The Epidemiology, Management and Therapeutic Outcomes of Subdural Empyema in Neonates with Acute Bacterial Meningitis

Abstract

Background: Subdural empyema is one of the more serious complications of bacterial meningitis and therapeutic challenges to clinicians. We aimed to evaluate the clinical characteristics, treatment, and outcome of subdural empyema in neonates with bacterial meningitis. Methods: A retrospective cohort study was conducted in two medical centers in Taiwan that enrolled all cases of neonates with subdural empyema after bacterial meningitis between 2003 and 2020. Results: Subdural empyema was diagnosed in 27 of 153 (17.6%) neonates with acute bacterial meningitis compared with cases of meningitis without subdural empyema. The demographics and pathogen distributions were comparable between the study group and the controls, but neonates with subdural empyema were significantly more likely to have clinical manifestations of fever (85.2%) and seizure (81.5%) (both p values < 0.05). The cerebrospinal fluid results of neonates with subdural empyema showed significantly higher white blood cell counts, lower glucose levels and higher protein levels (p = 0.011, 0.003 and 0.006, respectively). Neonates with subdural empyema had a significantly higher rate of neurological complications, especially subdural effusions and periventricular leukomalacia. Although the final mortality rate was not increased in neonates with subdural empyema when compared with the controls, they were often treated much longer and had a high rate of long-term neurological sequelae. Conclusions: Subdural empyema is not uncommon in neonates with acute bacterial meningitis and was associated with a high risk of neurological complications, although it does not significantly increase the final mortality rate. Close monitoring of the occurrence of subdural empyema is required, and appropriate long-term antibiotic treatment after surgical intervention may lead to optimized outcomes.

Keywords: Streptococcus agalactiae; bacterial meningitis; late-onset sepsis; neurological sequelae; subdural empyema.

Figure 1

CTs of empyema complicated by bacterial meningitis in neonates. The axial CT of a neonate with bacterial meningitis with subdural empyema. This patient had a mild brain midline shift.

Figure 2

The time course of all neonates with subdural empyema, including the onset of meningitis, first neuroimaging, diagnosis of subdural empyema, and treatment courses, including surgical intervention and antibiotic treatment. The star indicates the day of the two mortality cases.

Figure 3

The MRI of a 3-month-old neonate with E. coli meningitis showed progressive bilateral subdural effusion (A). The apparent diffusion coefficient-weighted (B) and diffusion-weighted (C) MRIs of a subdural empyema over the left convexity are also noted.