Acute Bacterial Meningitis
Marjorie Lazoff, MD
Emergency Medicine
Philadelphia, Pennsylvania
Medical Editor
Medical Computing Today

accepted for publication in Medical Computing Today October 1997
(updated) September 1998

Originally published in edited form October 1997 in Medical Software Reviews.

Education - Journals - Resources - Organizations - Research - Patient Ed - Lists of Lists - In Summary

The Internet is publicized as a timely, scholarly, and practical resource for clinicians practicing state-of-the-art medical care. How well does the Web fulfill this promise? To help answer the question, the Web was examined for information on two specific diseases, each affecting a wide range of physicians and patients. This article looks at an acute and serious infectious disease; the next will focus on a chronic debilitating neurologic disease.
Few conditions are as respectfully feared as acute bacterial meningitis, and by so many different types of physicians: general internists, family practitioners, pediatricians, neurologists, infectious disease specialists, emergency physicians, neonatologists, occupational specialists caring for large groups of young people, and neurosurgeons caring for their post-op patients. We know the Hib vaccine has dramatically decreased the incidence of H. flu meningitis. We know the emergence of drug-resistant strains of pneumococcal meningitis has changed treatment protocols in the United States. We know meningococcus draws media attention as the source of potential deadly epidemics of meningitis that typically strike young adults. We know that when and for how long, if ever, to pre-treat with dexamethasone is controversial. We know delaying minutes in instituting treatment can often mean the difference between life and neurologic disability or death, and we know in actual practice how hard it is to diagnose and treat within that time restraint.
Sections Education
Several Web sites accommodate students and physicians looking for basic instruction or review. Outlines, unfortunately dated (in that they ignore changes in H. flue epidemiology and only briefly discuss treatment controversies regarding resistant strains and dexamethasone), are available from Michigan State University's Meningitis, and Pedbase's Bacterial Meningitis. More satisfying for medical students, especially with their links to related topics, is Kansas University Medical Center's Meningitis.
The Virtual Hospital's Infections of the Central Nervous System concentrates on pathophysiology; look under Meningitis for text and embedded thumbnail graphics on pyogenic meningitis, and general comments and comparisons to other forms of meningitis. University of Utah WebPath's CNS Pathology posts this and the next six more slides of gross pathology and CSF stains, all of excellent quality.
Several sites educate using clinical pathology case presentations and discussions. For example, University of Pittsburgh's clinical microbiology section presents Fever, purpura, and hypotension. See the first two cases on Cornell's CNS Pathophysiology Cases.
Sections Journals
There are surprisingly few online journal articles on meningitis. The October 2 issue of NEJM includes (alas, only the abstract of) Active Surveillance Team's Bacterial Meningitis in the United States in 1995. In reference to another NEJM article, a Letter and its response discuss various recommendations for treatment of suspected pneumococcal meningitis.
The AMA presents the full text of the recent Archives of Internal Medicine article reviewing Iceland's 20-year experience with Bacterial Meningitis in Adults. A nice summary of this article appears on the American Family Physician site.
Searching "meningitis" resulted in several abstracts from the basic research-oriented Brain.  
Sections Online Resources
Searches performed on the growing number of commercial medical sites brought up a great variety of minor tidbits and references, but also several major articles of varying quality.
After selecting Journal Room on Medscape's home page, scroll all the way down to access Infections in Medicine, then scroll down to the December 1995 issue, under which is listed Gregory C. Townsend, MD, and W. Michael Scheld, MD's Adjunctive Corticosteroids for Adult Bacterial Meningitis. It's worth the effort to obtain this readable, scholarly review. On, registered users can directly link to David Anderson's CNS Infections - 30 minutes to Act, a largely forgettable article from the May 30, 1996, issue of Patient Care, although the section on treatment is quite readable.
Online quick references are the latest medical Web craze, and some sites are more successful than others. Once registered (for free), Avicenna's search engine supplies an Outline in Clinical Medicine on Meningitis, which emphasizes bacterial meningitis in treatment and Meningococcemia.
Search "bacterial meningitis" under the Doctors Guide to the Internet News to bring up a few news/press release items, such as a recent convention reporting on a multi-center trial demonstrating the efficacy and safety of meropenem in children, and a process report on a meningococcal vaccine.
Sections Organizations
Several organizations have created resources. UK's National Meningitis Trust is a registered charity dedicated to warning physicians and nonprofessionals about meningitis. Patient Fact Sheets and Specialist Views form the nucleus of information, as described under Patient Education. An online newsletter includes international news items and progress on research. The photos and narratives from people whose lives have been unalterably affected by meningitis are touching.
The well-meaning Meningitis Foundation of America is the colonies' version of the UK Trust. Its organization and much of the source material come from the Trust, to which users are best referred. Physicians looking to frighten themselves will enjoy Could it be meningitis?. Prepared for Britain's Medical Protection Society, it describes several missed diagnoses.
The National Institutes of Health is a popular medical and health information site, but in this instance other government agencies have better online offerings. The Centers for Disease Control (CDC) provides patient education resources on epidemiology and travel, described below. WHO's Emerging and other Communicable Diseases Surveillance and Control gathers its site articles together on a Meningitis page. Health officials are described working to control meningitis in Africa in a short article from Focus, a government newsletter on new and emerging infections.
Sections Research
The NIH and WHO are performing research into the immunology and epidemiology of meningitis, and many educational institutions are involved in clinical trials. However, the only detailed online descriptions of research activities I found come from Great Britain. UK's Meningitis Research Foundation has somewhat confusing information and slow loading photographs, but it provides a 24 hour hotline number and lists research projects and funding. To search for genetic vulnerabilities, it solicits volunteers among UK families with close family members who had meningitis or septicemia.
Sections Patient Education
Patients seeking education about meningitis will fare less well than professionals. The CDC's Bacterial Meningitis offers a succinct fact sheet addressing common concerns such as symptoms, diagnosis, contagion, and routine and travel immunizations, along with several MMWR links. Less satisfying but often-quoted (usually without acknowledgment) is a New York State Department of Health fact sheet on meningitis. The information is dated despite its April 1996 notation. The UK Meningitis Merseyside Support's Meningococcal Septicaemia and Meningitis is filled with typos but does something rare among fact sheets and databases: it lists the author. A person identified only by his or her e- mail address has posted About Meningitis, a site recommended less for content than for its heartfelt labor-of-love presentation.
KidsHealth's description of meningitis and lumbar puncture is accurate and cleanly presented, but it did not convey enough important information about either the disease or the procedure.
Sections Lists of Lists
I did not encounter any lists on acute bacterial meningitis. Of the two Web search engines that use MESH terms, Sweden's Karolinska Institute Library search was more helpful than Oregon Health Science University's CliniWeb. Organizing Medical Networked Information (OMNI) offers a variety of search methods, including its own annotated listing. Check out the experimental OMNI Havester, a new MESH term search engine that provided several very good resources not listed elsewhere. Silverplatter's WebMedLit searches 23 major medical online journals but, like Health Clinics USA, readers will need to search "meningitis" manually as its search engine does not permit linking to search results. Finally, a NetView on Patient Education lists many of the major Web sites in this category, most of which include information on meningitis.
Sections In Summary
Reviewing the online resources on acute bacterial meningitis confirms that, for physicians, the Web is competitive with mainstream print references on this topic. High end primary sources are lacking, it is true, nor are all Web references well maintained and updated. But this is balanced by the presence of several top research and journal articles even before their publication date, and by the daily snippets of news items, press releases, and abstracts.
In contrast, information for patients and nonmedical persons is discouragingly inadequate. No site visited was both accurate and technically proficient, and no discussion group was both active and moderated. Incredibly, a number of sites lifted whole paragraphs and pages of information without crediting the original Web source. Well-meaning or not, physician-authored or not, too many Web sites that ostensibly offer health education are in fact confusing, outdated or inaccurate.
Yet, while far from ideal, the looming problem on the Web for physicians and their patients is not content, but access to content. I found searching the Web for any information on meningitis abysmally inefficient. Worse, for all the time wasted, I have no way of knowing if I missed superior resources.
Other problems in accessing Web content emerged. Some (free) registered commercial medical sites permit outsiders to link to specific articles, interrupting the process only for the user to quickly register or log in before linking to the reference. But most sites are not so accommodating, and they bring the now logged-in user to the site's home page, losing forever the link that brought the user there in the first place. I suppose this serves the site's purposes in capturing new hits, but serious users are going to sorely resent their search efforts being undermined. The future of these sites may be limited less by subscription fees and in-your-face advertising then their inability (or unwillingness) to contribute and link with the rest of the Web.
Search engines that use .cgi scripts or other technology can not be bookmarked. I found this limiting in two respects. First, it prevents saving frequently-used searches, a godsend when the search is complex and unique to that site. Second, it prevents saving any reference identified using the search engine. For this review I tried to backtrack and re-identify these references by their file namea time consuming and often unsuccessful endeavor, so characteristic of accessing the Web nowadays for a specific clinical or educational purpose.
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