***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objective : To study changes in the epidemiology and management of meningococcal  disease in one health district during a period of high local incidence of disease . Design : Prospect i ve case ascertainment and data collection over 14 years , with retrospective analysis of cases . Setting : West Gloucestershire ( population 320 000 ) . Subjects : Residents developing meningococcal disease between 1 January 1982 and 31 December 1995 . Results : 252 cases of invasive meningococcal disease were identified , of which 102 ( 40 % ) were officially notified and 191 ( 76 % ) were confirmed by culture from a deep site . The observed disease incidence of 5.6/100 000/year was about 2.7 times the national incidence ( as measured by either statutory notifications or reference laboratory reports ) . The period 1983–90 was characterised by a prolonged localised outbreak due to serogroup B serotype 15 sulphonamide resistant ( B15R ) strains . General practitioners gave benzylpenicillin before hospital admission to 18 % of patients who presented with meningococcal disease in the first half of the study period and to 40 % who presented in the second half . The overall case fatality rate was 6.7 % ( 17/252 ) . Four deaths were directly or indirectly related to lumbar puncture . Of 120 patients whose lumbar puncture yielded meningococci , nine ( 8 % ) showed no abnormality on initial examination . Conclusions : Neither laboratory records nor formal notifications alone can give an accurate estimate of the incidence of meningococcal disease . Because of the dangers of lumbar puncture , the frequency of misleading negative initial findings , and the advent of new diagnostic techniques , the need for sample s of cerebrospinal fluid should be critically question ed in each case of suspected meningococcal disease . Key messages The first doctor to suspect a diagnosis of meningococcal disease should start treatment immediately Education and encouragement can increase the proportion of patients with meningococcal disease receiving benzylpenicillin before admission to hospital Specimens for polymerase chain reaction testing should be collected from all patients suspected of having meningococcal disease in admission to hospital The need for lumbar puncture should be considered carefully in suspected meningococcal meningitis ; it is contraindicated in meningococcal septicaemia Notifications of meningococcal disease remain incomplete ; accurate estimation of numbers of cases requires reconciliation of notifications with laboratory diagnoses and local clinical Objectives —Delays in parenteral antibiotic treatment may contribute to the high mortality in meningococcal disease . This study aim ed to record “ door to needle ” time in children with meningococcal disease before and after the introduction of a specific teaching programme about the disease . Methods —“Door  to needle ” time  in 33 children with meningococcal disease , admitted June 1995–December 1996 , were studied . Regular teaching sessions encouraging prompt treatment were started in January 1997 .  “ Door to needle ” time  was then studied for 42 children admitted January 1997–December 1998 . Results —More of the second cohort attended accident and emergency ( A&E ) directly ( 9 of 33 v 24 of 42 ; p=0.01 ) rather than being referred by a GP . Similar proportions received pre-admission antibiotics  from a GP ( 8 of 24 v 5 of 18 ) . Mortality was similar in the two groups ( 2 of 33 v 5 of 42 ) . “ Door to needle ” time was significantly shorter in the second cohort in those with a typical rash ( median 60 minutes v 18 minutes ; p=0.0004 ) . Only 1 of 23 ( 4 % ) children in the second cohort with a typical , petechial rash waited more than 60 minutes for  antibiotics  , compared with 6 of 24 in the first cohort ( p=0.06 ) . Conclusions —Significant improvements in “ door to needle ” time in meningococcal disease can be achieved when awareness is heightened by regular teaching . Those with a typical , petechial rash can be treated within 60 minutes of arrival . Strategies to improve immediate treatment of meningococcal disease should include education of A&E staff , especially as an increasing proportion of cases present directly to Short-term treatment with ceftriaxone 2 g once daily for two days ( group 1 ) was compared to treatment with a st and ard regimen of penicillin G ( group 2 ) for six days in adults with meningococcal meningitis . Thirty-six patients were allocated in a r and omized fashion to a treatment group : 16 to group 1 and 20 to group 2 . The clinical and microbiological results were comparable in the two treatment groups . In both groups cultures of cerebrospinal fluid were sterile after 24 hours . One patient in each group died . In group 1 one case of fulminant meningococcemia and one case of brain abscess required further antibiotic treatment . It is concluded that short-term treatment with ceftriaxone is feasible but patients with severe forms of meningitis would not be eligible for treatment with this regimen , and careful follow-up of the patients receiving ceftriaxone is necessary Summary Thein vitro activity of ceftriaxone , ampicillin and chloramphenicol was studied at a reference laboratory against the isolates of the first 33 patients enrolled in a pediatric Swiss Multicenter Meningitis Study . The predictive value of the MIC data of 31 of the strains was further corroborated by two sets of bacterial killing curves in broth supplemented with 2 g/l of albumin . Ceftriaxone had the lowest geometric mean MIC values against all groups of isolates except for ampicillin againstStreptococcus agalactiae . The bactericidal activity of ceftriaxone and that of ampicillin , alone and in combination with chloramphenicol , was compared at six times the respective MICs and at pharmacologically readily achievable concentrations in cerebrospinal fluid . The bactericidal power of ceftriaxone at six times the MIC was as good or better than that of ampicillin alone or in combination againstNeisseria meningitidis and Streptococcus pneumoniae despite the very low drug concentrations of ceftriaxone compared to that of the competitors ; and it was barely lower at six times the MIC and at 1 mg/l ( a level that is readily surpassed in CSF at the 24 h trough level after a single daily dose of ceftriaxone of 100 mg/kg ( neonates 50 mg/kg ) than that of ampicillin and chloramphenicol at much higher concentrations againstHaemophilus influenzae type b . ZusammenfassungDieIn vitro-Aktivität von Ceftriaxon , Ampicillin und Chloramphenicol wurde i m Rahmen einer pädiatrischen Schweizerischen Multizenter-Meningitis-Studie gegen die Erreger der ersten 33 Patienten mit akuter bakterieller Meningitis geprüft . Bei 31 Stämmen wurden die MHK-Werte — in mit 2 g/l Albumin-angereichertem Medium — zusätzlich durch je zwei Sätze Abtötungskurven ergänzt . Ceftriaxon zeigte gemessen am geometrischen Mittel die niedrigsten Hemmkonzentrationen für alle Bakterienspezies ausgenommen der von Ampicillin gegenStreptococcus agalactiae . Die bakterizide Aktivität von Ceftriaxon und Ampicilin — alleine und in Kombination mit Chloramphenicol — wurden bei je sechsfacher MHK der Isolate sowie bei i m Liquorraum gut erreichbaren antibakteriellen Konzentrationen getestet . Die bakterizide Aktivität von Ceftriaxon entsprach derjenigen , von Ampicillin alleine oder in Kombination gegenNeisseria meningitidis undStreptococcus pneumoniae , oder übertraf sie , obschon die Konzentration von Ceftriaxon bei sechsfacher MHK sehr viel kleiner als die der Vergleichspräparate war . Selbst gegen die auf die Ampicillin-Chloramphenicol-Kombination äußerst empfindlichenHaemophilus influenzae Typ b erwies sich Ceftriaxon als nur geringfügig weniger aktiv als höhere Konzentrationen von besagter Kombination Aims : To determine in children with meningitis whether there is any difference in mortality and neurological sequelae using chloramphenicol as first line treatment , with a change to ceftriaxone if chloramphenicol resistance is shown in vitro , compared to using ceftriaxone as first line treatment , with a change to chloramphenicol if there is no evidence of in vitro resistance . Methods : An observational study with a retrospective control group nested within a r and omised trial of fluid management for bacterial meningitis where clinical care was st and ardised . Chloramphenicol is st and ard treatment for bacterial meningitis in Papua New Guinea . In the first 150 cases we used chloramphenicol and only changed treatment to ceftriaxone if chloramphenicol resistance for cerebrospinal fluid isolates was proved . After finding 20 % of Haemophilus influenzae were resistant to chloramphenicol , and that most affected children had poor outcomes , we changed to an alternative strategy . In the next 196 cases first line treatment was ceftriaxone and treatment was changed to chloramphenicol if the isolated bacteria were found to be susceptible . Results : When chloramphenicol was used as first line treatment for meningitis followed by ceftriaxone when in vitro resistance was shown , there was invariably a very poor outcome in chloramphenicol resistant disease ( 71 % of children died or had severe neurological complications ) . Using ceftriaxone as first line treatment was effective in reducing mortality and neurological sequelae from chloramphenicol resistant Haemophilus influenzae type ( 71 % v 9 % , relative risk 0.13 ; 95 % CI 0.02 to 0.87 ; p = 0.013 ) . Changing to chloramphenicol if there was no evidence of in vitro resistance was less than half the cost of empirical use of ceftriaxone for a full course for all children with meningitis . Conclusions : Using a third generation cephalosporin as first line treatment is effective in dealing with the problem of poor outcomes from meningitis due to Haemophilus influenzae that is resistant to chloramphenicol , and a strategy of changing to chloramphenicol if in vitro susceptibility is shown will reduce the use of expensive third generation cephalosporins without comprising on clinical outcomes . This highlights the urgent need to reduce the costs of third generation cephalosporins , to improve bacteriological services in developing countries , and to introduce effective and affordable vaccines against H influenzae and Streptococcus pneumoniae One hundred patients ages 1 month to 15 years received either ceftazidime ( CZ ) at a dose of 150 mg/kg/day divided every 8 hours or conventional treatment with chloramphenicol and ampicillin ( CA ) . Seventy-eight had isolates recovered from the cerebrospinal fluid : 40 ( 51 % ) were Haemophilus influenzae ( all ampicillin-susceptible ) ; 16 ( 21 % ) were Streptococcus pneumoniae ; 14 ( 18 % ) were Neisseria meningitidis ; 3 ( 4 % ) were salmonellae ; 1 ( 2 % ) was Pseudomonas ; and 1 ( 2 % ) was Group B Streptococcus . Six patients with negative cerebrospinal fluid culture had positive latex agglutination ( two H. influenzae , three N. meningitidis , one S. pneumoniae ) . Sixty-one patients had positive blood cultures .  CZ inhibited 100 % of H. influenzae at 0.78 micrograms/ml , S. pneumoniae at 0.39 , N. meningitidis at 0.04 and salmonellae at 0.39 micrograms/ml . The mean peak serum concentration of CZ was 36.4 micrograms/ml with a mean cerebrospinal fluid level of 7.4 micrograms/ml . If one eliminates from the statistics those patients who died less than or equal to 24 hours after admission , five ( 10 % ) of 49 patients treated with CZ  died , one ( 2 % ) improved and 43 ( 88 % ) were cured . Overall 29 patients died , 12 receiving CZ ( 20 % ) and 8 receiving CA ( 21 % ) . There were no significant  CZ-related toxicities . Gross neurologic sequelae were noted in 5 % of 38 CZ patients and 4 % of 28 CA patients . CZ compared favorably to CA for treatment of meningitis BACKGROUND Bacterial meningitis is an important cause of morbidity and mortality in developing countries , but the duration of treatment is not well established . We aim ed to compare the efficacy of 5 and 10 days of parenteral ceftriaxone for the treatment of bacterial meningitis in children . METHODS We did a multicountry , double-blind , placebo-controlled , r and omised equivalence study of 5 versus 10 days of treatment with ceftriaxone in children aged 2 months to 12 years with purulent meningitis caused by Streptococcus pneumoniae , Haemophilus influenzae type B , or Neisseria meningitidis . Our study was done in ten paediatric referral hospitals in Bangladesh , Egypt , Malawi , Pakistan , and Vietnam . We r and omly assigned children who were stable after 
    Output:
    
We found no reliable evidence to support the use pre-admission antibiotics for suspected cases of non-severe meningococcal disease .