By

James Yost, MD, MS, MBA

PGY 2
Emory Family Medicine

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Background

1805
Meningitis was originally recognized and was virtually
100 percent fatal.

1892
Gram-negative meningitis was first recognized

1930s and 40s

Cases were described resulting from abortion,
genitourinary manipulation, and spinal anesthesia

1950s and 60s

Recognized as an occasional complication of injuries and
neurosurgical procedures

Background

Continued

Two age groups are affected

Neonates/infants
Adults
community-acquired meningitis
nosocomial meningitis

Epidemiology

Frequency
Gram-negative bacilli account for 1.5 4.3% of all cases
of meningitis
E. coli and Klebsiella account for more than 50-70% of
cases of gram-negative bacillary meningitis
There was an inverse relationship with age with E. coli
74% E. coli in neonates
10% E. coli and 40% Klebsiella in adults

Epidemiology

Frequency
Neonatal and infant meningitis

Gram-negative bacilli are the fifth most common cause

accounting for 3.6% of all cases
40.3% of all Gram-negative bacilli cases occur in this
age group
53% of those were caused by E. coli

Community-acquired gram-negative meningitis

accounting for only 9 of 253 episodes (3.6%) in a
report from the United States

Epidemiology

Frequency Continued
Nosocomial acquired gram-negative meningitis
33-69% of bacterial meningitis are believed to
nosocomial
36 to 50% of cases occurred after neurosurgical procedures

Associated bacteremia
Neonates and infants were 55%
Community-acquired gram-negative meningitis were
58%
Nosocomial were 43%

Epidemiology

Mortality/Morbidity
The mortality rate of untreated disease approaches 100
percent.
The mortality in adults and children with gram-negative
meningitis has ranged from 40 to 80%
E. coli meningitis has a mortality rate from 50 to 90%, in
patients in a coma or with bacteremia
Transient or permanent neurologic morbidity occurred in
21 to 28% of survivors

Epidemiology

Mortality/Morbidity Continued
Three baseline clinical features were independently
associated with an adverse outcome (defined as inhospital death or neurologic deficit at discharge):
hypotension, altered mental status, and seizures

9% adverse outcome had no clinical risk factors

33% adverse outcome had intermediate risk (one clinical
factor)
57% adverse outcome had high risk (two or three clinical
factors)

Epidemiology

Risk Factors
In a report of 197 cases of nosocomial meningitis, the
major risk factors were:

neurosurgery or head trauma within the past month

a neurosurgical device
a CSF leak.
These accounted for 75 percent of cases

Vaginal birth and the hands of health care workers

Immunocompromised states for community-acquired

Pathophysiology

The CSF is normally deficient in immunoglobulins

The development of bacterial meningitis progresses
through four interconnected phases
Bacterial invasion of the host with subsequent infection
of the CNS
Bacterial multiplication and induction of inflammation in
the subarachnoid and ventricular space
Progression of inflammation with associated
pathophysiologic alterations
Development of neuronal damage

Pathophysiology

Continued

E. coli have two mechanisms that aid in the

pathogenesis of meningitis
K1 capsular polysaccharide
bacterial capsule
Similar to those of S. pneumoniae, N. meningitidis, and
Haemophilus influenzae
Can assist the organism in evading host defenses

S fimbriae
Facilitates CSF entry particularly at the choroid plexus

Clinical

History

head trauma
neurosurgery
debilitated patients

elderly people
alcoholics
diabetics
cancer
immunosuppressive state

Clinical

History Continued

Most cases of postoperative gram-negative

meningitis occur 10 or more days after surgery
Range of 1-20 days

The time interval is similar in infants, with a mean

of 5.5 days following surgery
Range 1 to 15 days

Causes

Neonatal E. coli meningitis

acquired during or soon after delivery
vaginal flora of the mother
the hands of hospital personnel

Nosocomial E. coli meningitis

neurosurgery
head trauma within the past month
a neurosurgical device
CSF leak
temporary epidural catheters
tunneled intraspinal catheter systems

Causes

Continued

Community-acquired meningitis
Any Immunosuppressed state
Alcohol-induced cirrhosis
Diabetes
Malignancy
Splenectomy
glucocorticoid therapy
Instrumentation of the urinary tract

Treatment

for the Adult

Vancomycin to cefotaxime or ceftriaxone as

empiric treatment until culture and susceptibility
results are available
Dexamethasone is 0.15 mg/kg every six hours
suspected pneumococcal meningitis and a Glasgow coma
scale score of 8 to 11
should be continued for four days if the Gram stain
reveals organisms consistent with S. pneumoniae
should be discontinued if the gram stain and/or cultures
reveal another pathogen

If using steroids, use Rifampin in place of Vanc.

Complications
Ventriculitis
Subdural effusion
Brain abscess
Syndrome of inappropriate antidiuretic hormone secretion
Hydrocephalus
Seizure disorder
Spastic paralysis
Mental retardation
Hearing deficit
Metastatic septic abscesses
Acute disseminated encephalomyelitis

Prognosis
In virtually all studies, one of the most important factors
predicting survival is the state of consciousness at the time of
admission.
In a large series from Massachusetts, patients who were
unresponsive or responsive only to pain had a 49 percent
mortality rate compared to 16 percent for those who were alert or
only lethargic

The

two Bartholin's glands secrete mucus to

provide moisture for the vulva

Cysts

and abscesses are the most common

disorders

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www.aafp.org

Bartholin's

Gland Cyst

Bartholin's

Gland Abscess

Chronic inflammation can obstruct the

orifice of the Bartholin's gland duct
leads to cystic dilatation of the duct
Result of a polymicrobial infection
The predominant aerobic and
facultative bacteria are Escherichia
coli and N. gonorrhea
The most common anaerobic bacteria
are Bacteroides species.

E.

coli meningitis is a very rare disease

with a very high mortality rate.
Most common causes in adults were from
neurosurgical procedures, trauma or
urinary tract manipulation
In a literature search from 1966 to the
present, a case of E. coli meningitis
resulting from incision and drainage of a
bartholins gland has not been found.

Thank You