Gram-negative bacillary meningitis: Epidemiology, clinical features, and diagnosis
- N Deborah Friedman, MPH, MBBS, FRACP, MD
N Deborah Friedman, MPH, MBBS, FRACP, MD
- Associate Professor of Medicine, Infectious Diseases Physician
- Barwon Health, Geelong, VIC Australia
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Most cases of gram-negative bacillary meningitis occur in neonates or infants . Gram-negative bacilli are the fifth most common cause of meningitis in infants, accounting for 3.6 percent of cases . By contrast, gram-negative bacilli are an uncommon etiology of community-acquired meningitis in adults, but are a common cause of nosocomial meningitis, often occurring as a complication of head trauma and craniotomy .
The epidemiology, clinical features, and diagnosis of gram-negative bacillary meningitis will be reviewed here. Issues related to treatment are discussed separately. (See "Gram-negative bacillary meningitis: Treatment".)
Gram-negative meningitis was first recognized and reported in 1892. In the 1930s and 40s, cases were described resulting from abortion, genitourinary manipulation, and spinal anesthesia. In the following two decades, gram-negative bacillary meningitis was recognized as an occasional complication of injuries and neurosurgical procedures .
Subsequently, gram-negative bacillary meningitis has become an important cause of hospital-associated central nervous system (CNS) infection in adults, usually due to neurosurgery . The likelihood of post-neurosurgery meningitis being due to gram-negative organisms is increased when antimicrobial prophylaxis, which predominantly provides gram-positive coverage, is given to prevent surgical site infection . (See "Epidemiology of bacterial meningitis in adults", section on 'Healthcare-associated meningitis' and "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Neurosurgery'.)
Although the incidence of gram-negative bacillary meningitis has increased as progressively more complex neurosurgical techniques and operations become more commonplace, this is still a rare infection. As an example, meningitis caused by Enterobacteriaceae accounted for 1.5 percent of all cases of acute bacterial meningitis in adults over a 20 year period in one Danish hospital . In addition, of 1961 isolates of gram-negative bacilli from blood and/or cerebrospinal fluid (CSF) specimens over a two-year period at our institution, only 47 (2.4 percent) were from the CSF (unpublished data).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Theccanat G, Hirschfield L, Isenberg H. Serratia marcescens meningitis. J Clin Microbiol 1991; 29:822.
- Unhanand M, Mustafa MM, McCracken GH Jr, Nelson JD. Gram-negative enteric bacillary meningitis: a twenty-one-year experience. J Pediatr 1993; 122:15.
- Wolff MA, Young CL, Ramphal R. Antibiotic therapy for enterobacter meningitis: a retrospective review of 13 episodes and review of the literature. Clin Infect Dis 1993; 16:772.
- Berk SL, McCabe WR. Meningitis caused by gram-negative bacilli. Ann Intern Med 1980; 93:253.
- Rahal JJ, Simberkoff MS. Host defense and antimicrobial therapy in adult gram-negative bacillary meningitis. Ann Intern Med 1982; 96:468.
- Korinek AM, Baugnon T, Golmard JL, et al. Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurgery 2006; 59:126.
- Harder E, Møller K, Skinhøj P. Enterobacteriaceae meningitis in adults: a review of 20 consecutive cases 1977-97. Scand J Infect Dis 1999; 31:287.
- Simberkoff MS, Moldover NH, Rahal J Jr. Absence of detectable bactericidal and opsonic activities in normal and infected human cerebrospinal fluids. A regional host defense deficiency. J Lab Clin Med 1980; 95:362.
- Landesman SH, Cherubin CE, Corrado ML. Gram-negative bacillary meningitis. New therapy and changing concepts. Arch Intern Med 1982; 142:939.
- Leib SL, Täuber MG. Pathogenesis of bacterial meningitis. Infect Dis Clin North Am 1999; 13:527.
- Lu CH, Chang WN, Chuang YC, Chang HW. The prognostic factors of adult gram-negative bacillary meningitis. J Hosp Infect 1998; 40:27.
- Castelblanco RL, Lee M, Hasbun R. Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infect Dis 2014; 14:813.
- Mulder CJ, van Alphen L, Zanen HC. Neonatal meningitis caused by Escherichia coli in The Netherlands. J Infect Dis 1984; 150:935.
- Peter G, Nelson JS. Factors affecting neonatal E. coli K1 rectal colonization. J Pediatr 1978; 93:866.
- Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 1993; 328:21.
- Huang CR, Lu CH, Chang WN. Adult Enterobacter meningitis: a high incidence of coinfection with other pathogens and frequent association with neurosurgical procedures. Infection 2001; 29:75.
- Filka J, Huttova M, Tuharsky J, et al. Nosocomial meningitis in children after ventriculoperitoneal shunt insertion. Acta Paediatr 1999; 88:576.
- Haile-Mariam T, Laws E, Tuazon CU. Gram-negative meningitis associated with transsphenoidal surgery: case reports and review. Clin Infect Dis 1994; 18:553.
- Pai S, Bedford L, Ruramayi R, et al. Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital. QJM 2016; 109:85.
- Peeters A, Vandercam B, Sindic CJ, et al. Community-acquired Serratia marcescens meningitis. J Infect 1997; 35:303.
- Buckwold FJ, Hand R, Hansebout RR. Hospital-acquired bacterial meningitis in neurosurgical patients. J Neurosurg 1977; 46:494.
- Pegues DA, Carr DB, Hopkins CC. Infectious complications associated with temporary epidural catheters. Clin Infect Dis 1994; 19:970.
- Byers K, Axelrod P, Michael S, Rosen S. Infections complicating tunneled intraspinal catheter systems used to treat chronic pain. Clin Infect Dis 1995; 21:403.
- Reefhuis J, Honein MA, Whitney CG, et al. Risk of bacterial meningitis in children with cochlear implants. N Engl J Med 2003; 349:435.
- van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351:1849.
- Pomar V, Benito N, López-Contreras J, et al. Spontaneous gram-negative bacillary meningitis in adult patients: characteristics and outcome. BMC Infect Dis 2013; 13:451.
- Cherubin CE, Marr JS, Sierra MF, Becker S. Listeria and gram-negative bacillary meningitis in New York City, 1972-1979. Frequent causes of meningitis in adults. Am J Med 1981; 71:199.
- Ibrahim AW. E. coli meningitis as an indicator of intestinal perforation by V-P shunt tube. Neurosurg Rev 1998; 21:194.
- Chang WN, Lu CH, Chang CS, Huang CR. Community-acquired spontaneous bacterial meningitis in patients with alcoholic liver disease. J Formos Med Assoc 2003; 102:653.
- Li CK, Shing MM, Chik KW, et al. Klebsiella pneumoniae meningitis in thalassemia major patients. Pediatr Hematol Oncol 2001; 18:229.
- Tang LM, Chen ST. Klebsiella pneumoniae meningitis: prognostic factors. Scand J Infect Dis 1994; 26:95.
- Tang LM, Chen ST. Klebsiella oxytoca meningitis: frequent association with neurosurgical procedures. Infection 1995; 23:163.
- Parodi S, Lechner A, Osih R, et al. Nosocomial enterobacter meningitis: risk factors, management, and treatment outcomes. Clin Infect Dis 2003; 37:159.
- Chang CJ, Chang WN, Huang LT, et al. Bacterial meningitis in infants: the epidemiology, clinical features, and prognostic factors. Brain Dev 2004; 26:168.
- Eppes SC, Woods CR, Mayer AS, Klein JD. Recurring ventriculitis due to Citrobacter diversus: clinical and bacteriologic analysis. Clin Infect Dis 1993; 17:437.
- Anoop P, Anjay MA, Vincent J, Girija B. Fulminant citrobacter meningitis with multiple periventricular abscesses in a three-month-old infant. Braz J Infect Dis 2003; 7:429.
- Tang LM, Chen ST, Lui TN. Citrobacter meningitis in adults. Clin Neurol Neurosurg 1994; 96:52.
- Chang HJ, Christenson JC, Pavia AT, et al. Ochrobactrum anthropi meningitis in pediatric pericardial allograft transplant recipients. J Infect Dis 1996; 173:656.
- Pers C, Gahrn-Hansen B, Frederiksen W. Capnocytophaga canimorsus septicemia in Denmark, 1982-1995: review of 39 cases. Clin Infect Dis 1996; 23:71.
- Perrin I, Blanc P, Karam T, Carbajal R. [Meningitis and osteitis caused by Pasteurella multocida in a three-month-old infant]. Arch Pediatr 2003; 10:439.
- Wade T, Booy R, Teare EL, Kroll S. Pasteurella multocida meningitis in infancy - (a lick may be as bad as a bite). Eur J Pediatr 1999; 158:875.
- Gorse GJ, Thrupp LD, Nudleman KL, et al. Bacterial meningitis in the elderly. Arch Intern Med 1984; 144:1603.
- Kaplan SL. Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis. Infect Dis Clin North Am 1999; 13:579.
- Proulx NL, Freedman MS, Chan JW, et al. Acute disseminated encephalomyelitis associated with Pasteurella multocida meningitis. Can J Neurol Sci 2003; 30:155.
- Leib SL, Boscacci R, Gratzl O, Zimmerli W. Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery. Clin Infect Dis 1999; 29:69.
- Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017.
- Hussein K, Bitterman R, Shofty B, et al. Management of post-neurosurgical meningitis: narrative review. Clin Microbiol Infect 2017; 23:621.
- Jackson WL Jr, Shorr AF. The yield of lumbar puncture to exclude nosocomial meningitis as aetiology for mental status changes in the medical intensive care unit. Anaesth Intensive Care 2006; 34:21.
- Palabiyikoglu I, Tekeli E, Cokca F, et al. Nosocomial meningitis in a university hospital between 1993 and 2002. J Hosp Infect 2006; 62:94.
- Schuurman T, de Boer RF, Kooistra-Smid AM, van Zwet AA. Prospective study of use of PCR amplification and sequencing of 16S ribosomal DNA from cerebrospinal fluid for diagnosis of bacterial meningitis in a clinical setting. J Clin Microbiol 2004; 42:734.
- Oliver WJ, Shope TC, Kuhns LR. Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma. Pediatrics 2003; 112:e174.
- Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001; 345:1727.
- Aronin SI, Peduzzi P, Quagliarello VJ. Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing. Ann Intern Med 1998; 129:862.
- Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med 1997; 336:708.
- Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
- Neonatal meningitis
- Nosocomial meningitis
- Spontaneous gram-negative meningitis
- CLINICAL FEATURES
- Outcome of infection
- Complications of meningitis
- Cerebrospinal fluid analysis
- Blood cultures
- Computed tomographic scanning
- SOCIETY GUIDELINE LINKS