Clinical features and prognostic factors in adults with bacterial meningitis
Open accessAbstract
BACKGROUND: We conducted a nationwide study in the Netherlands to determine clinical features and prognostic factors in adults with community-acquired acute bacterial meningitis. METHODS: From October 1998 to April 2002, all Dutch patients with community-acquired acute bacterial meningitis, confirmed by cerebrospinal fluid cultures, were prospectively evaluated. All patients underwent a neurologic examination on admission and at discharge, and outcomes were classified as unfavorable (defined by a Glasgow Outcome Scale score of 1 to 4 points at discharge) or favorable (a score of 5). Predictors of an unfavorable outcome were identified through logistic-regression analysis. RESULTS: We evaluated 696 episodes of community-acquired acute bacterial meningitis. The most common pathogens were Streptococcus pneumoniae (51 percent of episodes) and Neisseria meningitidis (37 percent). The classic triad of fever, neck stiffness, and a change in mental status was present in only 44 percent of episodes; however, 95 percent had at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status. On admission, 14 percent of patients were comatose and 33 percent had focal neurologic abnormalities. The overall mortality rate was 21 percent. The mortality rate was higher among patients with pneumococcal meningitis than among those with meningococcal meningitis (30 percent vs. 7 percent, P<0.001). The outcome was unfavorable in 34 percent of episodes. Risk factors for an unfavorable outcome were advanced age, presence of otitis or sinusitis, absence of rash, a low score on the Glasgow Coma Scale on admission, tachycardia, a positive blood culture, an elevated erythrocyte sedimentation rate, thrombocytopenia, and a low cerebrospinal fluid white-cell count. CONCLUSIONS: In adults presenting with community-acquired acute bacterial meningitis, the sensitivity of the classic triad of fever, neck stiffness, and altered mental status is low, but almost all present with at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status. The mortality associated with bacterial meningitis remains high, and the strongest risk factors for an unfavorable outcome are those that are indicative of systemic compromise, a low level of consciousness, and infection with S. pneumoniae.
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Gram staining for bacteria in CSF has high specificity up to 100%, but sensitivity varies between 30% and 90% depending on the bacterial species.
“While specificity for the detection of bacteria is high—up to 100%— sensitivity varies between 30%–90% depending on the bacterial species (1–5).”
From Molecular diagnostics in cerebrospinal fluid for the diagnosis of central nervous system infections (2024) · cites this paper as [2]
The results (p. 6) report high specificity (97%) and sensitivity of 80% for Gram staining of CSF. They do not report specificity reaching 100% or sensitivity ranging from 30% to 90% by bacterial species. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPotential prognostic factors and their classifications were prespecified and based on general knowledge and previous research.
“Potential prognostic factors and their classifications were prespecified and based on general knowledge and previous research,16,17”
From Clinical features and prognostic factors in adults with viral meningitis. (2023) · cites this paper as [16]
The Methods (p. 3) say that 20 potential predictors were chosen on the basis of previous research and pathophysiologic interest. They do not say that the predictors or their classifications were prespecified, or that the classifications were based on those grounds. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThe presence of two or more of headache, neck stiffness, fever and altered consciousness has a sensitivity of 95% for ABM.
“The presence of two or more of headache, neck stiffness, fever and altered consciousness, has a sensitivity of 95% for ABM. 4”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [4]
The Results (p. 2) report that 95% of 696 episodes had at least two of the four symptoms, supporting the stated sensitivity within the study population. The study covered adults with community-acquired acute bacterial meningitis; the claim states 95% for ABM without that limitation. (LLM, conf=0.83)
Experimental — accuracy not yet measuredCSF microscopy and Gram staining for bacteria has a sensitivity of 50-99% (dependent on organism and prior antibiotics) and a specificity of 97-100% in the diagnosis of ABM.
“CSF microscopy and Gram staining for bacteria has a sensitivity of 50-99% (dependent on organism and prior antibiotics) and a specificity of 97-100% in the diagnosis of ABM. 4”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [4]
The results (p. 6) report 80% sensitivity and 97% specificity for CSF Gram staining, values within the claimed ranges, but do not establish the full ranges. They also say the yield was similar with and without prior antimicrobial therapy, rather than showing the claimed dependence on prior antibiotics. (LLM, conf=0.88)
Experimental — accuracy not yet measuredCSF opening pressure is usually raised (>20 cm H2O) in ABM.
“CSF opening pressure should be measured (unless LP is performed in seated position, which artificially raises the opening pressure) and is usually raised (>20 cm H20) in ABM. 4”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [4]
The results (p. 6) report that opening pressure was normal—below 200 mm of water, or 20 cm H₂O—in only 18% of the 216 episodes evaluated. This supports the claim that pressure is usually raised in adult bacterial meningitis. The cited paper does not address the sentence’s advice to measure opening pressure or its exception for a seated lumbar puncture. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Laboratory testing is essential for definitive diagnosis of infectious ME as the presenting signs and symptoms lack predictive value, particularly in young infants.
“Laboratory testing is essential for definitive diagnosis of infectious ME as the presenting signs and symptoms lack predictive value, particularly in young infants (17, 18).”
From Multicenter Evaluation of BioFire FilmArray Meningitis/Encephalitis Panel for Detection of Bacteria, Viruses, and Yeast in Cerebrospinal Fluid Specimens (2016) · cites this paper as [18]
The Conclusions (p. 2) report low sensitivity for the classic symptom triad in adults, and the Methods (p. 2) describe confirmation by cerebrospinal fluid culture. But the paper does not study young infants or establish that presenting signs and symptoms generally lack predictive value; it reports that 95% of affected adults had at least two of four common symptoms (Discussion, p. 7). (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe risk of an unfavourable outcome was not associated with the type of virus.
“Of interest, the risk of an unfavourable outcome was also not associated with the type of virus, which contrasts with bacterial meningitis, where the prognosis varies between different bacteria.16”
From Clinical features and prognostic factors in adults with viral meningitis. (2023) · cites this paper as [16]
The Glasgow Outcome Scale used to assess outcome was developed to evaluate recovery after brain injury and is not validated for CNS infections.
“The GOS used to assess the outcome in the present study was developed to evaluate recovery after brain injury35 and is—although frequently used16,17,36—not validated for CNS infections.”
From Clinical features and prognostic factors in adults with viral meningitis. (2023) · cites this paper as [16]
The case-fatality ratio for pneumococcal meningitis has been estimated to be 30%.
“The case-fatality ratio for pneumococcal meningitis has been estimated to be 30%.4”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [4]
The most consistent clinical symptom in ABM is headache; however, no individual symptom can satisfactorily discriminate ABM from other conditions.
“The most consistent clinical symptom in ABM is headache; 4 however, no individual symptom can satisfactorily discriminate ABM from other conditions.30”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [4]
Citation 30 is attached to the claim about distinguishing ABM from other conditions. The Results (p. 4) report symptom frequencies among patients with bacterial meningitis, and the Conclusions (p. 2) discuss the low sensitivity of the classic triad, but neither assesses how well an individual symptom distinguishes ABM from other conditions. The headache claim is attached to citation 4, not this citation. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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- Authors
- van de Beek, D., de Gans, J., Spanjaard, L., Weisfelt, M., Reitsma, J. B., & Vermeulen, M.
- Affiliations
- Amsterdam UMC Location University of Amsterdam (NL)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2004-10-28
- Volume
- 351
- Issue
- 18
- Pages
- 1849-1859
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2077137971
- Cited by
- 1,639
- References
- 43
- Citations by year
- 2026: 59 · 2025: 77 · 2024: 82 · 2023: 93 · 2022: 66 · 2021: 63 · 2020: 75 · 2019: 99 · 2018: 80 · 2017: 86 · 2016: 102 · 2015: 89 · 2014: 74 · 2013: 83 · 2012: 90
- FWCI
- 42.38
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- UvA-DARE (University of Amsterdam) (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Topics
- Life Sciences › Immunology and Microbiology › Microbiology › Bacterial Infections and Vaccines
- Health Sciences › Medicine › Surgery › Infectious Diseases and Tuberculosis
- Health Sciences › Medicine › Infectious Diseases › Infectious Encephalopathies and Encephalitis
- Keywords
- community-acquired bacterial meningitis, adults, clinical features, prognostic factors, mortality, Streptococcus pneumoniae, Neisseria meningitidis, pneumococcal meningitis, meningococcal meningitis, Glasgow Outcome Scale, Glasgow Coma Scale, risk factors, thrombocytopenia, otitis media, sinusitis, headache, neck stiffness, altered mental status
- MeSH terms
- Acute Disease, Adult, Consciousness Disorders, Female, Fever, Haemophilus influenzae, Headache, Humans, Male, Middle Aged, Neck, Neisseria meningitidis, Netherlands, Prognosis, Prospective Studies, Risk Factors, Staphylococcus, Streptococcus, Streptococcus pneumoniae, Multivariate Analysis, Meningitis, Bacterial, Community-Acquired Infections
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