Clinical observation of meningitis caused by penicillin-susceptible and -non-susceptible Streptococcus pneumoniae in Taiwanese children

AIM: To compare differences between clinical features and outcome in bacterial meningitis caused by penicillin-susceptible Streptococcus pneumoniae (PSSP) with that caused by penicillin-non-susceptible Streptococcus pneumoniae (PNSP). METHODS: All patients <18 yrs hospitalised with pneumococcal meningitis between January 1984 and December 2002 at Chang Gung Children's Hospital, Taipei were reviewed retrospectively. RESULTS: There were 28 PNSP (63.6%) and 16 PSSP cases of meningitis eligible for the study. The incidence of PNSP meningitis increased significantly over the 8-yr period (p = 0.007). Age <4 yrs (78.6% vs 50%), a lower initial white blood count (mean 11.7 vs 19.9 x10(9)/L), admission to the intensive care unit (70.4% vs 50%) and mortality (28.6% vs 6.3%) were more common in the PNSP group. However, the only significant finding was a lower proportion of polymorphic neutrophils in the CSF of the PNSP meningitis group (p = 0.04). CONCLUSIONS: There was an increase in PNSP isolates from patients with meningitis over the 8-yr study period. No major differences were observed in clinical or laboratory features or outcome between the PSSP and PNSP groups.     

Pneumococcal meningitis in children: relationship of antibiotic resistance to clinical characteristics and outcomes.

BACKGROUND: The relationship of antibiotic susceptibility to clinical outcome in children with pneumococcal meningitis is uncertain. Previous studies have been limited by inclusion of relatively few patients infected with nonsusceptible pneumococci and inconsistent use of empiric vancomycin. METHODS: Medical records of 86 children with culture-confirmed pneumococcal meningitis at a single institution from October, 1991, to October, 1999, were retrospectively reviewed, and differences in presentation and outcome based on antibiotic susceptibility of pneumococcal isolates were assessed. RESULTS: Of 86 isolates 34 were nonsusceptible to penicillin (12 resistant). Of 60 isolates for which cefotaxime susceptibility data were available, 17 were nonsusceptible (12 resistant). Antibiotic susceptibility was not significantly associated with death, intensive care unit admission, mechanical ventilation, focal neurologic deficits, seizures, secondary fever, abnormal neuroimaging studies or hospital days. Children with penicillin-resistant isolates had significantly higher median blood leukocyte counts (24,100/microliter vs. 15,700/microliter, P = 0.03) and lower median CSF protein concentrations (85 mg/dl vs. 219 mg/dl, P = 0.04), were more likely to have a CSF glucose concentration of > or = 50 mg/dl (7 of 11 vs. 15 of 68, P = 0.009) and had lower rates of sensorineural hearing loss (1 of 8 vs. 25 of 40, P = 0.02) than children with isolates that were not resistant to penicillin. Children with cefotaxime-nonsusceptible isolates had an increased median duration of primary fever compared with those with nonsusceptible strains (6 days vs. 3.5 days, P = 0.02). CONCLUSIONS: In children with pneumococcal meningitis, penicillin resistance was associated with a reduced risk of hearing loss, while cefotaxime resistance was associated with a longer duration of fever. Other outcome measures were not significantly influenced by the antibiotic susceptibility of pneumococcal isolates.     

The emergence of resistant pneumococcal meningitis--implications for empiric therapy.

BACKGROUND: Following the emergence of penicillin and cephalosporin resistant pneumococcal meningitis in the United States, inclusion of vancomycin in empiric therapy for all suspected bacterial meningitis was recommended by the American Academy of Pediatrics. Few data are available to evaluate this policy. AIMS: To examine the management and clinical course in relation to antibiotic therapy of a large unselected cohort of children with pneumococcal meningitis in a geographic area where antibiotic resistance has recently increased. METHODS: Retrospective review of all cases of pneumococcal meningitis in a defined population (Sydney, Australia), 1994-99. RESULTS: A total of 104 cases without predisposing illnesses were identified; timing of lumbar puncture (LP) was known in 103. Resistance to penicillin increased from 0 to 20% over the study period. Only 57 (55%) had an early LP (prior to parenteral antibiotics); 55 (96%) had organisms on Gram stain. Severe disease (intensive care admission or death) increased significantly from 57 cases with early LP (28%) to 33 with delayed LP (42%) to 13 with no LP (62%). Evidence of pneumococcal infection was available within 24 hours in 85% of those with delayed or no LP. Outcome was not related to empiric vancomycin use, which increased from 5% prior to 1998 to 48% in 1999. CONCLUSION: LP is frequently delayed in pneumococcal meningitis. Based on disease severity, empiric vancomycin is most justified when LP is deferred. If an early LP is done, vancomycin can be withheld if Gram positive diplococci are not seen.     

The emergence of resistant pneumococcal meningitis--implications for empiric therapy

Background: Following the emergence of penicillin and cephalosporin resistant pneumococcal meningitis in the United States, inclusion of vancomycin in empiric therapy for all suspected bacterial meningitis was recommended by the American Academy of Pediatrics. Few data are available to evaluate this policy. Aims: To examine the management and clinical course in relation to antibiotic therapy of a large unselected cohort of children with pneumococcal meningitis in a geographic area where antibiotic resistance has recently increased. Methods: Retrospective review of all cases of pneumococcal meningitis in a defined population (Sydney, Australia), 1994–99. Results: A total of 104 cases without predisposing illnesses were identified; timing of lumbar puncture (LP) was known in 103. Resistance to penicillin increased from 0 to 20% over the study period. Only 57 (55%) had an early LP (prior to parenteral antibiotics); 55 (96%) had organisms on Gram stain. Severe disease (intensive care admission or death) increased significantly from 57 cases with early LP (28%) to 33 with delayed LP (42%) to 13 with no LP (62%). Evidence of pneumococcal infection was available within 24 hours in 85% of those with delayed or no LP. Outcome was not related to empiric vancomycin use, which increased from 5% prior to 1998 to 48% in 1999. Conclusion: LP is frequently delayed in pneumococcal meningitis. Based on disease severity, empiric vancomycin is most justified when LP is deferred. If an early LP is done, vancomycin can be withheld if Gram positive diplococci are not seen.     

Antibiotic Susceptibility of 629 Bacterial Blood and CSF Isolates from Swedish Infants and the Therapeutic Implications

Tullus, K., Olsson-Liljequist, B., Lundström, G. and Burman, L. G. (Department of Paediatrics, St. Göran's Children's Hospital and Department of Bacteriology, the National Bacteriological Laboratory, Stockholm, Sweden). Antibiotic susceptibility of 629 bacterial blood and CSF isolates from Swedish infants and the therapeutic implications. Acta Paediatr Scand 80: 205, 1991.
Blood and CSF isolates ( n =629) from Swedish infants up to one year of age were tested in vitro against 13 antimicrobial agents in order to update the guidelines for empiric therapy of septicaemia and meningitis. Ampicillin plus gentamicin provided inadequate empiric therapy for meningitis, due to the poor CSF penetration of the aminoglycoside and the frequent occurrence of bacterial resistance to ampicillin. Ceftazidime and cefuroxime were moderately active, particularly against isolates from small infants. Cefotaxime today seemed to provide the best empiric therapy of septicaemia and meningitis in infants. Because of the occurrence of Listeria and enterococcal infections, ampicillin should initially be added and other combinations are also advisable for the occasional cases of Enterobacter, Citrobacter, Serratia , and Pseudomonas infections. For coagulase-negative staphylococci only vancomycin offered a broad activity (100% at achievable serum levels).     

Dexamethasone adjunctive treatment for tuberculous meningitis

During a 5-year period, 280 of 2010 patients admitted to the meningitis ward of a referral hospital in Cairo, Egypt, were clinically diagnosed as having tuberculous meningitis and were treated with either antituberculous chemotherapy and dexamethasone or antituberculous chemotherapy alone. Fatality rates and neurologic sequelae were compared for the 2 treatment groups in the 160 patients who had cerebrospinal fluid cultures positive for Mycobacterium tuberculosis. The overall mortality rate of 51% reflects the delay in receiving appropriate therapy (79% with symptoms for more than 2 weeks) and the severity of illness on admission (56% in coma, 39% drowsy). The fatality rate was significantly lower in the group receiving dexamethasone (43% vs. 59%, P less than 0.05), particularly in the drowsy patients (15% vs. 40% P less than 0.04), and in patients surviving long enough to receive at least 10 days of treatment (14% vs. 33%, P less than 0.02). Development of neurologic complications after initiation of therapy (4 vs. 10) and permanent sequelae (6 vs. 13) were significantly lower in the dexamethasone-treated group (P less than 0.02).     

Long-term outcome of neonatal meningitis.

OBJECTIVE--To determine the long-term outcome of neonatal bacterial meningitis and the relationship between the outcome and specific features in the acute stage of the disease; and to compare the outcome between infants with neonatal meningitis and high-risk infants without meningitis. DESIGN--Prospective clinical evaluations of 21 survivors of meningitis and 21 matched controls who were retrospectively selected from a high-risk patient population. SETTING--Program of follow-up performed at the Children and Youth Project's High Risk Center of the Department of Pediatrics, University of Louisville, Louisville, Ky. Neonates were inborn at a university hospital with a high-risk obstetric unit and level III nursery. PATIENTS--Twenty-six consecutive neonates born between 1970 and 1980 with culture-proven bacterial meningitis, excluding neonates with congenital neurologic defects. Nineteen of 21 survivors and 21 controls matched by age, sex, race, birth weight, and gestational age were followed up from 1 to 14 years (mean, 7.8 years). Both survivors and controls fell below the federal poverty guidelines. RESULTS--Gram-positive meningitis was twice as common as gram-negative meningitis with co-occurrence of meningitis and sepsis in half of the cases. Neonates with gram-positive meningitis and higher birth weight had a higher survival rate, but this finding was not statistically significant. The mortality rate in neonates with gram-negative meningitis was almost three times higher than that of neonates with gram-positive meningitis, but no significant difference was observed between their morbidity rates. Eight (38%) of 21 survivors were normal, while another eight (38%) and five (24%) had mild and moderate to severe sequelae, respectively. Survivors of meningitis had lower IQ scores and more severe sequelae than matched controls. CONCLUSION--Neonatal bacterial meningitis results in poorer long-term outcome than in controls, but improved outcome compared with previous studies of neonatal meningitis.     

Bacterial meningitis in older neonates

During a five-year period, 24 patients' conditions (age range, 2 to 6 weeks) were diagnosed, and they were treated for bacterial meningitis. Organisms recovered from the CSF included group B Streptococcus (n = 6), Escherichia coli (n = 5), Listeria monocytogenes (n = 5), Hemophilus influenzae (n = 4), Streptococcus pneumoniae (n = 2), and group D and group A Streptococcus (one each). Initial antimicrobial therapy must include antibiotics that are effective across this spectrum of potential pathogens. Symptoms and signs were often subtle. Six children (25%) experienced major neurologic residua, including five patients (21%) in whom hydrocephalus developed. Ultrasound examination of the head at the end of therapy was an effective technique for early assessment of neurologic sequelae.     

Randomized trial of four vs. seven days of ceftriaxone treatment for bacterial meningitis in children with rapid initial recovery

BACKGROUND: Seven days or more of antimicrobial treatment is the standard for bacterial meningitis, although third generation cephalosporins are usually able to sterilize cerebrospinal fluid within 24 h. The limited experience from shorter regimens in children is encouraging, and we hypothesized that in rapidly recovering patients older than 3 months of age it would pose no risk for adverse outcome. METHODS: Strict clinical and laboratory criteria were used to define rapid initial recovery, in which case ceftriaxone therapy was either stopped after 4 days (4 injections) in children born on even dates (N = 53) or continued for 7 days in patients born on odd dates (N = 47). Outcomes were compared on Day 7 of hospitalization and at 1 to 3 months after discharge. RESULTS: On Day 7 no differences (P > 0.05 for each criteria) were observed between the 4-day and the 7-day groups regarding fever, clinical signs or serum C-reactive protein concentration. At the follow-up visit 1 to 3 months after discharge the 4-day group had fewer sequelae than the 7-day group (0% vs. 5% neurologic sequelae, P = 0.39 and 3% vs. 9% hearing loss, P = 0.49, respectively). One child in the 4-day group who had fully recovered was subsequently readmitted 53 days after the first hospitalization with recurrent Haemophilus influenzae meningitis. CONCLUSIONS: Four days of ceftriaxone therapy proved to be a safe alternative in patients with rapid initial recovery from bacterial meningitis. A 4-day course of treatment is particularly beneficial for countries with limited resources.     

Pediatric West Nile virus infection: neurologic disease presentations during the 2002 epidemic in Cuyahoga County, Ohio

Knowledge is currently limited about West Nile virus (WNV) infection and its sequelae among children. Available evidence suggests that when compared with adults, children less than 18 years old can be at high risk for WNV exposure and infection yet manifest a lower risk for WNV-related morbidity and mortality. We detail clinical features of pediatric West Nile-associated neurologic disease (WNND) epidemic cases in Cuyahoga County during 2002. We present a structured review of pediatric and adult WNND cases hospitalized in Cuyahoga County, Ohio. During the epidemic, 5 children were hospitalized with confirmed WNND (estimated incidence = 1.4/100,000 children 5-17 years old at risk). Compared with adults, children had shorter hospitalization (mean, 4.6 versus 12.3 days), fewer neurologic symptoms, better neurologic outcomes, and lower mortality (0% versus 5.3%). Cerebrospinal fluid results were similar. When compared with adults, children had significantly lower rates of WNND. Children are at a decreased risk for severe WNV and less likely to present with neurologic signs or suffer neurologic sequelae.     

Bacterial meningitis in infants two to six weeks old

We reviewed our experience with bacterial meningitis in older neonates (2 to 6 weeks of age) during a five-year period. Seventeen patients with bacterial meningitis were diagnosed and treated. Bacteria recovered from the cerebral spinal fluid (CSF) included pneumococci (29%), E. coli and meningococci (23% each), group B streptococci (12%), Enterobacter and H. influenzae (6% each). There were no cases of Listeria monocytogenes. The mean duration of symptoms before admission was 3.1 days. The mortality rate was high (30%), and 36% of the patients had significant neurologic residua. Our study shows that this specific age group is different from newborns or older infants. Therefore, the initial selection of antibiotics for the treatment of meningitis in this age group should include antibiotics that are effective across this spectrum of potential pathogens.     

Serum cortisol levels in children with acute bacterial and aseptic meningitis.

OBJECTIVE: To study serum cortisol levels in acute childhood meningitis with respect to the severity of illness and the outcome. DESIGN: Prospective observational study. SETTING: Pediatric services of a tertiary care teaching and referral hospital. SUBJECTS: A total of 30 consecutive children, 2 months to 12 yrs of age, with suspected bacterial meningitis. METHODS: Serum cortisol levels (by enzyme-linked immunosorbent assay) obtained at admission were correlated with clinical characteristics (including Glasgow Coma Scale and Pediatric Risk of Mortality scores) recorded at admission and with neurologic and hearing status 2 months after discharge using SPSS 10.0. RESULTS: Mean +/- sd serum cortisol was 467 +/- 251 ng/dL in patients with bacterial (n = 16) and 319 +/- 159 ng/dL in aseptic meningitis (n = 14, p = .068). Glasgow coma scale score, systolic blood pressure, age, Pediatric Risk of Mortality, and cerebrospinal fluid protein were significant independent predictors of serum cortisol on stepwise multivariate regression analysis (each had an R change of >5%). Patients with neurologic or hearing sequelae had significantly higher median serum cortisol (450 ng/mL, n = 12) than those without sequelae (300 ng/mL, n = 17; p = .043 by Mann-Whitney U test). On multivariate logistic regression analysis, a serum cortisol of >/=420 ng/mL (odds ratio, 0.022; 95% confidence interval, 0.01-0.43) and systolic blood pressure (odds ratio, 1.35; 95% confidence interval, 1.04-1.74) were significant independent predictors of neurologic and hearing sequelae. CONCLUSION: Low serum cortisol is uncommon in acute bacterial meningitis of nonmeningococcal pathogenesis. Very high levels are likely to be associated with sequelae.     

Prediction of neurologic sequelae in childhood tuberculous meningitis: a review of 20 cases and proposal of a novel scoring system

BACKGROUND: Despite effective antituberculous medications, the mortality and morbidity remain high in children with tuberculous meningitis (TBM). The traditional clinical staging for TBM developed by Lincoln et al in 1960 has been widely used to predict long term neurologic sequelae (NS). In the current era of critical care medicine and corticosteroid therapy, a new scoring system is needed to predict NS more accurately in children with TBM. METHODS: We reviewed all available cases of TBM in San Diego, CA, during 1991-2001 retrospectively, and we developed a novel scoring system to predict NS in children with TBM. We assessed a tuberculous meningitis acute neurologic (TBAN) score at day 0 and on day 3 of hospitalization, to compare children who subsequently developed severe NS with those who did not. RESULTS: Among 20 children with TBM, 7 children developed severe NS and 1 child died during hospitalization. The TBAN score was higher on day 0 in those with severe NS (5.5 versus 2.0, P = 0.09), and the difference became statistically significant by day 3 of hospitalization (5.5 versus 0.0, P = 0.02). Sensitivity and specificity of the TBAN score (> or =4) on day 0 (75 and 92%) and day 3 (88 and 100%) to predict severe NS were superior to the traditional clinical staging system on day 0 (63 and 58%). CONCLUSIONS: The TBAN score is an objective marker for predicting severe NS in children with TBM.     

Tuberculous meningitis in children

Summary Of the 280 cases of tuberculous meningitis, 75.8 per cent were under 5 years of age. The males were twice as often affected as females. Testing for neck stiffness in a young febrile child is important for early diagnosis of tuberculous meningitis. Tuberculin test was negative in 18 per cent of cases. Tuberculous meningitis as a part of a miliary process occurs in a very small number of cases (2.5% in this series). The overall mortality was 24.3 per cent and sequelae were observed in 39.6 per cent of the suivivors. The prognosis with regard to mortality and neurologic sequelae, was the worst for group III patients. From the Department of Paediatrics, L.L.R.M. Medical College, Meerut.     

Acute purulent meningitis associated with chronic subdural hematoma and subdural hygroma

A male infant aged nine months with meningeal irritation and +3.5SD expansion of the circumference of the head was admitted. Brain computed tomography (CT) detected right chronic subdural hematoma and contralateral subdural hygroma. Since the cell count was increased on a cerebrospinal fluid test, acute purulent meningitis was diagnosed. A rapid latex test and culture of cerebrospinal fluid identified Streptococcus pneumoniae (PSSP) as the pathogen. Panipenem/betamiprom (PAPM/BP) was administered at 100 mg/kg/3 times for 14 days and dexamethasone was administered at 0.6 mg/kg/4 times for 4 days, and the patient recovered without sequelae. Acute purulent meningitis complicated by chronic subdural hematoma and subdural hygroma is rare. In this case, acute subdural hygroma may have concomitantly developed with acute purulent meningitis in the presence of the chronic subdural hematoma, and rapid disequilibrium of intracranial pressure may have been the developmental mechanism.     

Acute bacterial meningitis in children admitted to a rural Kenyan hospital: increasing antibiotic resistance and outcome

BACKGROUND: Acute bacterial meningitis (ABM) is an important cause of mortality in Africa, but most studies are based in urban referral hospitals. Poor laboratory facilities make diagnosis difficult, and treatment is limited to inexpensive antibiotics. METHODS: We retrospectively reviewed data from children admitted with ABM to a Kenyan district hospital from 1994 through 2000. We calculated the minimum incidence in children admitted from a defined area. We also examined the antibiotic susceptibility patterns. RESULTS: We identified 390 cases (1.3% of all admissions) of whom 88% were <5 years old. The apparent minimum annual incidence in children younger than 5 years of age increased from 120 to 202 per 100,000 between 1995 and 2000 (P < 0.001). Increasing the lumbar punctures performed by including prostrated or convulsing children significantly increased the number of cases detected (P < 0.005). The most common organisms in infants <3 months were streptococci and Enterobacteriaceae. Streptococcus pneumoniae (43.1%) and Haemophilus influenzae (41.9%) were predominant in the postneonatal period. The overall mortality was 30.1%, and 23.5% of survivors developed neurologic sequelae. Chloramphenicol resistance of H. influenzae rose from 8% in 1994 to 80% in 2000 (P < 0.0001) accompanied by an apparent increase in mortality. A short history, impaired consciousness and hypoglycemia were associated with death. Prolonged coma and low cerebrospinal fluid glucose were associated with neurologic sequelae. CONCLUSION: ABM in rural Kenya is a severe illness with substantial mortality and morbidity. Prognosis could be improved by broadening the criteria for lumbar puncture and use of appropriate antibiotics.     

BACTERIAL MENINGITIS IN CHILDHOOD IN AN AFRICAN CITY

ABSTRACT. In a retrospective study of 120 children aged 1 month and above with bacterial meningitis confirmed by positive CSF culture, 88.4 % were found to be due to three common organisms: H. influenzae, Str. pneumoniae and N. meinigitidis. Gram-negative enteric organisms accounted for 10% of the infections. Despite intensive antibiotic and ancillary therapy, there has been no significant change in case fatality and sequelae over the past decade in this institution. The present study confirms that factors related to the organism and the host are important in determining the outcome of therapy. H. influenzae and Str. pneumoniae infections are associated with statistically significant rise in case fatality rate and neurologic sequelae at the end of therapy. The presence of neurological abnormality at the time of diagnosis significantly increases case fatality rate while delay in diagnosis appears to primarily influence the frequency of neurological sequelae. Protein-energy malnutrition increases the frequency of neurological sequelae and death from bacterial meningitis without significantly influencing the pattern of bacterial aetiology. The finding of enteric Gram-negative meningitis in association with diarrhoeal disease in the present study adds a new dimension to one of the most prevalent health problems in developing countires and needs to be confirmed.     

Salmonella meningitis: clinical experience of third-generation cephalosporins

Fifteen paediatric patients with Salmonella meningitis were retrospectively reviewed. Presenting symptoms and signs included fever, vomiting, seizures, poor activity, diarrhoea and bulging anterior fontanelle in most patients. Seven out of eight patients with prolonged fever for > 10 days had neurologic sequelae; therefore, prolonged fever is a significant prognostic factor of a poor outcome ( p < 0. 005). All 15 patients had a brain ultrasound or computed tomography in the acute stage and 11 patients had abnormal findings. The 14 surviving patients were treated with a third-generation cephalosporin for at least 3 weeks. Seven patients (47%) made complete recoveries; two of them were treated solely with a third-generation cephalosporin. Only one mortality (6%) occurred and there were no relapses. In conclusion, high frequencies of prolonged fever, neuroimaging abnormalities and neurologic sequelae were seen in patients with Salmonella meningitis treated with third-generation cephalosporins.     

Empiric antibiotic therapy in children with community-acquired pneumonia

OBJECTIVE: To assess the possible change of clinical response to empiric antibiotic therapy among children survivors hospitalized with community-acquired pneumonia at a teaching hospital during 1991-2001. METHODS: This was a retrospective observational study. The medical records of children (aged 29 days to 12 years) with diagnosis of presumed bacterial pneumonia at hospital discharge were reviewed and patients data were extracted, using standardized forms. The principal outcome was patients response to empiric antibiotic therapy. The secondary outcome was length of hospital stay. RESUltS: 893 patients were included for this study. Penicillin and derivatives were the most commonly used empiric antibiotics throughout the studied period. There was a slight but statistically significant increase in the mean rate of antibiotic failure from 1991-1998 to 1999-2001 (3.8% vs 11.4% P<0,001). The most common causes for antibiotic failure were inadequate coverage of initial antibiotics between 1991-1998 and presumed antibiotic resistance between 1999-2001. No significant difference was observed regarding the means of length of hospital stay during the whole studied period (P=0.08). CONCLUSION: Empiric antibiotic therapy was effective among children with community-acquired pneumonia treated at a teaching hospital between 1991-2001, inspite of a slight increase in the rate of presumed antibiotic resistance in later years.     

Epidemiology of Haemophilus influenzae type b meningitis in 2 French departments

Meningitis represents a frequent and severe expression of Haemophilus influenzae type b disease. The results of a 7 year-epidemiologic study (Jan 1980 to Dec 1986) undertaken in 2 French departments are reported herein. One hundred and twenty-three cases of meningitis were detected, representing a yearly rate of 15 cases for 100,000 children aged 0 to 4 years. The real incidence is probably higher and has been estimated as 17/100,000 which corresponds to 572 annual cases for the entire country. The death rate was 3.3% and severe sequelae were documented in 1.6%. To these should be added less severe neurologic (9%) and hearing (2.4%) deficits. These results show that the incidence of meningitis is comparable to the rate observed in Northern Europe but lower than the one reported in the United States. However, the rates of mortality and of neurologic deficit published in recent studies are comparable to those in the present report. Hearing sequelae are probably underestimated and would need systematic screening during the immediate follow-up period.