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Predictors of Dismal Prognosis

Nicolau Barquet, MD; Pere Domingo, MD; Joan A. Caylà, MD; Julià González, MD; Carlos Rodrigo, MD; Pedro Fernández-Viladrich, MD; Fernando A. Moraga-Llop, MD; Francesc Marco, MD; Julio Vázquez, MD; Juan A. Sáez-Nieto, MD; Julio Casal, MD; Jaume Canela, MD; Màrius Foz, MD; for the Barcelona Meningococcal Disease Surveillance Group

Arch Intern Med. 1999;159:2329-2340.

Context  Studies on meningococcal disease in large urban communities have rarely been performed and are usually based on passive epidemiologic surveillance. Active surveillance may provide new insights.

Objectives  To determine epidemiologic, clinical, and bacteriological characteristics and predictors of dismal prognosis (death and sequelae) in meningococcal disease.

Design  Prospective, population-based study.

Setting  All the acute care hospitals (n=24) in Barcelona, Spain.

Patient  The 643 patients whose conditions were diagnosed from 1987 through 1992 were detected by 2 active surveillance methods.

Outcome Measures  Incidence and notification to Public Health Service. Clinical and bacteriological features were determined. Dismal prognosis predictors were determined by logistic regression.

Results  Average annual incidence was 6.41 per 100,000 inhabitants, with no clear trend of change (P=.08). Sensitivity of the Public Health Service surveillance system was 69.1%. Children younger than 10 years from the inner city were at higher risk than those from the highest income district (relative risk, 3.00; 95% confidence interval [CI], 1.84-5.06). Increasing annual incidence of serogroup C (0.82-1.29/100,000; P=.008) and decreasing incidence of serogroup B (5.11-2.82/100,000; P=.004) was noted. Average annual mortality was 0.40 per 100,000 inhabitants, while the annual average potential years of life lost was 18 per 100,000 inhabitants. Overall case-fatality rate was 6.4%. Independent predictors of death were hemorrhagic diathesis (odds ratio [OR], 63; 95% CI, 21-194), focal neurologic signs (OR, 10; 95% CI, 3-30), and age 60 years or older (OR, 6; 95% CI, 2-17), whereas preadmission antibiotic therapy was associated with favorable outcome (OR, 0.07; 95% CI, 0.02-0.3). Four percent of survivors presented with sequelae. Independent predictors of sequelae were hemorrhagic diathesis (OR, 21; 95% CI, 3-131), focal neurologic signs (OR, 16; 95% CI, 5-53), age 60 years or older (OR, 7; 95% CI, 2-26), and age between 15 and 59 years (OR, 5; 95% CI, 2-14), whereas preadmission antibiotic therapy had a protective effect (OR, 0.2; 95% CI, 0.04-0.5).

Conclusions  Active epidemiologic surveillance significantly improved detection of cases and allowed us to observe that meningococcal disease still causes much morbidity and mortality, especially among children living in the inner city. Hemorrhagic diathesis, focal neurologic signs, and age were independent predictors of dismal prognosis, whereas preadmission antibiotic therapy had a protective effect.

From the CAP Gràcia, Institut Català de la Salut (Dr Barquet), Hospital de la Santa Creu i Sant Pau (Dr Domingo), Institut Municipal de la Salut (Dr Caylà), Hospital Clínic (Drs González and Marco), Hospital Infantil Vall d'Hebron (Dr Moraga-Llop), and Departament de Salut Pública i Legislació Sanitària (Dr Canela), Barcelona; Hospital Germans Trias i Pujol, Badalona (Drs Rodrigo and Foz); Hospital de Bellvitge (Dr Fernández-Viladrich), L'Hospitalet de Llobregat; Laboratorio de Referencia de Meningococos, Centro Nacional de Microbiología, Virología e Inmunología Sanitarias, Madrid (Drs Vázquez, Sáez-Nieto, and Casal), Spain. A complete list of the participating centers and other members of the Barcelona Meningococcal Disease Surveillance Group not listed as authors appears below.

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