Highlights • The symptoms experienced also differ between adult patients and children. • Antibiotics are rarely administered before hospital admission: the authors say this practice must improve to optimize outcomes. |
Prompt recognition of symptoms and treatment is vital to obtain good results in cases of meningitis . However, new research to be presented at this year’s European Congress of Clinical Microbiology and Infectious Diseases shows that both adults and children mostly have only one of the "classic triad" symptoms commonly associated with the disease (fever). , altered mental status and neck stiffness), and rarely have all three, with a substantial proportion (one in seven) having none.
The study, conducted by Dr. Nichlas Hovmand (Center for Research and Disruption in Infectious Diseases (CREDID), Copenhagen University Hospital, Denmark) and colleagues, was a retrospective observational study of pre-hospital and hospital data in patients with acquired bacterial meningitis in the community (CABM) between January 2016 and December 2021 admitted to a hospital in the Capital Region of Denmark (population approx. 1.8 million). Reported symptoms were extracted from audio files collected from initial telephone calls to the emergency medical service. Of the 209 patients, 171 (82%) were adults and 38 (18%) were children.
The most frequent symptoms were altered mental status (58% of all patients / 61% of adults / 42% of children) and fever (57% of all patients / 50% adults / 92% children), while neck stiffness was the least common (9% all patients/6% adults/18% children).
Children , compared to adults, presented fever (92% v 50%), fatigue (71% v 49%), skin rashes (16% v 1%) and neck stiffness (18% v 6%) more frequently. , while adults more frequently presented with altered mental status (61% v 42%), headache (36% v 21%) and leg pain (15% v 3%).
Most patients (85%) had at least one of the three symptoms of the classic meningitis triad, but very few (3%) had all three. A significant proportion (15% overall, 16% adults, 8% children) did not present any of these symptoms
. Number of symptoms presented (headache, fever and altered mental status) Children N=38 Adults N=171 Total N=209 Zero 3 (8%) 28 (16%) 31 (15%) 1 15 (39%) 89 (52%) 104 (50%) 2 17 (45%) 50 (29%) 67 (32%) 3 3 (8%) 4 (2%) 7 (3%)
The average time from initial contact to hospitalization was 1.2 hours (children 1.8 hours and adults 1.2 hours). Children were more likely to be told to stay home (34% vs. 11%) and less likely to have an ambulance sent to them compared to adults (21% vs. 69%). Only one child (3%) and 7 adults (4%) received antibiotics before admission.
Dr. Hovmand states: "Patients with bacterial meningitis presented to emergency medical services with a variety of symptoms that differed significantly in children and adults. The classic triad of symptoms was rare for both children and adults. Very few patients "They received antibiotics before admission. We suggest asking about additional relevant symptoms in all cases of patients with fever or altered mental status."
On low pre-hospital antibiotic prescribing, he says: "This is a very complex issue, and low pre-hospital antibiotic prescribing rates are probably related to non-specific symptoms that make early diagnosis very difficult. Ensuring early antibiotic treatment is a key issue and, unfortunately, this is a common and ongoing problem that causes morbidity and mortality from meningitis, despite the availability of effective treatment. Bridging the delay in treatment of this disease remains an issue of enormous importance if "Our goal is to improve patient outcomes and it is something we are currently investigating in our study group."
Questioning the symptoms, he adds: "the relevant symptoms will vary from case to case, as sometimes some symptoms may be enough to confirm the suspicion of meningitis and therefore further questioning would not change the strategy from there." If, for example, all three symptoms of the triad are present, any other symptom is unlikely to eliminate the suspicion of meningitis. If in doubt, additional questioning could help differentiate between meningitis and other suspicious diagnoses, which with most often would be other infections or strokes. Therefore, knowledge about what symptoms patients with meningitis have is an important tool to help find patients as soon as possible, but it is difficult because the symptoms are often nonspecific in the early stages of the disease.
We suggest that all patients with fever and/or an altered mental status be asked about specifically related symptoms, such as stiff neck, leg pain, headache, and rash. However, it is very important to note that most patients with bacterial meningitis will not present with all the specific symptoms , especially in the early stages of the disease. The potential symptoms are many, and in addition to those already mentioned may include tremors or seizures, back pain, diarrhea, cold-like symptoms, difficulty breathing, and vomiting."
