Bacterial meningitis among children under the age of 2 years in a high human immunodeficiency virus prevalence area after Haemophilus influenzae type b vaccine introduction

Aim: The aim of this study was to describe bacterial causes of meningitis among children < 2 years in a high human immunodeficiency virus (HIV) prevalence area after introduction of routine Haemophilus influenzae type b vaccination. Methods: Data collected between April 2003 and December 2008 were extracted from a surveillance database and medical records of children < 2 years admitted in Mbarara Hospital, Uganda with suspected bacterial meningitis. HIV infection was confirmed using rapid tests and polymerase chain reaction and bacterial meningitis by using cerebrospinal fluid culture. Results: Between April 2003 and December 2008, 1464 children under 5 years were admitted with suspected bacterial meningitis of which 1235 (84.4%) had cerebrospinal fluid collected; 894 (72.4%) of these samples were from children < 2 years. Of the 894 samples, 64 (7.2%) grew an organism including Streptococcus pneumoniae (26; 41%), Salmonella species (20; 31%), H. influenzae (6; 9%) and coliforms (7; 11%), and five (8%) grew contaminants that are all coagulase negative Staphylococcus. Of the 894 children, 468 (52.3%) were tested for HIV; 16.7% were positive. Fifty‐one children had a pathogenic isolate and a treatment outcome, and 23 (45%) died; 13 (56.6%) deaths were due to S. pneumoniae, eight (34.8%) were due to Salmonella spp., one (4.3%) was due to H. influenzae and one (4.3%) was due to coliforms. HIV infection was associated with a threefold increase in mortality, increased likelihood of a bacterial isolate and decreased likelihood of malaria parasitaemia. Conclusion: Following H. influenzae type b vaccine introduction, S. pneumoniae and Salmonella spp. are the major causes of bacterial meningitis among children < 2 years in Uganda. Pneumococcal conjugate vaccines and reduction in mother to child transmission of HIV could reduce the observed mortality.     

Childhood bacterial meningitis in Pondicherry, South India

Objective: To identify causative bacteria from cerebrospinal fluid (CSF) of children with miningits and analyse various clinical and laboratory parameters.Methods: Over a 20 month period, September 1994 to April 1996, one hundred episodes of acute bacterial meningitis in children aged 1 month–12 years were studied in a tertiary urban hospital in South India. Organisms were isolated from the cerebrospinal fluid (CSF) in 35% of cases. Among infants and children, the two major pathogens wereH. influenzae (17%) andS.pneumoniae (12%).Results: The illness at presentation was mild in 13% and severe in 36% of cases. The association of subdural effusion in children with Salmonella Gp B meningitis merits attention. The overall case fatality rate was 25%.S.pneumoniae had a higher case fatality rate than Salmonella Gp B andH.influenzae (50% vs 17% vs 12%). All the three infants below 3 months of age withS.pneumoniae meningitis died. On analysis of selected clinical and laboratory features by discriminant analysis, CSF culture was the significant (P=0.02) variable in relation to outcome. In pneumococcal meningitis, CSF WBC count was a highly significant variable in relation to outcome (Wilk’s Lambda 0.15, F=24.64, P=0.0002).Conclusion: Prevention of infections due toH.influenzae andS.pneumoniae should be given higher priority.     

Associations between Potential Bacterial Pathogens in the Nasopharynx of HIV Infected Children

Objective

To investigate bacterial associations of S. pneumoniae, S. aureus, and H. influenzae in the nasopharynx of ambulatory children with HIV infection.

Methods

A cross-sectional nasopharyngeal swab survey of 148 children with HIV infection from West Bengal presenting for routine outpatient care was conducted.

Results

Forty-one (28 %) children carried S. pneumoniae, 35 (24 %) carried S. aureus and 39 (26 %) carried H. influenzae. Seventeen (11 %) had dual colonization with S. pneumoniae and H. influenzae, 13(8.8 %) had dual colonization with S. pneumoniae and S. aureus, and 6(4 %) had dual colonization with S. aureus and H. influenzae. Three (2 %) had triple carriage with H. influenzae, S. aureus, and S. pneumoniae. Neither Cotrimoxazole prophylaxis nor ART (antiretroviral therapy) affected colonization with any organism. There was no association between HIV immune status, recent antibiotic use, exposure to other children, household tuberculosis exposure and colonization with any organism. There was a strong negative association between malnutrition and colonization with H. influenzae.

Conclusions

The negative association between S. pneumoniae and S. aureus colonization in the nasopharynx described in healthy populations was not present. The authors found a strong positive association between carriage with H. influenzae and S. pneumoniae. These findings provide insight into the increased risk of invasive disease from these organisms in HIV infected children.     

Recent Chemotherapy for Child Pneunomia and Empyema

Recent progress in chemotherapy has contributed to the remarkable decrease in mortality from pneumonia in infancy and childhood; however, wide use of antimicrobials has resulted in incapability of etiologic diagnosis. Appropriate chemotherapy for pneumonia should be initiated based on the relative frequency of causative organisms related to age groups, and their antimicrobial susceptibility. Therapeutic development should be reevaluated by the pathogens isolated prior to antimicrobial administration. S. aureus is the most important causative agent in fatal cases of pneumonia. Judging from our studies on offending bacteria in bronchopulmonary infections, H. influenzae, S. pneumoniae and S. aureus are the major pathogens in pneumonia. Therefore, the main initial antimicrobials in uncompromised infants and children should be ampicillin (plus penicillinase-resistant penicillin) covering these organisms. Methicillin-resistant S. aureus, ampicillin-resistant H influenzae and penicillin-resistant S. penumoniae are of great concern. Chemotherapy for these strains is discussed. Treatment with macrolides is mainly recommended for M. pneumoniae. Chemotherapeutic results of treatment of C. trachomatis will be elucidated in a few years.     

Infection by Streptococcus pneumoniae in children with or without radiologically confirmed pneumonia

Objective

Community-acquired pneumonia is an important cause of morbidity in childhood, but the detection of its causative agent remains a diagnostic challenge. The authors aimed to evaluate the role of the chest radiograph to identify cases of community-aquired pneumonia caused by typical bacteria.

Prevalence of Chlamydia pneumoniae in acute lower respiratory infection in the pediatric population in Japan

Chlamydia pneumoniae has been established as an important etiologic agent of acute respiratory tract infection in humans, especially in adults. However, there is little information available on C. pneumoniae infection in the pediatric age group. The microimmunofluorescence test and Chlamydia pneumoniae-specific polymerase chain reaction (PCR) method were applied to reveal the role of C. pneumoniae as an etiologic agent of acute lower respiratory tract infection in children in Japan. Among 136 patients aged between 2 months and 15 years with acute lower respiratory tract infection, five patients with pneumonia were found to have recent C. pneumoniae infection by the microimmunofluorescence test. C. pneumoniae-specific PCR products were detected from specimens of four patients among these five. Neither C. trachomatis nor C. psittaci infection was found in this population. These results suggest that C. pneumoniae is an important causative agent of acute childhood pneumonia and may be the most prevalent pathogen among the genus Chlamydia that causes acute lower respiratory disease in this age group in Japan.     

A retrospective epidemiological study of bacterial meningitis in an urban area in Belgium

In order to obtain epidemiological data on the incidence of bacterial meningitis (BM) before the systematic introduction of vaccination against Haemophilus influenzae type b, a retrospective study of 124 children with proven BM was performed in an urban area in Belgium. N. meningitidis was the most prevalent cause, followed by H. influenzae and S. pneumoniae. Over a period of 6 years the incidence of BM increased ten fold, mainly due to an increase in N. meningitidis. The median age of the children with BM was 17 months and 35% of those with H. influenzae were younger than 1 year. Significant risk factors for BM as a whole were: age under 1 year, male gender, non-Caucasian descent and winter time. These findings may have implications for future vaccination policy in Belgium. Conclusion Future vaccination schemes in Belgium should take into account that N. meningitis was the prevalent cause of bacterial meningitis and that certain factors increase the risk for developing bacterial meningitis. Received: 26 February 1996 / Accepted: 14 October 1996     

The changing trend in the pattern of infective etiologies in childhood acute lower respiratory tract infection

The etiologic agents causing acute lower respiratory tract infection (LRTI) in hospitalized children were compared for 1995 and 1988. Between May 1994 to April 1995, 397 children were admitted to Tan Tock Seng Hospital for acute LRTI compared to 240 children in 1988. The following criteria for LRTI were used: (i) age less than 12 years with a community-acquired LRTI; (ii) presence of cough or fever of less than 2 weeks' duration; and (iii) presence of tachypnea, chest retractions or pulmonary infiltrates on chest X-ray. Sputum cultures were considered suitable for culture if there were less than 25 epithelial cells per low power field. Moraxella catarrhalis was considered only if heavy growth of more than 3+ was seen. Etiological agents were found in about 70% of patients in both studies. Viruses constituted 41.3% of the etiologic agents in 1995 but constituted only 28% in 1988; 36% had a bacterial etiology in 1995 compared to 15% in 1988. The most common bacteria in 1995 was M. catarrhalis (34.7%) followed by non-type B Haemophilus influenzae (33%). In contrast, in 1988, Mycoplasma (33%) was the predominant organism followed by H. influenzae (17%) and M. catarrhalis (11.4%). The increased incidence of M. catarrhalis could be due to antibiotic selection. A mixed viral-bacterial etiology was found in 12.3% of the 1995 cohort. The majority of the bacteria were positive by sputum cultures; only 4 (3.3%) had positive blood cultures. No penicillin resistance was detected in 1988; however, in 1995, penicillin resistance was found in 17% of the Streptococcus pneumoniae, 38.5% of H. influenzae and 83% of M. catarrhalis. It was also found that 30% of the S. pneumoniae were also resistant to erythromycin, and 23% were resistant to sulfamethoxaxole-trimethoprim; 5% of the H. influenzae had multiple resistance to erythromycin, sulfamethoxazole-trimethoprim and chloramphenicol. Among those patients with antibiotic resistance, 30% had received prior antibiotics of which 18% had had two or more antibiotics, frequently erythromycin or amoxycillin/ampicillin. Judicious use of antibiotics is required to check the rising trend of antibiotic resistance.     

Non‐typeable Haemophilus influenzae purulent pericarditis in a child with cystic fibrosis

Early airway colonization and infection with Haemophilus influenzae in children with cystic fibrosis (CF) is common. Although the pathogenicity of non‐typeable H. influenzae (NTHi) in patients with CF is controversial, this organism can cause both upper and lower respiratory tract infections. Extra‐pulmonary disease, however, is rare. Purulent pericarditis is a suppurative complication of bacterial infection of the pericardial space that can arise as a result of direct extension from an adjacent infection. We describe a case of purulent pericarditis due to NTHi in a young child with CF that developed as a complication of inadequately treated bronchopneumonia.     

Antibiotic resistance patterns among respiratory pathogens at a german university children’s hospital over a period of 10 years

Growing antimicrobial resistance among Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis is raising major concern worldwide. Strains of S. pneumoniae, H. influenzae and M. catarrhalis isolated from children with respiratory tract as well as invasive infection in a South-Western region of Germany between 1993 and 2002 were tested for susceptibility to common antibiotics including penicillins, cephalosporins and macrolides. A total of 2,362 S. pneumoniae, 2,501 H. influenzae, and 1,982 M. catarrhalis isolates were tested. Only two S. pneumoniae strains were found to be highly resistant to penicillin. The overall rate of intermediate resistance to penicillin was 3.5%. There was a significant increase in erythromycin resistance from 5% in 1993 to 12.2% in 2002 ( P =0.001). No increase in ampicillin resistance was observed for H. influenzae over time. The rate of cefaclor resistance, however, increased from 4.5% to 11.8% ( P <0.0001). Furthermore, a massive increase in erythromycin resistance from 26% to 40% was observed ( P <0.0001). The vast majority of M. catarrhalis isolates were -lactamase positive, the minimal inhibitory concentration to ampicillin, however, exceeded only in 3% of all strains the cut-off of 1.5 mg/l. The erythromycin resistance rate of M. catarrhalis was 0.3%. Conclusion:There is still a low rate of penicillin/ampicillin resistance in S. pneumoniae, and H. influenzae, but an alarming increase in resistance to erythromycin, and in H. influenzae a significant increase in cefaclor resistance was observed over the 10-year period in South-Western Germany.     

Prolonged and secondary fever in childhood bacterial meningitis

In order to study the causes of prolonged and secondary fever in bacterial meningitis, a group of 102 infants and children with proven bacterial meningitis were studied. The causative agent wasHaemophilus influenzae in 58% of patients,Streptococcus pneumoniae in 25% andNeisseria meningitidis in 17%. Prolonged fever was observed in 12% of the patients. The established causes include, in order of frequency, subdural effusion, drug fever, otitis media, gastroenteritis and urinary tract infection. Secondary fever was noted in 18% of the patients. The causes, in order of frequency, were urinary tract infection, subdural effusion, otitis media, phlebitis, pneumonia and drug fever. Neither relapse of the meningitis nor inadequate response to antibiotic therapy was the cause for prolonged or secondary fever. Neurological sequalae were observed in 21 patients. There was no correlation between prolonged or secondary fever and neurological sequalae. We conclude that prolonged and secondary fever in patients with treated bacterial meningitis is rarely caused by the primary infection.     

Nasopharyngeal carriage of Haemophilus influenzae

Objective: Nasopharyngeal colonization ofHaemophilus influenzae (H. influenzae) in young children may be important in developing countries.Method: In this study, we screened school going children for carriage ofH. influenzae. A total of 44H. influenzae isolates out of a collection of 162 were characterized for biotypes, capsular serotypes and antibiotic resistance.Results:A significant proportion ofH. influenzae (25/44) isolates were serotype b. High antibiotic resistance was observed against commonly administered antibiotics like ampicillin (79%), chloramphenicol (20%), trimethoprim sulfamethoxazole (84%) and erythromycin (95%). Comparison of antibiotic resistance profile of nasopharyngeal isolates was observed to be correlated with those ofH. influenzae from disease.Conclusion: Multidrug resistant nasopharyngealH. influenzae in young healthy children may act as reservoir. Monitoring of antibiotic resistance among nasopharyngealH. influenzae as a surrogate for invasiveH. influenzae seems an attractive option.     

Dexamethasone and antibiotics for the empirical treatment of bacterial meningitis in Canadian children: A survey of paediatric infectious diseases specialists

PURPOSE:

With the changing epidemiology of the etiological agents causing bacterial meningitis in Canada, the purposes of this study were to determine what empirical antibiotic(s) is/are advocated, and whether dexamethasone is recommended as adjunctive therapy by paediatric infectious diseases specialists for suspected meningitis caused by Streptococcus pneumoniae, Neisseria meningitides, Haemophilus influenzae type b, and partially treated (PT) bacterial meningitis.

METHODS:

A questionnaire invoking the specialists’ preferred choices in treating bacterial meningitis was circulated by e-mail in March 1999 to 41 paediatric infectious diseases specialists or microbiologists (Paediatric Investigators Collaborative Network on Infections in Canada [PICNIC] members) who practised in 13 paediatric centres located in eight provinces.

RESULTS:

Thirty-two (78% response rate) replies were received by July 1999 from 11 paediatric centres in seven provinces. Dexamethasone was recommended by 11 of 32 (34%) respondents for suspected S pneumoniae, four of 32 (12%) for suspected N meningitides, 18 of 32 (56%) for suspected H influenzae type b and five of 32 (16%) for suspected PT meningitis. A trend for more frequent recommended use of dexamethasone for S pneumoniae, H influenzae type b and N meningitides meningitis was found in eastern provinces (Ontario, Quebec and Nova Scotia), as opposed to the western provinces (Manitoba, Saskatchewan, Alberta and British Columbia). The most commonly recommended first line empirical antibiotic therapy was vancomycin plus 3rd-generation cephalosporin (V+3C). This was recommended by 27 of 32 (84%) respondents for suspected S pneumoniae, seven of 32 (22%) for suspected N meningitides, six of 32 (19%) for suspected H influenzae type b and 24 of 32 (75%) for PT meningitis; the remainder recommended using a 3C empirically for each type of meningitis. The major reason cited by respondents for using V+3C for suspected S pneumoniae was the presence of high-and intermediate-level penicillin-resistant S pneumoniae in their centres. No differences were found in the choice of antibiotic(s) between practitioners in the eastern and western provinces.

CONCLUSIONS:

Although regional differences exist, the majority of paediatric infectious diseases experts no longer favour the use of dexamethasone for empirical therapy in most cases of bacterial meningitis. V+3C has become the regimen of choice in Canada for most cases of suspected bacterial meningitis.     

Prise en charge des pneumonies chez l'enfant

Lower respiratory tract infections are a common cause of morbidity among children. The child's age is an important help for the etiological diagnosis. Viruses are the most common cause of pneumonia in preschool children and Streptococcus pneumoniae is the most common bacterial pathogen at all ages. Mycoplasma pneumoniae is frequently isolated in children older than 2 years but can also infect preschool children. Pneumonia diagnosis is based on the patient's history and physical examination combined to appropriate use of chest radiograph and laboratory tests as needed. Hospitalization and intravenous antibiotics are recommended in infants, patients with pre-existing lung disease, or when oral treatment is not efficient. In preschool children, antibiotic is not systematic and is recommended in case of severe pneumonia or suspicion of bacterial co-infection. At all ages, amoxicillin is the drug of choice when Streptococcus pneumoniae is suspected. Children older than 2 years old with atypical pneumonia must been given empiric treatment with macrolid. In preschool children, immunization with anti-haemophilus B vaccine has helped decrease the incidence of invasive Haemophilus influenzae type B infection, and the newly introduced heptavalent pneumococcal vaccine translates into a similar benefit for Streptococcus pneumoniae infection.     

Bacterial meningitis in Saudi children

During the four years period from 1988 to 1991, 50 pediatric patients were diagnosed to have bacterial meningitis, out of a total number of 9057 pediatric admissions at Qatif Central Hospital, Qatif, Saudi Arabia, and 82% were less than two years of age. The causative organisms were isolated in 27 (54%) patients. The bacteria grown includedhaemophilus influenzae type B in 8 patients (29.6%),Neisseria meningitidis in 8 patients (29.6%),Streptococcus pneumonia in 6 (22%) patients, and other bacteria in 5 patients (18.5%). Cerebro spinal fluid cultures from twenty three patients (46%) showed no organisms, however their clinical and C.S.F. findings were compatible with bacterial meningitis. One case ofH. influenzae type B was resistant to ampicillin. Six patients died with an over all mortality of 12%, and 10 patients (20%) developed some kind of C.N.S. sequelae. Partially treated meningitis formed a large percentage of our sample.     

The microbiologic and immunologic basis for recurrent otitis media in children

 Otitis media is very common in children. A subpopulation of children, representing 5–10% of the general population, are otitis prone and they experience 4 or more episodes of acute otitis media (AOM) in the first year of life. Nasopharyngeal colonization with the three major middle ear pathogens, S. pneumoniae, nontypeable H. influenzae and M. catarrhalis is frequent in otitis prone children and is directly related to the frequency of AOM. Colonization stimulates the production of mucosal as well as serum antibodies to the pathogens. Specific IgA mucosal antibody limits the duration and frequency of colonization. Serum IgG antibody protects children against the development of otitis media but does not affect colonization. Antibody detected in the middle ear often reflects passive transfer from serum rather than local production. Antibody responses to the three pathogens following AOM are generally reduced in the first 2 years of life and rise rapidly thereafter. There are many different strains of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Among the different strains, there are heterologous surface antigens and some conserved antigens. Conserved antigens induce broadly protective antibodies while strain specific antigens induce limited protection. Although otitis prone children may display strain specific immunity, they often fail to develop a broadly protective antibody response. This subtle immunologic defect makes them susceptible to recurrent and persistent otitis media. Conclusions Otitis media is common. Otitis prone children appear to display a subtle immunologic abnormality that predisposes them to recurrent infections. Recent advances in vaccine development may reduce the frequency of otitis media in the general population but the impact on otitis prone children remains unknown. Received: 18 September 2000 and in revised form: 25 January 2001 / Accepted: 30 January 2001     

Prevention and therapy of bacterial infections for children with asplenia or hyposplenia

The asplenic state, whether functional or anatomic, is associated with an increased risk of life threatening infection or postsplenectomy sepsis (PSS). Because the risk of bacteremia with encapsulated bacteria is enhanced in children with asplenia, vaccination to prevent infection by Streptococcus pneumoniae, Haemophilus influenzae type b (Hib) and Neiserria meningitidis is recommended. Despite the increasing prevalence of penicillin-resistant S pneumoniae, prophylactic penicillin use is also recommended for children with asplenia who are younger than five years of age, and for at least one year following splenectomy. Continuation of antibiotic prophylaxis beyond these times depends on individual clinical circumstances and the prevalence of penicillin-resistant S pneumoniae in the community. When children with asplenia develop fever or nonspecific symptoms, they should be assessed immediately. If bacterial sepsis is suspected, blood and other appropriate body fluids should be cultured, and treatment should begin immediately with parenteral broad spectrum antibiotics that are also effective against the strains of S pneumoniae circulating in the community. In children with asplenia with overwhelming S pneumoniae bacteremia, the mortality rate is high, even with prompt initiation of appropriate antibiotic therapy. Thus, preventive measures are important.     

Bacterial antigen detection test in meningitis

Objective : To evaluate the role of bacterial antigen detection test in cerebrospinal fluid (CSF) for a rapid etiological diagnosis of bacterial meningitis.Methods : The study included 36 cases of bacterial meningitis and 14 controls. Latex particle agglutination test (LPA test) for detection of bacterial antigen was done in the CSF using slidex meningitis kit (Biomeriux, France).Results : Using LPA test, an etiological diagnosis could be made in 83% cases of bacterial meningitis. In contrast, CSF Gram stain and culture showed 36% and 6% positivity, respectively. The sensitivity and specificity of LPA test were 83% and 100%, respectively. The common etiological organisms were S.pneumoniae, H. influenzae type b andN. meningitidis A. S. pneumoniae was encountered in all age groups whileH. influenzae type b was found only below one year of age.Conclusions : LPA test is a rapid and superior diagnostic tool as compared to CSF Gram stain and culture. The study recommends LPA test as an adjunct laboratory test for rapid etioiogical diagnosis of bacterial meningitis for prompt institution of proper antibiotics.