title: Implementation of a Meningitis Care Bundle in the Emergency Room Reduces Mortality Associated With Acute Bacterial Meningitis.
abstract: BACKGROUND
  Prompt administration of antibiotics, adjunctive steroid therapy, and optimization of antibiotic delivery to cerebrospinal fluid (CSF) are factors associated with improved outcome of patients hospitalized for acute bacterial meningitis (ABM). However, the impact of a bundle of these procedures has not been reported.
  
  
  OBJECTIVE
  To assess mortality and neurological sequelae at hospital discharge in a cohort of patients with ABM managed according to a predefined bundle.
  
  
  METHODS
  Prospective study of all the patients hospitalized for ABM in two provinces of Northern Italy, over two consecutive periods (2005-2009, 2010-2013). The bundle included: i) supportive care if needed; ii) immediate administration of dexamethasone and 3rd generation cephalosporin; and iii) addition of levofloxacin if turbid CSF. Patients managed according to the bundle were compared with a historical group of patients cared for ABM before the bundle was implemented.
  
  
  RESULTS
  Overall, 85 patients with ABM were managed according to the bundle and were compared with 92 historical controls. In-hospital mortality rates for bundle and control group were 4.7% and 14.1% (p=0.04). Among survivors, 13.5% and 18.9% (p=0.4) of bundle and control-group patients presented neurological sequelae. The only variable associated with mortality at multivariate analysis was ICU admission (HR 3.65). After adjusting for ICU admission, patients managed according with the ABM bundle had significantly lower mortality rate compared to historical controls.
  
  
  CONCLUSIONS
  Use of a bundled protocol and antibiotics with excellent CSF penetration for the initial management of ABM in emergency department is feasible and associated with significant reduction in mortality.
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Viale
authors.affiliation: Clinical Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Policlinic San Matteo Foundation, Pavia, Italy.
authors.forename: Luigia
authors.initials: L
authors.lastname: Scudeller
authors.affiliation: Institute of Clinical Pharmacology & Toxicology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Department of Experimental and Clinical Medical Sciences, University of Udine, Udine, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Pea
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Tedeschi
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Russell
authors.initials: R
authors.lastname: Lewis
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Bartoletti
authors.affiliation: Department of Medicine, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy.
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Sbrojavacca
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Cristini
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Tumietto
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Nicoletta
authors.initials: N
authors.lastname: Di Lauria
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Fasulo
authors.affiliation: Infectious Diseases Unit - Department of Medical and Surgical Sciences, University of Bologna, Teaching Hospital S. Orsola-Malpighi - Bologna, Italy maddalena.giannella@libero.it.
authors.forename: Maddalena
authors.initials: M
authors.lastname: Giannella
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D002511:Cephalosporins / Q000627:therapeutic use; D003907:Dexamethasone / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D065386:Historically Controlled Study; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D064704:Levofloxacin / Q000627:therapeutic use; D008297:Male; D016920:Meningitis, Bacterial / Q000188:drug therapy / Q000401:mortality* / Q000503:physiopathology; D008875:Middle Aged; D064872:Patient Care Bundles; D011446:Prospective Studies
chemical_list: D000900:Anti-Bacterial Agents; D000893:Anti-Inflammatory Agents; D002511:Cephalosporins; D064704:Levofloxacin; D003907:Dexamethasone