Prognostic factors in pediatric pneumococcal meningitis patients in mainland China: a retrospective multicenter study

Figures & data

Table 1 Clinical baseline characteristics, laboratory findings, and neurological sequelae of patients with PM

Characteristic	Cases n (%)	Characteristic	Cases n (%)
Total	132(100)
Sex		Neurological findings on admission
Male	88(66.7)	Triad syndrome	22(16.7)
Female	44(33.3)	Abnormal mental status	46(34.8)
Age		Coma	20(15.2)
Median age (IQR, months)	13(28)	Convulsions on admission	49(37.1)
≤28 months	94(71.2)	Laboratory findings
>28 months	38(28.8)	Positive CSF culture	76(57.6)
Hospital stay		Positive blood culture	31(23.5)
Median time (IQR, days)	22(18)	Positive CSF and blood culture	25(18.9)
Symptoms and signs on admission		WBCs in blood (median, IQR, ×10^9/L)	14.5(14.7)
Headache	33(25.0)	Neutrophil proportion in blood (median, IQR, %)	78.5(17.5)
Nausea	80(60.6)	C-Reactive Protein (median, IQR, mg/L)	95.8(111.1)
Neck stiffness	68(51.5)	WBCs in CSF (median, IQR, ×10^6/L)	400.0(1756.0)
Bulging fontanelles	27(20.5)	Neutrophil proportion in CSF (median, IQR, %)	80.0(12.8)
Fever	129(97.7)	Protein in CSF (median, IQR, g/L)	1.4 (2.6)
Septic shock	7(5.3)	Glucose in CSF (median, IQR, mmol/L)	1.1 (1.9)
Mechanical ventilation	17(11.4)	Focal neurological deficits n=107	39(29.5)
Multiple organ failure	5(3.8)	Hypophrenia or behavioral deficits	18(13.6)
Respiratory failure	9(6.8)	Aphasia	17(12.9)
Predisposing factors^a n=34	34(25.8)	Dyskinesia	13(9.8)
Recent or remote cerebral trauma	11(8.3)	Hearing impairment	12(9.1)
CSF leakage	13(9.8)	Hydrocephalus	8(6.1)
Previous history of meningitis	6(4.5)	Hemiparesis	8(6.1)
Intracranial structure malformation	5(3.8)	Cranial nerve palsies	5(3.8)
Previous intracranial surgery^b	4(3.0)	Secondary epilepsy	4(3.0)
Craniotomy	4(3.0)	Quadriplegia	3(2.3)
Concomitant diseases n=84	84(63.6)	Subdural effusion or abscess	2(1.5)
Pneumonia	49(37.1)	Visual impairment	2(1.5)
Sinusitis	22(16.7)	Cerebellar ataxia	1(0.8)
Mastoiditis	24(18.2)	Hypothalamus ataxia	1(0.8)
Otitis	5(3.8)
Ear or intracranial abnormalities	8(6.1)

Notes: ^aPredisposing diseases were defined as previous head trauma, history of intracranial surgery, dura disruption, ear or intracranial abnormalities etc. ^bIntracranial surgery (ventriculostomy, cochlear implantation, ventriculoperitoneal shunt, removal of lateral ventricular reservoir sac, cranioplasty, etc.)

Abbreviations: PM, pneumococcal meningitis; IQR, interquartile range; CSF, cerebrospinal fluid; WBC, white blood cell.

Figure 1 Flowchart of pediatric pneumococcal meningitis (PM) patients' inclusion.

Table 2 Complications of 132 pediatric pneumococcal meningitis patients on admission and during hospitalization examined by cranial computed tomography (CT) or magnetic resonance imaging (MRI) for

Characteristic	Patients n (%)^a
Total number of abnormalities^b	71(53.8)
Subdural effusion	47(35.6)
Sinusitis or otitis	35(26.5)
Cerebritis	29(22.0)
Cerebral edema	22(16.7)
Hydrocephalus	17(12.9)
Intracranial hemorrhage	15(11.4)
Empyema or abscess	12(9.1)
Cerebral atrophy	7(5.3)
Skull fracture	7(5.3)
Cerebral hernia	5(3.8)
Brain infarction	4(3.0)
Arachnoid cyst	3(2.3)
Other abnormalities^c	7(5.3)

Notes: ^aData are numbers (%). Percentages are calculated per number of episodes with cranial CT or MRI undertaken. ^bNumbers do not add up to totals because of the presence of multiple abnormalities in several patients. ^cMiddle ear malformation in three, pneumocephalus in two, meningioma in one, and cerebral vascular malformation in one.

Table 3 Associations of the clinical features with complications in pediatric PM patients analyzed by chi-squared test

Parameters	Subgroups	Complications		Chi-squared	P-value
		NO	YES
Sex	Male	21	23	0.061	0.805
	Female	40	48
Age	≤28 months)	34	60	13.247	0.000
	>28 months	27	11
Duration of disease	≤4 days	37	48	0.691	0.406
	>4 days	24	23
Consciousness state	Normal	44	42	2.488	0.288
	Decline in consciousness	10	16
	Coma	7	13
Convulsions on admission	NO	46	36	8.511	0.004
	YES	15	35
Respiratory failure	NO	56	67	0.339	0.560
	YES	5	4
MODS	NO	59	68	0.081	0.776
	YES	2	3
Mechanical ventilation	NO	56	61	1.129	0.288
	YES	5	10
Septic shock on admission	NO	58	67	0.033	0.855
	YES	3	4
Adjuvant steroid therapy	NO	16	18	0.013	0.909
	YES	45	53
Antibiotics treatment	Early	15	12	1.192	0.275
	Late	46	59
WBCs in blood	High	48	36	11.104	0.001
	Low	13	35
WBCs in CSF	High	15	18	0.010	0.920
	Low	40	50
Glucose in CSF	High	24	28	0.000	0.991
	Low	37	43
Protein in CSF	Low	28	38	1.515	0.218
	High	29	25
Predisposing factors	NO	22	12	6.301	0.012
	YES	39	59
Concomitant disease	NO	38	46	0.030	0.863
	YES	22	25

Note: Bold, indicates P<0.05.

Abbreviations: PM, pneumococcal meningitis; MODS, multiple organ dysfunction syndrome; CSF, cerebrospinal fluid; WBC, white blood cell.

Table 4 Associations of the clinical features with complications in pediatric PM patients analyzed by multivariate logistic regression

Parameters	P-value	OR	95%CI
Age (≤28 months vs >28 months)	0.036	2.654	1.067	6.600
Convulsions on admission (YES vs NO)	0.156	1.823	0.795	4.181
WBCs in blood (low vs high)	0.006	3.169	1.395	7.202
Predisposing factors (YES vs NO)	0.150	1.946	0.785	4.825

Note: Bold, indicates P<0.05.

Abbreviations: PM, pneumococcal meningitis; WBC, white blood cell.

Table 5 Associations of the clinical features with accumulating OS in pediatric PM patients analyzed by Cox’s proportional hazard regression

Parameters	Univariate analysis				Multivariate analysis
	P-value	HR	95%CI		P-value	HR	95%CI
Sex (female vs male)	0.010	2.812	1.276	6.199	0.189	1.774	0.754	4.171
Age (≤28 months vs >28 months)	0.028	5.032	1.186	21.346	0.034	6.479	1.153	36.404
Duration of disease (>4 days vs ≤4 days)	0.189	1.692	0.772	3.709
Complications (YES vs NO)	0.473	0.750	0.342	1.645
Consciousness state	0.000				0.002
Normal		Ref				Ref.
Decline in consciousness	0.202	2.071	0.678	6.332	0.079	2.916	0.882	9.643
Coma	0.000	10.641	4.321	26.201	0.000	9.808	2.802	34.323
Convulsions on admission (YES vs NO)	0.043	2.258	1.025	4.976	0.205	0.442	0.125	1.560
Respiratory failure (YES vs NO)	0.000	8.988	3.705	21.806	0.396	1.903	0.431	8.401
MODS (YES vs NO)	0.001	6.363	2.170	18.659	0.326	1.808	0.555	5.888
Mechanical ventilation (YES vs NO)	0.000	5.781	2.547	13.124	0.194	2.572	0.619	10.683
Septic shock on admission (YES vs NO)	0.000	14.465	5.519	37.914	0.053	3.927	0.983	15.693
Adjuvant steroid therapy (NO vs YES)	0.000	4.491	2.036	9.906	0.001	4.768	1.946	11.678
Antibiotics treatment (late vs early)	0.531	1.408	0.483	4.102
WBCs in blood (low vs high)	0.174	1.723	0.786	3.776
WBCs in CSF (low vs high)	0.144	2.054	0.782	5.399
Glucose in CSF (low vs high)	0.147	1.990	0.785	5.049
Protein in CSF (high vs low)	0.034	2.536	1.074	5.984	0.953	1.039	0.292	3.693
Concomitant disease (YES vs NO)	0.065	2.512	0.943	6.696
Predisposing factors (YES vs NO)	0.780	0.883	0.369	2.114

Note: Bold, indicates P<0.05.

Abbreviations: OS, overall survivalPM, pneumococcal meningitis; MODS, multiple organ dysfunction syndrome; CSF, cerebrospinal fluid; WBC, white blood cell.

Figure 2 Associations of clinical characteristics with accumulating overall survival in pediatric pneumococcal meningitis (PM) patients were analyzed by Kaplan-Meier plot curves and logrank test. (A) age; (B) consciousness; (C) steroid therapy.

Table 6 Associations of the clinical features with accumulating SFS analyzed by Cox’s proportional hazard regression

Parameters	Univariate analysis				Multivariate analysis
	P-value	HR	95%CI		P-value	HR	95%CI
Sex (female vs male)	0.521	1.184	0.706	1.985
Age (≤28 months vs >28 months)	0.181	1.485	0.832	2.650
Duration of disease (>4 days vs ≤4 days)	0.064	1.593	0.973	2.609
Complications (YES vs NO)	0.457	1.208	0.735	1.984
Consciousness state	0.000				0.000
Normal		Ref				Ref
Decline in consciousness	0.079	1.735	0.939	3.207	0.080	1.789	0.932	3.434
Coma	0.000	4.971	2.732	9.046	0.000	5.841	2.652	12.864
Convulsions on admission (YES vs NO)	0.050	1.638	1.001	2.683	0.915	1.034	0.559	1.912
Respiratory failure (YES vs NO)	0.000	4.337	2.037	9.233	0.566	1.413	0.433	4.607
MODS (YES vs NO)	0.003	4.041	1.591	10.260	0.209	1.868	0.704	4.954
Mechanical ventilation (YES vs NO)	0.008	2.404	1.252	4.618	0.783	1.148	0.430	3.060
Septic shock on admission (YES vs NO)	0.000	5.446	2.307	12.858	0.040	2.949	1.049	8.290
Adjuvant steroid therapy (NO vs YES)	0.030	1.785	1.058	3.011	0.055	1.771	0.989	3.173
Antibiotics treatment (late vs early)	0.425	0.794	0.450	1.399
WBCs in blood (low vs high)	0.059	1.610	0.982	2.641
WBCs in CSF (low vs high)	0.062	1.695	0.974	2.950
Glucose in CSF (low vs high)	0.004	2.345	1.304	4.217	0.004	2.523	1.336	4.765
Protein in CSF (high vs low)	0.318	1.301	0.777	2.178
Concomitant disease (YES vs NO)	0.848	1.051	0.633	1.744
Predisposing factors (YES vs NO)	0.990	0.997	0.566	1.755

Note: Bold, indicates P<0.05.

Abbreviations: SFS, sequelae-free survival; PM, pneumococcal meningitis; MODS, multiple organ dysfunction syndrome; CSF, cerebrospinal fluid; WBC, white blood cell.

Figure 3 Associations of clinical characteristics and laboratory parameters with accumulating sequelae-free survival in pediatric pneumococcal meningitis (PM) patients were analyzed by Kaplan-Meier plot curves and logrank test. (A) Consciousness; (B) septic shock; (C) glucose in cerebrospinal fluid (CSF).