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Acute meningitis with a negative Gram’s stain: clinical and management outcomes in 171 episodes.



To characterize the diagnostic spectrum and physician management decisions of patients presenting to an emergency department with an acute, community-acquired illness, cerebrospinal fluid (CSF) white blood cell count > 5/mm3, and a negative Gram’s stain for bacteria.


In this retrospective cohort study over a 2-year period, symptoms, examination findings, paraclinical data, physician management, and clinical outcomes were assessed for each patient.


One hundred sixty-eight patients (171 patient episodes) were evaluated. Almost half of the cohort presented in nonsummer months (48%); 20% of concurrent comorbid
disease, and 15% had identified immunocompromising conditions. The reported examination findings were diverse, with diverse, with fever [49%] and neck stiffness [39%] being the most frequent findings. The majority were hospitalized (70%), with a median stay of 4 days. Approximately one half underwent computed tomography or magnetic resonance imaging (49%), and received empiric treatment with antibiotics (52%). A diagnostic cause was established in 23%, with the majority being inherently treatable diseases (including syphilis, bacteremia,
Lyme disease). Variables significantly associated with a subsequent proven diagnostic cause included: age > 60 years; presence of comorbid
disease (especially immunodeficiency); and presentation in winter months.


A large proportion of patients presenting with acute meningitis and a negative CSF Gram’s stain undergo hospitalization, noninvasive cranial imaging, and receive empiric antibiotic therapy. Better clinical guidelines are needed to identify the diagnostic and management decisions that benefit patient outcome.

Am J Med. 1996 Jan;100(1):78-84. [1]