Childhood bacterial meningitis in Mbarara Hospital,Uganda: antimicrobial susceptibility and outcome of treatment

Background

The recommended antibiotic treatment of bacterial meningitis has come under scrutiny following frequent reports of in-vitro resistance by the common causative organisms to penicillin and chloramphenicol.

Objective

The study recorded the causative organisms, antibiotic sensitivity patterns and outcome of treatment of bacterial meningitis in children and examined the impact of various factors on the recorded outcome.

Design

This was a retrospective review of all case records of patients treated for bacterial meningitis over a one-year period.

Setting

The study was set in the paediatric wards of Mbarara University Teaching Hospital, in south western Uganda.

Results

A total of 77 patients were treated. Among 56 patients with available CSF results the frequency of bacterial causes was as follows: H. influenzae 13(23.2%), coliforms 7(12.5%), uncultured Gram-negative bacilli 7(12.5%), S. pneumoniae 5(8.9%) and N. meningitidis 3(5.4%). Most isolates tested were resistant to both penicillin and chloramphenicol, but all were sensitive to ciprofloxacin and perfloxacin. Twenty eight(36.8%) patients died, 22(28.9%) survived with sequelae and 15(19.7%) improved without sequelae. 14/18 who received perfloxacin and/or ciprofloxacin survived compared with 23/47 who did not: p=0.04).

Conclusions

The high case-fatality rates and the high frequency of resistance to penicillin and chloramphenicol make a case for a review of the currently recommended antibiotic treatment of bacterial meningitis in this region. Fluoroquinolones need further evaluation as potential alternatives to chloramphenicol in the treatment of bacterial meningitis.     

Community-acquired pneumonia of mixed etiology: prevalence, clinical characteristics, and outcome

Community-acquired pneumonia (CAP) of mixed etiology has increasingly been appreciated in the literature, but its clinical significance remains unknown. The aim of this analysis was to describe the prevalence, clinical characteristics, and outcome of CAP of mixed etiology. Data were obtained from a 2-year prospective study of consecutive patients with CAP in whom an extensive microbiological workup was performed. Predefined strict criteria were used to establish the etiology. A total of 493 patients were included. A single pathogen was detected in 222 (45%) cases and two or more pathogens in 28 (5.7%) cases. Mixed infections were seen across all age groups and in patients treated both in hospital and as outpatients. The most frequent combinations of pathogens were those of a bacterium plus an atypical organism (28.6%) and of two bacterial organisms (28.6%). Compared with patients with monomicrobial pneumonia, patients with mixed pneumonia were more likely to have underlying conditions (64% vs. 45%, p=0.04) and dementia (25% vs. 10%, p=0.02). The incidence of a defined series of complications was higher in patients with mixed pneumonia (39.3% vs. 18.6%; OR=2.84; p=0.02). Community-acquired pneumonia of mixed etiology is uncommon. Patients with mixed pneumonia are more likely to have underlying medical conditions, and they may have a more severe course of disease.     

Chemotactic activity of cerebrospinal fluid in pyogenic meningitis.

Cerebrospinal fluid from patients with pyogenic meningitis was found to be chemotactic for polymorphonuclear neutrophil leucocytes. No significant difference was found between the mean chemotactic activity of cerebrospinal fluid obtained from patients with pneumococcal meningitis or meningococcal meningitis. The chemotactic factor present in cerebrospinal fluid is probably a low molecular weight protein, perhaps a complement component.     

Childhood macrophage activation syndrome differs from infection-associated hemophagocytosis syndrome in etiology and outcome in Taiwan.

BACKGROUND AND PURPOSE: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome composed of macrophage activation syndrome (MAS), infection-associated hemophagocytosis syndrome (IAHS), malignancy-associated HLH and genetic HLH. Differentiation of MAS from IAHS and other HLH is important for early appropriate treatment. METHODS: A retrospective analysis was used to differentiate childhood MAS from IAHS and other HLH in Chang Gung Memorial Hospital (CGMH), Kaohsiung. All relevant clinical features, laboratory data, treatments and outcomes were analysed. RESULTS: Seventeen patients with childhood HLH were found at CGMH, Kaohsiung in the past decade, and could be classified into 3 categories: IAHS (9 patients), MAS (5 patients), and HLH of unknown etiology (3 patients). The diagnosis of MAS first appeared in this hospital in 2001. Patients with IAHS tended to be younger than those with MAS. Boys were more frequently found in the IAHS group whereas girls (with systemic lupus erythematosus or juvenile idiopathic arthritis) were more frequently found in the MAS group. The majority of mortality cases were noted in the IAHS group (44%, 4/9). All patients with MAS survived with early cyclosporine A treatment. CONCLUSIONS: Childhood MAS is different from IAHS in terms of age, gender, etiology and mortality. Early administration of cyclosporine A for MAS results in a lower mortality. Further prospective studies are required to confirm these findings.     

Predictors of antidepressant treatment outcome in melancholia: psychosocial, clinical and biological indicators.

Predictive variables of response to imipramine and to phenelzine at 6 weeks and 6 months were studied in 116 patients suffering from major depression with melancholia (DSM-III). Several sociodemographic, clinical, and biological variables were studied. For imipramine-treated patients, high social support predicted a better response at 6 weeks, while development of hypomania during follow-up was associated with a better response at 6 weeks; absence of life events during the 6-month follow-up and initial non-suppression of dexamethasone predicted a better outcome at 6 months. For phenelzine-treated patients, development of hypomania during follow-up was associated with a better outcome at 6 months and absence of life events prior to the onset of the episode was associated with a worse outcome at 6 months.     

Somatic symptoms in primary care: etiology and outcome

Although somatic complaints are the predominant reason for seeking general medical care, their etiology and prognosis remain poorly understood. In a random sample of the records of all patients visiting an urban primary care clinic during four 1-month periods, 289 patients had one or more somatic symptoms, a total of 433 symptoms. Using explicit criteria, physician raters classified nearly half (48%) of the symptoms as either psychiatric or idiopathic in etiology. Reviewing follow-up notes for 12 months after the index visit, raters found that at least one-fourth of the symptoms persisted. Independent predictors of symptom persistence were prior visits for the same symptom, symptom type (i.e., headache or back pain), male gender, and greater medical comorbidity (i.e., seven or more medical diagnoses). Developing better management strategies for prevalent, medically unexplained, persistent somatic symptoms is a health care priority.     

Bacteriological study of pyogenic meningitis with special reference to latex agglutination

Bacterial meningitis is an important and frequent devastating disease. The present study was carried out to determine the prevalence of pyogenic meningitis in our hospital in children and to find out the sensitivity of Gram stain, CRP and latex agglutination tests for the diagnosis of pyogenic meningitis from CSF sample. Out of 150 CSF samples studied, 40 were diagnosed as pyogenic meningitis. H. influenzae was the commonest organism (22.5%), followed by Streptococcus pneumoniae 15%, Staphylococcus aureus--10%, Acinetobacter species and coagulase negative Stapylococci 7.5% each, E-coli 5%, and a case each of Klebsiella species, Group B streptococci, Proteus, Pseudomonas and Enterococci. The sensitivity of Gram stain and Latex agglutination test was 90% and that of CRP test was 62.5%. As most of the cases included in our study were treated earlier, the culture positivity was only 62.5%. Hence, Gram stain and/or latex agglutination tests, if done properly are most rapid and reliable tests for the diagnosis of pyogenic meningitis.     

Bacteriological study of pyogenic meningitis with special reference to C-reactive protein

Seventy five clinically, biochemically and microscopically diagnosed cases of pyogenic meningitis including 28 adults and 47 paediatric patients were studied. Gram positive isolates in adults and gram negative bacilli in paediatric age group were the predominant organisms. Estimation of C-reactive protein (CRP) in cerebrospinal fluid (CSF) and serum was done in all cases as an early marker for rapid diagnosis of pyogenic meningitis. Simultaneous estimation of CRP levels in serum and CSF was found to have a significant diagnostic utility as compared to culture.     

Cerebrospinal fluid and serum immunoglobulins and antibody titers in mumps meningitis and aseptic meningitis of other etiology.

Cerebrospinal fluid (CSF) and serum from 19 patients with mumps meningitis and 19 patients with meningitis of other etiology were investigated on two or more occasions for at least 1 month after onset. Intrathecal synthesis of immunoglobulin (Ig) G was found in 55%, of IgA in 26%, and of IgM in 24% of the patients. Oligoclonal Ig was demonstrable by agarose gel electrophoresis in 37% of the patients, mostly already during the first week after onset, and could persist for years. Mumps virus antibody synthesis within the central nervous system occurred in 37% of the mumps meningitis patients. The inflammatory reaction within the central nervous system as reflected by mononuclear pleocytosis, Ig synthesis, and oligoclonal Ig was not correlated to the clinical course. The blood-brain barrier was evaluated by determination of the CSF total protein, CSF/serum albumin ratio, and CSF/serum alpha2-macroglobulin ratio. A significant correlation was found among these three parameters. Persistence of the elevated CSF/serum albumin ratio seems to influence prognosis, and this parameter is recommended for evaluation of the blood-brain barrier function.     

Viral etiology of aseptic meningitis among children in southern Iran

Aseptic meningitis refers to a clinical syndrome of meningeal inflammation in which bacteria cannot be identified in the cerebrospinal fluid (CSF). The viral etiology and the epidemiological, clinical, and laboratory characteristics of aseptic meningitis among children aged 2 months to 15 years in Shiraz, southern Iran were determined. From May 2007 to April 2008, 65 patients were admitted to the hospital with aseptic meningitis. Seven viruses, non-polio human enteroviruses, mumps virus, herpes simplex virus (HSV), varicella-zoster virus (VZV), human cytomegalovirus (HCMV), human herpes virus type 6 (HHV-6), and Epstein-Barr virus (EBV) were investigated by polymerase chain reaction (PCR) method. Viruses were detected in 30 (46.2%) patients in whom non-polio human enterovirus and mumps virus were detected in 13 (43.3%) and 11 (36.7%), respectively. The remaining 6 (20%) of the cases were caused by HSV, VZV, HCMV, and HHV-6. Haemophilus influenzae and non-polio human enterovirus were detected in one patient simultaneously. Viral meningitis was found to be more frequent during spring and summer. The majority (66.6%) of the patients were treated in the hospital for 10 days and had received antibiotics in the case of bacterial meningitis. Rapid diagnosis of viral meningitis using PCR testing of CSF can help shorten hospitalization, and avoid the unnecessary use of antibiotics.     

Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis

Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.     

Incidence and outcome of pneumococcal meningitis in northern England

Since pneumococcal meningitis continues to have high mortality and morbidity, and may be under-reported to national surveillance systems, the present study was conducted to assess the incidence, features, and outcomes of microbiologically confirmed cases of pneumococcal meningitis in North Yorkshire, England, between 1997 and 2002. The review revealed 50 cases, which accounted for an incidence of 1.1. per 100,000 per year. The incidence was markedly seasonal, with 76% of cases occurring in the winter months. Mortality was 28%, and 28% of the survivors suffered long-term sequelae. A high Glasgow Coma Score on hospital admission was significantly associated with survival. There were 12 children in the study, aged 2 months to 2 years, and none of them would have been classified as candidates for conjugate pneumococcal vaccination according to UK recommendations.     

Changing etiology of community-acquired bacterial meningitis in adults: a nationwide multicenter study in Korea

Epidemiologic data on the etiologic organisms is important for appropriate empirical antibiotic treatment of bacterial meningitis. We identified the etiologies of community-acquired bacterial meningitis in Korean adults and the associated epidemiological factors. A retrospective, multicenter nationwide study was carried out. Patients 18 years of age or older with community-acquired bacterial meningitis with a confirmed pathogen were enrolled. Demographic, clinical, and microbiological data were collected. One hundred and ninety-five cases were collected. Streptococcus pneumoniae was the most common pathogen (50.8%), followed by Staphylococcus aureus (10.3%), Klebsiella pneumoniae (7.7%), Listeria monocytogenes (6.7%), and group B Streptococcus (3.1%). The penicillin resistance rate of the S. pneumoniae was 60.3%; 40.0% of the organisms were not susceptible to third-generation cephalosporins. The combination of third-generation cephalosporin with vancomycin was used in 76.3% of cases. Steroids were given before or with the first dose of antibiotics in 37.4% of patients. The 30-day mortality rate was 20.5% and neurological sequelae developed in 15.6% of cases. S. pneumoniae was the most common organism identified in community-acquired bacterial meningitis among Korean adults. S. aureus, K. pneumoniae, L. monocytogenes, and group B Streptococcus were also common. S. pneumoniae had high rates of resistance to penicillin and third-generation cephalosporins.     

Shoulder disorders in general practice: prognostic indicators of outcome.

BACKGROUND: Shoulder pain is common in primary health care. Nevertheless, information on the outcome of shoulder disorders is scarce, especially for patients encountered in general practice. AIM: To study the course of shoulder disorders in general practice and to determine prognostic indicators of outcome. METHOD: For this prospective follow-up study, 11 Dutch general practitioners recruited 349 patients with new episodes of shoulder pain. The participants filled out a questionnaire at presentation and further ones after 1, 3, 6 and 12 months; these contained questions on the nature, severity and course of the shoulder complaints. The association between potential prognostic indicators and the status of shoulder complaints (absence or presence of symptoms) was evaluated after one and 12 months of follow-up. RESULTS: After one month, 23% of all patients showed complete recovery; this figure increased to 59% after one year. A speedy recovery seemed to be related to preceding overuse or slight trauma and early presentation. A high risk of persistent or recurrent complaints was found for patients with concomitant neck pain and severe pain during the day at presentation. CONCLUSION: A considerable number of patients (41%) showed persistent symptoms after 12 months. It may be possible to distinguish patients who will show a speedy recovery from those with a high risk of long-standing complaints by determining whether there is a history of slight trauma or overuse, an early presentation or an absence of concomitant neck pain.     

Chemokine profiles in the cerebrospinal fluid (CSF) during the course of pyogenic and tuberculous meningitis

The concentrations of the chemokines IL-8, monocyte chemotactic protein-1 (MCP-1) and macrophage inflammatory protein-1α (MIP-1α) were measured in 120 CSF samples from 23 patients with pyogenic meningitis and from 11 patients with tuberculous meningitis (TBM) and in 10 CSF from subjects with non-infectious neurological diseases. The chemokine concentrations in patients with meningitis were significantly higher than in control subjects (P < 0.0001). The highest CSF levels were found for IL-8 (median 2917 pg/ml) and MCP-1 (median 2557 pg/ml), whereas those of MIP-1α were less significantly elevated (median 24 pg/ml) (P < 0.0001). Patients with pyogenic meningitis had higher levels of IL-8 and MCP-1 than those with TBM (P < 0.0001). In serial samples from patients with pyogenic meningitis IL-8 levels declined before MCP-1 and MIP-α. In the case of TBM, IL-8, MCP-1 and MIP-1α decreased more gradually during treatment and were detectable in the CSF for several weeks, without any characteristic time course of elimination. These data indicate that patients with pyogenic meningitis and TBM show different chemokine profiles in CSF. The distinct chemokine pattern could be responsible for a differential attraction and activation of leucocytes in the CSF which is reflected in differences in the inflammatory response and clinical course of pyogenic meningitis and TBM.