1. Changing Epidemiology of Adult Bacterial Meningitis in Southern Taiwan: A Hospital-Based Study Infection 2008; 36: 15–22 W.-N. Chang, C.-H. Lu, C.-R. Huang, N.-W. Tsai, Y.-C. Chuang, C.-C. Chang,S.-F. Chen, C.-C. Chien R4 문송미 /Prof. 이희주

2. Introduction  Many factors may influence the epidemiologic trend of adult bacterial meningitis (ABM) - age, preceding medical Hx,surgical conditions, status of vaccination mode of contraction, geographic distribution, period of the study  Early appropriate antibiotic therapy is one of the important and explicit steps in the management of potentially fatal CNS infection, these recent epidemiologic trends have influenced the choice of initial empiric antibiotic treatment.

3. Aim  The previous study - epidemiologic trend of ABM in southern Taiwan - 202 ABM patients collected in a 13.5-year time period (January 1986–June 1999)  To compare the causing pathogens of the time period (13.5 years, January 1986–June 1999) of our previous study  To analyze recent epidemiologic trends of ABM in order to provide a better therapeutic strategy

4. Method  Chang Gung Memorial Hospital (CGMH)-Kaohsiung - largest medical center in southern Taiwan - 2,482- bed acute-care teaching hospital - Southern Taiwan : two cities and three counties with a population of approximately 5,441,000 as of October 1998  Retrospectively reviewed the microbiological records of CSF and blood cultures, laboratory data, and medical records

5. Patients  Previous study - January 1986–June 1999, 13.5 years - 202 ABM patients collected  Present study - July 1999–December 2005, 6.5 years - 181 ABM patients - 130 men (18–82 years), 51 women (18–78 years) - 103 postneurosurgical state, 78 spontaneous ABM - 55 fatal group, 126 non-fatal group

6. Method  Definite diagnosis of bacterial meningitis (1) positive CSF culture of bacterial pathogen (2) clinical features of meningitis, consciousness disturbance, including fever,seizure, and signs of meningeal irritation (3) purulent CSF features - leukocytosis with WBC > 0.25 · 10 9 /l and predominant PMNs - LD > 3.5 mmol/L - glucose ratio (CSF/serum) < 0.4, glucose level < 2.5 mmol/l

7. Method  Nosocomial meningitis - a positive bacterial infection not present when the pt was admitted to the hospital, clinical evidence of an infection no sooner than 48 hours after admission or clinical evidence of meningitis within a short period of time  Postneurosurgical meningitis - related to head trauma with skull fractures or neurosurgical procedure  Spontaneous meningitis - no clear distinctive disease characteristics and who had not undergone any invasive procedures

8. RESULT

9. Results

12. 101 64 42 12 10 19 A. lwoffii. 19 8 6 78103 16

13. Results G (+) pathogens of in this studyG (+) pathogens of in previous study S. aureus (20, 10.9%)Streptococcus pneumoniae (19, 10.6%) CoNS (20, 10.9%)S. aureus (15, 8.3%) viridans streptococci (8, 4.4%)viridans streptococci (13, 7.2%) Streptococcus pneumoniae (6, 3.3%)CoNS (12, 6.7%) Enterococcus spp. (5, 2.7%)Enterococcus spp. (4, 2.2%) G (-) pathogens of in this studyG (-) pathogens of in previous study K. Pneumoniae (42, 23.0%)K. pneumoniae (57, 31.6%) Acinetobacter spp. (19, 10.4%)Pseudomonas spp. (20, 11.1%) E. coli (12, 6.6%)E. coli (9, 5.0%) Pseudomonas spp. (10, 5.5%)Acinetobacter spp. (6, 3.3%) Enterobacter spp. (7, 3.9%)Enterobacter spp. (5, 2.8%)

15. Discussion(1)  An annual increase of ABM in recent years, from 15 (202/ 13.5) cases/year to 27.8 (181/6.5) cases/year.  56.9% had a neurosurgical condition (from 25% to 49% in the two study periods) as the preceding event - increase of neurosurgeons and neurologists and the subsequent expansion of their services in our hospital  fever, altered consciousness, hydrocephalus, bacteremia, and seizure were the leading clinical features of ABM

16. Discussion(2)  K. pneumoniae was still the m/c pathogen of ABM - although its incidence has declined from 31.7% (57/180) to 25.5% (42/165) - spontaneous, community-acquired infection - ass. DM and liver disease  Acinetobacter meningntis - 3.3% (6/180)  11.5% (19/165) - 89.5% of the implicated Acinetobacter strains belonged to postneurosurgical infection - resulted in a serious challenge in the choice of empiric antibiotic in the treatment for ABM

17. Discussion(3)  a marked increase in the incidence of staphylococcal infection and a decrease in the incidence of Streptococcus pneumoniae infection  Staphylococcal spp. - 23% (38/165) - 81.6% (31/38) belonged to the postneurosurgical infections - 76% (29/38) were methicillin-resistant  Streptococcus pneumonia - spontaneous, community-acquired infection

18. Conclusion (1) More ABM cases have been identified due to the expansion of neurology and neurosurgical services, and the epidemiologic trend of ABM has changed. (2) Patients with post neurosurgical ABM outnumbered those with spontaneous meningitis. (3) Although the incidence of Klebsiella ABM decreased, K. pneumoniae remained the most commonly implicated pathogen. (4) Acinetobacter meningntis had the second m/c G(-) infection.

19. Conclusion (5) The incidence of Staphylococcal infections had also increased markedly, and most of the implicated strains were methicillin-resistant. (6) Resistant strains result in a therapeutic challenge in the choice of empiric antibiotics in the initial management of ABM. Yet despite advances in antibiotic therapy, the mortality rate of this CNS infectious disease remains high. Therefore, constant epidemiologic trend analysis is needed to further improve therapeutic outcome.