title: Acute meningitis with a negative Gram's stain: clinical and management outcomes in 171 episodes.
abstract: OBJECTIVE
  To characterize the diagnostic spectrum and physician management decisions of patients presenting to an emergency department with an acute, community-acquired illness, cerebrospinal fluid (CSF) white blood cell count > 5/mm3, and a negative Gram's stain for bacteria.
  
  
  METHODS
  In this retrospective cohort study over a 2-year period, symptoms, examination findings, paraclinical data, physician management, and clinical outcomes were assessed for each patient.
  
  
  RESULTS
  One hundred sixty-eight patients (171 patient episodes) were evaluated. Almost half of the cohort presented in nonsummer months (48%); 20% of concurrent comorbid disease, and 15% had identified immunocompromising conditions. The reported examination findings were diverse, with diverse, with fever [49%] and neck stiffness [39%] being the most frequent findings. The majority were hospitalized (70%), with a median stay of 4 days. Approximately one half underwent computed tomography or magnetic resonance imaging (49%), and received empiric treatment with antibiotics (52%). A diagnostic cause was established in 23%, with the majority being inherently treatable diseases (including syphilis, bacteremia, Lyme disease). Variables significantly associated with a subsequent proven diagnostic cause included: age > 60 years; presence of comorbid disease (especially immunodeficiency); and presentation in winter months.
  
  
  CONCLUSIONS
  A large proportion of patients presenting with acute meningitis and a negative CSF Gram's stain undergo hospitalization, noninvasive cranial imaging, and receive empiric antibiotic therapy. Better clinical guidelines are needed to identify the diagnostic and management decisions that benefit patient outcome.
authors.affiliation: Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Elmore
authors.forename: R I
authors.initials: RI
authors.lastname: Horwitz
authors.forename: V J
authors.initials: VJ
authors.lastname: Quagliarello
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000150:complications; D002648:Child; D015331:Cohort Studies; D004396:Coloring Agents; D017714:Community-Acquired Infections / Q000134:cerebrospinal fluid / Q000175:diagnosis / Q000628:therapy; D015897:Comorbidity; D003657:Decision Making; D005260:Female; D005334:Fever / Q000503:physiopathology; D006801:Humans; D016867:Immunocompromised Host; D007902:Length of Stay; D007958:Leukocyte Count; D008193:Lyme Disease / Q000150:complications; D008279:Magnetic Resonance Imaging; D008297:Male; D008582:Meningitis, Aseptic / Q000134:cerebrospinal fluid / Q000175:diagnosis / Q000628:therapy*; D008875:Middle Aged; D009333:Neck / Q000503:physiopathology; D012189:Retrospective Studies; D012621:Seasons; D013587:Syphilis / Q000150:complications; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D004396:Coloring Agents