In the JournalsPerspective

Prior head, neck surgery associated with Streptococcus pneumoniae meningitis

Prior head or spine surgery is associated with an increased risk for Streptococcus pneumoniae meningitis beyond the 30-day postoperative period, findings from a small study showed.

According to Victoria Chu, MD, MPH, pediatric resident at Kaiser Permanente Oakland Medical Center, and colleagues, cases of pneumococcal meningitis have been reported in patients years after a head injury, “presumably as a result of an injury-related cranial defect,” and past research has shown that patients with a head injury or prior brain surgery are at an increased risk for pneumococcal meningitis.

Chu and colleagues sought to determine if there is an association between prior head injury or prior spine or head surgery and pneumococcal meningitis among adults, many of whom are not vaccinated.

“Healthy U.S. children have been recommended to receive 7-valent pneumococcal conjugate vaccine (PCV7) since it was introduced in 2000; PCV13 was recommended in 2010,” they wrote. “Therefore, most of the current healthy adult population is unvaccinated against pneumococcal disease. Pneumococcal vaccination coverage among high-risk adults aged 19 to 64 years old is suboptimal. In 2016, coverage in this group was estimated at 24%; coverage among adults [at least] 65 years old was 67%.”

Chu and colleagues conducted a small, case-control study within Kaiser Permanente Northern California from Jan. 1, 2008, to Oct. 31,2017. They included any patients aged 18 years or older with an ICD9 or ICD10 diagnosis code of bacterial or pneumococcal meningitis. Inclusionary criteria were a positive cerebrospinal fluid (CSF) culture for S. pneumoniae or a CSF count of more than 10 leukocytes/L and a positive blood culture or polymerase chain reaction for S. pneumoniae within the same hospitalization period, according to the study.

Chu and colleagues identified 84 patients with pneumococcal meningitis and matched them to 168 controls. According to the study, 17.9% (n = 15) of patients with pneumococcal meningitis had a prior head injury (concussion, facial fracture or skull fracture) or spine or head surgery (eg, nasal surgery, mastoidectomy or posterior spinal fusions) compared with 3.6% (n = 6) of patients in the control group.

According to the findings, patients with pneumococcal meningitis had 5.6 higher odds of having a history of head injury or spine or head surgery than patients in the control arm (95% CI, 1.94-12.89). When assessed separately, the association between head injury and pneumococcal meningitis did not remain significantly elevated (OR = 3; 95% CI, 0.50-17.95), but the association between head or spine surgery and pneumococcal meningitis did (OR = 6; 95% CI, 1.94-18.6).

Chu and colleagues also assessed vaccination rates in both groups and found that 33.3% (n = 28) of patients with pneumococcal meningitis received at least one dose of a pneumococcal vaccine compared with 41.7% (n = 70) of individuals in the control group. They recommended vaccinating patients with upcoming or prior elective head or spine surgery.

“This is the first published study demonstrating an association between a history of [head/spine surgery] and pneumococcal meningitis outside the 30-day postoperative period,” Chu and colleagues wrote. “Additional investigations are needed to confirm these results, as this was a relatively small study. Future investigations are also needed to explore the risk of facial and skull fractures, as well as the risk of developing other neuroinfectious diseases in persons with prior [head/spine surgery].” – by Marley Ghizzone

Disclosures: Chu reports no relevant financial disclosures.

Prior head or spine surgery is associated with an increased risk for Streptococcus pneumoniae meningitis beyond the 30-day postoperative period, findings from a small study showed.

According to Victoria Chu, MD, MPH, pediatric resident at Kaiser Permanente Oakland Medical Center, and colleagues, cases of pneumococcal meningitis have been reported in patients years after a head injury, “presumably as a result of an injury-related cranial defect,” and past research has shown that patients with a head injury or prior brain surgery are at an increased risk for pneumococcal meningitis.

Chu and colleagues sought to determine if there is an association between prior head injury or prior spine or head surgery and pneumococcal meningitis among adults, many of whom are not vaccinated.

“Healthy U.S. children have been recommended to receive 7-valent pneumococcal conjugate vaccine (PCV7) since it was introduced in 2000; PCV13 was recommended in 2010,” they wrote. “Therefore, most of the current healthy adult population is unvaccinated against pneumococcal disease. Pneumococcal vaccination coverage among high-risk adults aged 19 to 64 years old is suboptimal. In 2016, coverage in this group was estimated at 24%; coverage among adults [at least] 65 years old was 67%.”

Chu and colleagues conducted a small, case-control study within Kaiser Permanente Northern California from Jan. 1, 2008, to Oct. 31,2017. They included any patients aged 18 years or older with an ICD9 or ICD10 diagnosis code of bacterial or pneumococcal meningitis. Inclusionary criteria were a positive cerebrospinal fluid (CSF) culture for S. pneumoniae or a CSF count of more than 10 leukocytes/L and a positive blood culture or polymerase chain reaction for S. pneumoniae within the same hospitalization period, according to the study.

Chu and colleagues identified 84 patients with pneumococcal meningitis and matched them to 168 controls. According to the study, 17.9% (n = 15) of patients with pneumococcal meningitis had a prior head injury (concussion, facial fracture or skull fracture) or spine or head surgery (eg, nasal surgery, mastoidectomy or posterior spinal fusions) compared with 3.6% (n = 6) of patients in the control group.

According to the findings, patients with pneumococcal meningitis had 5.6 higher odds of having a history of head injury or spine or head surgery than patients in the control arm (95% CI, 1.94-12.89). When assessed separately, the association between head injury and pneumococcal meningitis did not remain significantly elevated (OR = 3; 95% CI, 0.50-17.95), but the association between head or spine surgery and pneumococcal meningitis did (OR = 6; 95% CI, 1.94-18.6).

Chu and colleagues also assessed vaccination rates in both groups and found that 33.3% (n = 28) of patients with pneumococcal meningitis received at least one dose of a pneumococcal vaccine compared with 41.7% (n = 70) of individuals in the control group. They recommended vaccinating patients with upcoming or prior elective head or spine surgery.

“This is the first published study demonstrating an association between a history of [head/spine surgery] and pneumococcal meningitis outside the 30-day postoperative period,” Chu and colleagues wrote. “Additional investigations are needed to confirm these results, as this was a relatively small study. Future investigations are also needed to explore the risk of facial and skull fractures, as well as the risk of developing other neuroinfectious diseases in persons with prior [head/spine surgery].” – by Marley Ghizzone

Disclosures: Chu reports no relevant financial disclosures.

    Perspective

    I think the most practical thing to take home from this study is that doctors can and should be ensuring that patients get the pneumococcal vaccine. That is a real practical take-home message because they are probably undervaccinating their patients. When thinking of the diagnosis of meningitis, certainly one must be thinking pneumococcal meningitis as one of the leading diagnosis regardless. I think most physicians are going to think of the diagnosis of pneumococcal meningitis in the appropriate setting. It is interesting that more of these patients get pneumococcal meningitis compared with the general population, but once they come in with meningitis, you should be able to diagnose it anyway. Again, the major benefit of this study is that you can prevent it by giving pneumococcal vaccination. That is the most important take-home message. It is important and interesting that [patients with a prior head or spine surgery] have a higher risk [for S. pneumoniae meningitis], but from a diagnostic standpoint, it is not so critical. While one might not have known [of this association] or thought of it on their own to say you are at a permanent risk but, having said that, it is certainly something to be aware of.

    Further research should be focused on why there is an increased risk. Is there some potentially treatable or repairable damage that was not recognized? If you could repair that, maybe you could prevent it. I do not know if we will find something to correct — an unrecognized, but potentially treatable, cause for this increased rate. However, it would be great if we could figure that out.

    Overall, I think it is a very nice paper, an important study. The biggest take-home message is ensuring these patients are vaccinated because most of them are not.

    Aaron Glatt, MD, FACP, FIDSA, FSHEA

    Spokesperson, Infectious Diseases Society of America
    Chairman of the department of medicine, chief of infectious diseases and hospital epidemiologist
    South Nassau Communities Hospital

    Disclosure: Glatt reports no relevant financial disclosures.