title: Prediction of Outcome From Adult Bacterial Meningitis in a High-HIV-Seroprevalence, Resource-Poor Setting Using the Malawi Adult Meningitis Score (MAMS).
abstract: Acute bacterial meningitis (ABM) in adults residing in resource-poor countries is associated with mortality rates >50%. To improve outcome, interventional trials and standardized clinical algorithms are urgently required. To optimize these processes, we developed and validated an outcome prediction tool to identify ABM patients at greatest risk of death.
  
  
  
  We derived a nomogram using mortality predictors derived from a logistic regression model of a discovery database of adult Malawian patients with ABM (n = 523 [65%] cerebrospinal fluid [CSF] culture positive). We validated the nomogram internally using a bootstrap procedure and subsequently used the nomogram scores to further interpret the effects of adjunctive dexamethasone and glycerol using clinical trial data from Malawi.
  
  
  
  ABM mortality at 6-week follow-up was 54%. Five of 15 variables tested were strongly associated with poor outcome (CSF culture positivity, CSF white blood cell count, hemoglobin, Glasgow Coma Scale, and pulse rate), and were used in the derivation of the Malawi Adult Meningitis Score (MAMS) nomogram. The C-index (area under the curve) was 0.76 (95% confidence interval, .71-.80) and calibration was good (Hosmer-Lemeshow C-statistic = 5.48, df = 8, P = .705). Harmful effects of adjunctive glycerol were observed in groups with relatively low predicted risk of poor outcome (25%-50% risk): Case Fatality Rate of 21% in the placebo group and 52% in the glycerol group (P < .001). This effect was not seen with adjunctive dexamethasone.
  
  
  
  MAMS provides a novel tool for predicting prognosis and improving interpretation of ABM clinical trials by risk stratification in resource-poor settings. Whether MAMS can be applied to non-HIV-endemic countries requires further evaluation.
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.|Liverpool School of Tropical Medicine, Liverpool, United Kingdom.|Division of Infection and Immunity, University College London, United Kingdom.
authors.forename: Emma C
authors.initials: EC
authors.lastname: Wall
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.|Mahidol-Oxford Clinical Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Oxford Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, United Kingdom.
authors.forename: Mavuto
authors.initials: M
authors.lastname: Mukaka
authors.affiliation: Oxford University Hospitals, Oxford, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Scarborough
authors.affiliation: University of Manchester Academic Health Science Centre, North Manchester General Hospital, Manchester, UK.
authors.forename: Katherine M A
authors.initials: KMA
authors.lastname: Ajdukiewicz
authors.affiliation: Sheffield Teaching Hospitals, Sheffield, United Kingdom.
authors.forename: Katharine E
authors.initials: KE
authors.lastname: Cartwright
authors.affiliation: Department of Emergency Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Mulinda
authors.initials: M
authors.lastname: Nyirenda
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Brigitte
authors.initials: B
authors.lastname: Denis
authors.affiliation: Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
authors.forename: Theresa J
authors.initials: TJ
authors.lastname: Allain
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.|Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Brian
authors.initials: B
authors.lastname: Faragher
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.|Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi.|Division of Infection and Immunity, University College London, United Kingdom.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
mesh_terms: D000328:Adult; D002986:Clinical Trials as Topic; D003661:Decision Support Techniques; D003906:Developing Countries; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D016920:Meningitis, Bacterial / Q000175:diagnosis* / Q000401:mortality* / Q000473:pathology; D049451:Nomograms; D011379:Prognosis; D016896:Treatment Outcome; D055815:Young Adult
keywords: Africa; HIV; bacterial meningitis; outcome; severity score