Bacterial Meningitis By Allan R. Tunkel Philadelphia: Lippincott Williams & Wilkins, 2001. 288 pp., illustrated. $110.00 (hardcover)

Despite the advances in antibiotic therapy that have occurred in the past 3 decades, bacterial meningitis continues to be associated with significant morbidity and mortality. This disease can be caused by several pathogens, has a broad differential diagnosis, can occur in epidemics, and creates fear in the community and for the treating physician. The emergence of drug resistance and the widespread use of the Haemophilus influenzae conjugate vaccine have changed the epidemiology and the empiric management of meningitis.

Bacterial Meningitis is the only book in circulation that solely addresses bacterial meningitis. It does so with an authoritative and comprehensive review of the existing literature. The book starts with a very interesting historical chapter by Dr. Michael Scheld that reviews the anatomy of the CSF, the first clinical descriptions of meningitis, and the diagnosis and treatment of meningitis before and after the advent of antibiotic therapy.

The remaining 9 chapters were written by Dr. Allan R. Tunkel, a well-known researcher and publisher in the field of meningitis research. He has exhaustively provided each chapter with up-to-date references, and he has presented the material, including several tables and figures, in a clear, concise manner. Dr. Tunkel starts this portion of Bacterial Meningitis with a review of the changing epidemiologic characteristics and etiologies of bacterial meningitis noted both nationally and internationally, describing landmark studies from several different countries. This is followed by an in-depth review of the pathogenesis and pathophysiologic characteristics of bacterial meningitis, an area in which Dr. Tunkel has had extensive research and publishing experience. He reviews the mechanisms of nasopharyngeal colonization, the interaction of the virulence factors of the organisms and the host defense mechanisms, and the invasion of bacterial meningitis into the bloodstream and CNS. This chapter finishes with a review of the bacterial and host determinants that alter the blood-brain barrier, the subarachnoid inflammation mediated by chemokines and cytokines, and the development of cerebral edema with subsequent alteration of cerebral blood flow and neuronal injury. Then, in a separate chapter, Dr. Tunkel presents a unique review of the clinical presentation of patients with bacterial meningitis, according to age group (neonates, children, adults, and elderly persons), underlying condition, and etiologic agent.

The subsequent 5 chapters deal with the diagnosis, differential diagnosis, management, outcome, and prevention of bacterial meningitis. These chapters start with a review of the diagnostic accuracy of the different CSF parameters, including opening pressure, appearance, cell count, and glucose, protein, and lactate levels, and the results of Gram staining, culture, bacterial antigen testing, and PCR. The chapter finishes with a review of the CSF findings for patients with partially treated meningitis and CSF shunts, in addition to the findings of neuroimaging studies of patients with meningitis. The chapter about differential diagnosis describes, in detail, the different viral, rickettsial, mycobacterial, spirochetal, fungal, and protozoal organisms that can cause meningitis. That chapter is followed by a discussion of meningitis management that integrates data from animal models with data from clinical studies and meta-analyses to describe the effectiveness of antibiotic and adjunctive therapy (e.g., steroids). An algorithm for the empirical treatment of patients with meningitis is presented.

The subsequent chapter provides recommendations regarding pathogen-specific antibiotic therapy, duration of therapy, and use of adjunctive therapy. In the next chapter, Dr. Tunkel discusses the prevention of bacterial meningitis through use of both pathogen-specific chemoprophylaxis and vaccination.

In the past 3 decades, there have been several advances in our understanding of the pathogenesis of bacterial meningitis and in the pathophysiology, diagnosis, and treatment of this disease; however, bacterial meningitis continues to be associated with significant morbidity and mortality. In the final chapter, Dr. Tunkel recognizes that, to improve the prognosis of this ancient but still devastating disease, future investigators will need to focus on the development of new antimicrobial agents, new adjunctive therapies, and vaccines against the most common meningeal pathogens.