Pneumococcal Meningitis in Taiwanese Children: Emphasis on Clinical Outcomes and Prognostic Factors

SummaryPneumococcal meningitis causes high morbidity or mortality in childhood despite the progress inmedicine. Children with pneumococcal meningitis were identified and retrospectively reviewed. Forty-nine children were eligible, with mortality in 24.5% of all and neurological sequelae in 40.5% ofsurvivors. In the analysis of clinical profiles, ventilator support (p^0.001), septic shock (p_0.001),multiple organ failure (p_0.001) and lower cerebrospinal fluid (CSF) leukocyte count (p¼0.001) weremore frequently found in non-survivors. Besides, CSF protein (p^0.006) was higher in survivors withneurological sequelae. Initial dexamethasone usage and disease severity did not affect the occurrence ofneurological sequelae. Multivariate logistic regression analysis revealed that CSF leukocyte count·200mm 2 3 (p^0.013) and protein level ¸330gl 1 (p^0.022) were significantly risk factorsassociated with poor outcomes, and physicians should be cautious if such conditions occur.Key words: meningitis, Streptococcus pneumoniae, children, outcomes.IntroductionStreptococcus pneumoniae is the most commonpathogen of bacterial meningitis in children beyondthe neonatal period [1–3]. Despite continuingimprovements in antibiotic therapy, pneumococcalmeningitis still causes high morbidity or evenmortality in childhood, with fatality rates as high as20% [2, 4, 5].Recently, patients with suspected pneumococcalmeningitis were treated with penicillin or extended-spectrum cephalosporins; however, resistance toantibiotics has complicated the management ofinvasive S. pneumoniae infections, with more andmore reports of treatment failure in the useof penicillin or extended-spectrum cephalosporins[6–11]. Therefore, the American Academy ofPediatrics recommends vancomycin in addition toan extended-spectrum cephalosporin for treatment ofsuspected pneumococcal meningitis [12].However, there is little evidence that the use ofvancomycin improved clinical outcomes of invasivedisease caused by drug-resistant S. pneumoniae andseveral studies have not demonstrated differencesin outcomes of patients with meningitis caused bynon-susceptible pneumococci compared with thoseinfected with susceptible organisms [11, 13–16].Therefore, it seems that the results of high morbidityand mortality were not influenced by the antibioticsusceptibility of the pneumococci and factors relatedto poor clinical outcomes are needed to be furtherinvestigated.We conducted a retrospective review of childrenwith meningitis caused by S. pneumoniae. Thepurpose of our study was to characterize the clinicalfeatures of pneumococcal meningitis. In addition, theassociation between clinical parameters and pooroutcomes such as neurological sequelae or evenmortality were also evaluated.Materials and MethodsFrom January 1984 to December 2002, patients518years of age with pneumococcal meningitis admittedto Chang Gung Children’s Hospital were included inthis study. Pneumococcal meningitis was defined asisolation of S. pneumoniae from cerebrospinal fluid