Greater Attention to Bacterial Meningitis Needed

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Greater Attention to Bacterial Meningitis Needed
New treatments are urgently needed for bacterial meningitis, which killed an estimated 180,000 children younger than age 5 years in 2010, experts warn.

"Because drug-development companies are generally not interested in a disease that affects mainly patients in resource-poor countries, preclinical and clinical studies will need to be funded by governments or charitable foundations," Diederik van de Beek, MD, PhD, author of 3 papers on bacterial meningitis published online November 9 in The Lancet.

In a comment accompanying the series, Dr. van de Beek, from the University of Amsterdam in the Netherlands, notes that the burden of disease is especially high in lower-income countries, with the fatality rate as high as 50% in some resource-poor countries.

The global emergence of antibiotic-resistant pathogens threatens the effectiveness of many inexpensive and widely available antibiotics, Dr. van de Beek notes. Although various new antibiotics for the treatment of meningitis are in development, "clinical data for these new drugs have not kept pace with the rise of resistance," he writes.

Difficult Diagnosis

The first of the 3 papers outlines the dilemmas and difficulties in making an accurate diagnosis of acute community-acquired bacterial meningitis. The authors note that "classic" symptoms of meningitis — rash, neck stiffness, and impaired consciousness — often do not appear early, or may do not develop at all.

"Clinical assessment alone is insufficient to exclude acute bacterial meningitis, and a lumbar puncture with CSF [cerebrospinal fluid] analysis is needed in all patients with suspected acute bacterial meningitis," the authors say. "In some cases, cranial imaging is needed before lumbar puncture to detect brain shift; in these patients, empirical antibiotic treatment should be given before imaging."

The authors further point out that molecular diagnostic methods have emerged, but costs restrict their use around the world. Prediction models may be helpful in estimating the risk for acute bacterial meningitis, but these models need to be refined and validated further in several settings and populations.

"Clinical judgment of individual patients by their physicians remains the most important factor in the diagnosis of acute bacterial meningitis," the authors conclude.

Therapeutic Challenge

The second paper in the series examines the management of bacterial meningitis more closely, emphasizing that bacterial meningitis is "a substantial and evolving therapeutic challenge."

"Determination of which antibiotic agent will be most effective is becoming ever more difficult in the face of increasingly drug-resistant bacteria," the authors say, concluding that down the road widespread adoption of vaccination is likely to have the greatest effect on the burden of illness due to bacterial meningitis.

The final paper in the series tackles the issue of vaccines for bacterial meningitis. The authors note that 3 bacteria — Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis — are responsible for most cases of acute bacterial meningitis worldwide and can be prevented by vaccines.

The authors say widespread use of currently available vaccines in optimum schedules, especially where disease burden is greatest, "will have incremental effects on the global burden of acute bacterial meningitis, but important challenges remain. These include delivery of potent vaccines to difficult-to-access populations at risk; appropriately designed and done studies of effect, which require adequate surveillance to be in place many years before vaccine introduction; and development and testing of improved vaccines."

Lancet. Published online November 9, 2012. Executive summary

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