with bacterial meningitis at our hospital in Taiwan and to document the characteristics of these cases. Over a period of 15 years (January 1986 to December 2000), 243 adult patients with culture-proven bacterial meningitis were identified at Chang Gung Memorial Hospital-Kaohsiung. Of these 243 cases, 5 had NPC as an underlying condition. The records of these five patients were evaluated to determine the clinical manifestations, laboratory data, image findings and therapeutic outcome. The diagnosis of acute bacterial meningitis was based on (i) the isolation of a specific bacterial pathogen from one or more cerebrospinal fluid (CSF) cultures; (ii) typical CSF findings, including decreased glucose level, increased lactate and protein concentrations and pleocytosis; and (iii) classic clinical manifestations of meningeal irritation. Neuroimaging techniques including computed tomography and/or magnetic resonance imaging were used to study the brain condition and to detect skull lesions. The characteristics of the five cases of adult patients with NPC and bacterial meningitis are listed in Table 1. All five patients had undergone previous radiotherapy. The staging of NPC was recorded as T4N2aMx in one patient, T4N2cMx in two patients and was not done in two patients. Altered consciousness was the most consistent and shared clinical manifestation. The other common clinical manifestations were fever and seizure. Neuroimaging findings showed hydrocephalus in all five patients and skull-base bony lesions in three patients. The mean interval from the diagnosis of NPC to the occurrence of bacterial meningitis was 4.9 years. The laboratory data for CSF were as follows: leukocyte count, 0.28– 14.87 109/l; glucose, 0.11–0.55 mmol/l; protein, 1.4– 20.5 g/l and lactate, 9.35–32 mmol/l. A ventriculoperitoneal shunt was inserted in three cases. The outcomes included death during week 1 after admission in three patients and survival in two patients; one of the survivors had neurological sequelae. The incidence of NPC as an underlying condition among adult patients with culture-proven bacterial meningitis during the 15-year period studied was 2% (5/243). Patients with a malignancy are prone to develop serious infections. Nevertheless, the skull-base lesions present in three of our five patients with NPC may have resulted in a breakdown of the mechanical barrier of the central nervous system, providing another pathway for the pathogens [9]. This finding is consistent with the observation reported by Cheng et al. [10]. Moreover, radiotherapy-related complications such as chronic otitis media and sphenoid sinusitis as well as underlying conditions such as diabetes mellitus also offered opportunities for CNS infections to develop in our patients. All of the pathogens found in this study were gramnegative bacilli. In a previous study from northern Taiwan, Tang et al. [6] also found a high incidence of C. R. Huang · C. H. Lu · W. N. Chang ()) Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung, 123, Ta-Pei Road, Kaohsiung Hsien, Taiwan e-mail: cwenneng@ms19.hinet.net Tel.: +886-7-7317123 ext. 2283 Fax: +886-7-7333816