OBJECTIVE: To compare the performance of multiple international guidelines in selecting patients for head CT prior to lumbar puncture (LP) in suspected meningitis, focusing on identification of potential contraindications to immediate LP.
METHODS: Retrospective study of 196 patients with suspected meningitis presenting to an emergency department between March 2013 and March 2023 and undergoing head CT prior to LP. UK Joint Specialist Society Guidelines (UK), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) guidelines were evaluated by cross-referencing imaging criteria with clinical characteristics present at time of presentation. Sensitivity of each guideline for recommending neuroimaging in cases with brain shift on CT was evaluated, along with the number of normal studies and incidental or spurious findings.
RESULTS: 2/196 (1%) patients had abnormal CTs with evidence of brain shift, while 14/196 (7%) had other abnormalities on CT without brain shift. UK, ESCMID and IDSA guidelines recommended imaging in 10%, 14% and 33% of cases respectively. All three guidelines recommended imaging pre-LP in 2/2 (100%) cases with brain shift. IDSA guidelines recommended more CT studies with normal findings (59 vs 16 and 24 for UK and ESCMID guidelines respectively) and CT abnormalities without brain shift (4 vs 1 and 2 respectively) than the other guidelines.
CONCLUSIONS: UK, ESCMID and IDSA guidelines are all effective at identifying the small cohort of patients who benefit from a head CT prior to LP. Following the more selective UK/ESCMID guidelines limits the number of normal studies and incidental or spurious CT findings.

Bacillus anthracis spores if resources become limited or a multidrug-resistant B. anthracis strain is used (Hendricks KA, Wright ME, Shadomy SV, et al.; Workgroup on Anthrax Clinical Guidelines. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20:e130687; Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013;122:885-900; Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014;133:e1411-36). Specifically, this report updates antimicrobial drug and antitoxin use for both postexposure prophylaxis (PEP) and treatment from these previous guidelines best practices and is based on systematic reviews of the literature regarding 1) in vitro antimicrobial drug activity against B. anthracis; 2) in vivo antimicrobial drug efficacy for PEP and treatment; 3) in vivo and human antitoxin efficacy for PEP, treatment, or both; and 4) human survival after antimicrobial drug PEP and treatment of localized anthrax, systemic anthrax, and anthrax meningitis.
B. anthracis strain. In addition, these updated guidelines include new recommendations regarding special considerations for the diagnosis and treatment of anthrax meningitis, including comorbid, social, and clinical predictors of anthrax meningitis. The previously published CDC guidelines and recommendations described potentially beneficial critical care measures and clinical assessment tools and procedures for persons with anthrax, which have not changed and are not addressed in this update. In addition, no changes were made to the Advisory Committee on Immunization Practices recommendations for use of anthrax vaccine (Bower WA, Schiffer J, Atmar RL, et al. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices, 2019. MMWR Recomm Rep 2019;68[No. RR-4]:1-14). The updated guidelines in this report can be used by health care providers to prevent and treat anthrax and guide emergency preparedness officials and planners as they develop and update plans for a wide-area aerosol release of B. anthracis.

BACKGROUND: The incidence of community-acquired acute bacterial meningitis has decreased during the last decades. However, outcome remains poor with a significant proportion of patients not surviving and up to 50% of survivors suffering from long-term sequelae. These guidelines were developed by the Deutsche Gesellschaft für Neurologie (DGN) under guidance of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) to guide physicians through diagnostics and treatment of adult patients with acute bacterial meningitis.
CONCLUSIONS: The most important recommendations are: (i) In patients with suspected acute bacterial meningitis, we recommend that lumbar cerebrospinal fluid (with simultaneous collection of serum to determine the cerebrospinal fluid-serum glucose index and blood cultures) is obtained immediately after the clinical examination (in the absence of severely impaired consciousness, focal neurological deficits, and/or new epileptic seizures). (ii) Next, we recommend application of dexamethasone and empiric antibiotics intravenously. (iii) The recommended initial empiric antibiotic regimen consists of ampicillin and a group 3a cephalosporin (e.g., ceftriaxone). (iv) In patients with severely impaired consciousness, new onset focal neurological deficits (e.g. hemiparesis) and/or patients with newly occurring epileptic seizures, we recommend that dexamethasone and antibiotics are started immediately after the collection of blood; we further recommend that -if the imaging findings do not indicate otherwise -a lumbar CSF sample is taken directly after imaging. (v) Due to the frequent occurrence of intracranial and systemic complications, we suggest that patients with acute bacterial meningitis are treated at an intensive care unit in the initial phase of the disease. In the case of impaired consciousness, we suggest that this is done at an intensive care unit with experience in the treatment of patients with severe CNS diseases.
CONCLUSIONS: The German S2k-guidelines give up to date recommendations for workup, diagnostics and treatment in adult patients with acute bacterial meningitis.

Viral encephalitis (meningitis) is a common infectious disease of the central nervous system (CNS), which is an inflammatory disease caused by viruses invading the brain parenchyma and meninges. It is a global disease and a serious threat to human health as an acute and severe medical condition. CNS infections can be caused by a variety of viruses, including herpes viruses, enteroviruses, and arboviruses, etc. Identification and diagnosis of the pathogens remains a major clinical challenge. In order to standardize the application of nucleic acid and antibody tests of patients with viral encephalitis (meningitis), experts in the field of virology, infectious diseases, clinical medicine and laboratory testing in China reached the consensus after repeated discussions. The current consensus mainly consists of the domestic and foreign pathogen types, the detection techniques, the detection strategies and schemes for Chinese viral encephalitis, thereby providing a reference for the clinical diagnosis and disease prevention and control of viral encephalitis (meningitis).
病毒性脑（膜）炎是常见的中枢神经系统感染性疾病，是病毒侵袭脑实质与脑膜导致的炎症性疾病。病毒性脑（膜）炎呈世界性分布，临床以急症和重症常见，严重威胁人类健康。多种病毒可导致中枢神经系统感染，包括疱疹病毒、肠道病毒和虫媒病毒等，病原体鉴定仍是病毒性脑（膜）炎在临床上的主要难题。为规范、合理地应用病原体诊断技术开展脑脊液的病毒核酸检测与抗体检测，由国内病毒学、传染病学、临床医学及医学检验等领域的专家组成的专家组，经反复讨论达成本共识，主要从国内外病毒性脑（膜）炎病原种类、检测技术及检测策略等方面进行阐述，并提出针对我国病毒性脑（膜）炎病原体的检测策略和方案，以期为病毒性脑（膜）炎的临床诊断以及疾病预防控制提供参考。.

Streptococcus pneumoniae can commonly cause otitis media, sinusitis, pneumonia, or meningitis; however, these infections less frequently can develop into invasive pneumococcal disease (IPD). Vaccination for the prevention of pneumococcal disease has significantly decreased complications from severe infections, including pneumonia, meningitis, and IPD, in patients with certain risk factors. In this case study, we describe a unique presentation of disseminated S. pneumoniae meningitis and bacteremia in a patient who initially presented with acute otitis media (AOM). Due to the patient\'s multiple comorbidities of obesity, tobacco use, pre-diabetes, coronary artery disease, and lack of pneumococcal vaccination, their AOM rapidly progressed to life-threatening, an invasive pneumococcal infection which was successfully treated with timely initiation of antibiotics. In addition to discussing the patient\'s clinical course and treatment regimen, we will review pertinent updates to the pneumococcal vaccination guidelines for high-risk patients and their efficacy in preventing severe disease.

OBJECTIVE: Review of the scientific literature dedicated to clinical data and diagnosis modalities for aural tuberculosis published since the start of the 21st century.
METHODS: Search of the Medline, Cochrane and Embase databases for the period 2000-2020. Selection of articles in English, French and Spanish devoted to clinical cases and series documenting clinical data and diagnosis for aural tuberculosis of articles by two authors. Analysis performed according to SWiM guidelines. Extraction of data on pre-established files documenting clinical and diagnostic data.
RESULTS: In total, 173 articles: 163 case reports (228 patients) and 10 cohorts (177 patients) from 49 countries were analyzed. Female/male sex ratio was 1.05, with ages ranging from less than 1 month to 87 years. Tuberculosis involved another site in 35.1% of cases. Aural involvement was bilateral in 19.7% of cases. Clinical presentation corresponded to otitis media (prior antibiotic treatment and auricular surgery in 41.4% and 10.1% of cases, respectively) without any pathognomonic symptoms or signs. Associated severe locoregional complications were seen in 32% of cases, with 23.2% and 13% incidence of peripheral facial palsy and severe intracranial complications, respectively. Time to diagnosis ranged from less than 1 month to 384 months, and was longer than 12 months in 26.5% of case reports, without significant correlation (P=0.29) with severe revelatory locoregional complications. Incidence of Mycobacterium tuberculosis detection ranged from 33.4% of documented cases in auricular secretions to 64.6% in polyps, granulomas, and/or biopsies. In the case reports, diagnosis with certainty was done in 58.3% of cases, while it was based on involvement of another site and on indirect criteria or positive clinical progression after treatment in the other 10.1% and 31.6%, respectively.
CONCLUSIONS: Aural tuberculous must always be considered in case of unfavorable progression of otitis. Definitive diagnosis is based on multiple auricular sample sites, polymerase chain reaction, and γ interferon blood assay.

BACKGROUND: The early-onset sepsis calculator (EOSC) reduces unnecessary antibiotic treatment in newborns. However, its performance in identifying cases with early-onset disease (EOD) is unclear. We compared the sensitivity of the EOSC to the current Dutch and National Institute for Health and Care Excellence (NICE) guidelines when applied to a cohort of newborns with culture-positive early-onset sepsis and meningitis.
METHODS: Culture-positive Streptococcus agalactiae (GBS) and Escherichia coli (E. coli) sepsis and meningitis patients ≤3 days old with a gestational age ≥34 weeks, identified between 1/1/2018 and 31/1/2021 in a Dutch prospective nationwide cohort study were included. Cases were identified by treating physicians and microbiological surveillance. Primary outcome was the proportion of patients that would have been treated according to the EOSC, the Dutch, and the NICE EOD prevention guidelines. Differences between proportions were analysed using McNemar\'s test.
RESULTS: We included 81 GBS and 7 E. coli EOD cases. At 4 h after birth, the EOSC would have recommended antibiotic treatment in 32 (36%) patients, compared to 44 (50%) by the Dutch (p<0·01) and 48 (55%) by the NICE guideline (p<0·01). The EOSC would have initially recommended routine care for 52% of patients compared to 31% and 30% for the Dutch and NICE guidelines (p<0·01). At 24 h after birth, the EOSC would have recommended antibiotic treatment in 54 (61%) infants compared to 64 (73%) by the Dutch (p = 0·02) and 63 (72%) by the NICE guidelines (p = 0·06).
CONCLUSIONS: The sensitivity of the EOSC in identifying cases of EOD is lower compared to both Dutch and NICE guidelines, especially directly after birth. The EOSC relies more on clinical symptoms and results in less overtreatment of healthy newborns at the cost of later antibiotic treatment in initially well-appearing EOD patients.
BACKGROUND: This work was supported by grants received from Netherlands Organization for Health Research and Development (ZonMw; NWO-Vidi-Grant (grant number 917·17·308); NWO-Vici-Grant (grant number 918·19·627)), the Academic Medical Centre (AMC Innovative Impulse Grant) and Steun Emma Foundation Grant.

Systemic lupus erythematosus is an autoimmune disease that affects multiple organs and organ systems, subsequently requiring an elaborate regimen for management. We present the case of a 63-year-old female who developed unrelenting symptoms of drug-induced lupus, which persisted even after the offending agent was withdrawn, unmasking her underlying systemic lupus erythematosus. She continued to develop neuropsychiatric symptoms, including mania and hallucinations, which complicated the management of her disease. After exhausting the bank of anti-inflammatory and immunomodulators recommended by current guidelines, we found that a combination of rituximab infusions with thiothixene, an antipsychotic agent, significantly improved our patient\'s neuropsychiatric symptoms. Further research should be conducted to determine the efficacy of rituximab in the treatment of resistant lupus cerebritis, and to validate the use of thiothixene in the management of neuropsychiatric symptoms secondary to lupus.

BACKGROUND: Tuberculous meningitis (TBM) represents a diagnostic and management challenge to clinicians. The \"Thwaites\' system\" and \"Lancet consensus scoring system\" are utilized to differentiate TBM from bacterial meningitis but their utility in subacute and chronic meningitis where TBM is an important consideration is unknown.
METHODS: A multicenter retrospective study of adults with subacute and chronic meningitis, defined by symptoms greater than 5 days and less than 30 days for subacute meningitis (SAM) and greater than 30 days for chronic meningitis (CM). The \"Thwaites\' system\" and \"Lancet consensus scoring system\" scores and the diagnostic accuracy by sensitivity, specificity, and area under the curve of receiver operating curve (AUC-ROC) were calculated. The \"Thwaites\' system\" and \"Lancet consensus scoring system\" suggest a high probability of TBM with scores ≤4, and with scores of ≥12, respectively.
RESULTS: A total of 395 patients were identified; 313 (79.2%) had subacute and 82 (20.8%) with chronic meningitis. Patients with chronic meningitis were more likely caused by tuberculosis and had higher rates of HIV infection (P < 0.001). A total of 162 patients with TBM and 233 patients with non-TBM had unknown (140, 60.1%), fungal (41, 17.6%), viral (29, 12.4%), miscellaneous (16, 6.7%), and bacterial (7, 3.0%) etiologies. TMB patients were older and presented with lower Glasgow coma scores, lower CSF glucose and higher CSF protein (P < 0.001). Both criteria were able to distinguish TBM from bacterial meningitis; only the Lancet score was able to differentiate TBM from fungal, viral, and unknown etiologies even though significant overlap occurred between the etiologies (P < .001). Both criteria showed poor diagnostic accuracy to distinguish TBM from non-TBM etiologies (AUC-ROC was <. 5), but Lancet consensus scoring system was fair in diagnosing TBM (AUC-ROC was .738), sensitivity of 50%, and specificity of 89.3%.
CONCLUSIONS: Both criteria can be helpful in distinguishing TBM from bacterial meningitis, but only the Lancet consensus scoring system can help differentiate TBM from meningitis caused by fungal, viral and unknown etiologies even though significant overlap occurs and the overall diagnostic accuracy of both criteria were either poor or fair.

The Dutch fever without an apparent source (FWS) guidelines were published to timely recognize and treat serious infections. We determined the adherence to the Dutch FWS guidelines and the percentage of serious infections in infants younger than 3 months of age. Second, we identified which clinical criteria, diagnostic tests, and management were associated with nonadherence to the guidelines.
A retrospective cohort study was performed in 2 Dutch teaching hospitals. We assessed the charts of all infants with FWS who presented at the emergency departments from September 30, 2017, to October 1, 2019. Diagnostic and therapeutic decisions were compared with the recommendations, as published in the Dutch guidelines. Infants were categorized into the nonadherence group in case 1 or more recommendations were not adhered to.
Data on 231 infants were studied; 51.5% of the cases adhered to the Dutch guidelines and 16.0% suffered from a serious infection. The percentage of infants with a serious infection was higher in the adherence compared with the nonadherence group. We observed no relevant differences in clinical outcomes. Univariate regression analysis showed that an abnormal white blood cell count was associated with nonadherence (OR 0.4, P = 0.049). Not obtaining a urine and blood culture and not starting intravenous antibiotic treatment were the most frequent reasons for nonadherence to the guidelines.
Our study indicates that there was nonadherence in a large proportion of FWS cases. The guidelines may need to be adjusted to increase adherence.