Facteurs influençant le délai d'initiation de l'antibiothérapie des méningites aiguës bactériennes de l'adulte admises aux urgences

Abstract

Objective: To evaluate the delay to antibiotic therapy (DA) in acute bacterial meningitis (ABM) in adults admitted to the emergency department (ED) and to identify the clinical factors.

Patients and methods: A four-year retrospective study concerning patients admitted to the ED with a further proven diagnosis of ABM. Inclusion criteria: age > 15 years, non-tuberculous bacteria in cerebrospinal fluid (CSF) or in blood, proteinorrhachia > 0.40 g·L⁻¹, glycorrhachia/glycemia < 0.5, leukocytes > 5 mm⁻³ in CSF (≥ 80% polynuclear neutrophils) or cloudy CSF. Exclusion criteria: tuberculous or non-bacterial or nosocomial meningitis, uncertain diagnosis or established diagnosis of ABM before admission.

Results: Fifty-one patients, 27 males and 24 females, with a mean age of 45 years (range: 16–89 years) were included in the study. The mean DA was 216 min (range: 30–975 min). No patient was treated in less than 30 min. Factors associated with significantly longer DA included: a reason for administration other than “syndrome of meningeal irritation with fever” (P=0.041); unusual clinical features (P=0.032), in particular the absence of meningeal irritation or fever; the presence of a neurological deficiency; an advanced age (elderly); the realization of a cerebral CT scan before antibiotic therapy (P=0.0.27); management by a student instead of a senior in difficult cases (P=0.017); the recourse to the opinion of a specialist (P=0.013); and antibiotic therapy first administered in a department other than the ED (P=0.016).

Conclusion: Initiation of antibiotic therapy in ABM is too long. Interindividual variability of clinical features and fluctuations in time are the principal reasons. A cerebral scan and the opinion of a specialist before antibiotic therapy prolongs DA. The first administration of ATB must be done in the ED. The quality of the city-hospital network and emergency physicians' clinical experience are criteria for a more rapid DA. Therefore, a “too fundamentalist medical knowledge,” to the detriment of a “more pragmatic clinical education,” could explain the DA that we noted.