Gram-negative meningitis and the significance of SPICE organisms.

Abstract

A 6-week-old term female infant born via emergency Caesarean section for fetal bradycardia was admitted to exclude meningitis. She was febrile, anorexic, and irritable with a bulging anterior fontanelle. Empiric treatment with vancomycin and cefotaxime was started. Blood and cerebrospinal fluid (CSF) cultures showed no growth. MRI head confirmed the presence of a large abscess. The abscess was drained and cultures grew Citrobacter sp. Antibiotics were changed to meropenem and later ceftriaxone once the bacteria was further identified as Citrobacter koseri. Serial MRI monitoring directed two further abscess aspirations. The course was complicated by increasing hydrocephalus, requiring placement of an external ventricular drain, and as well by focal tonic clonic seizures. The latter were treated with phenobarbital followed by levetiracetam. After over 2 weeks, she was discharged home to complete parenteral therapy as an outpatient. At 12 weeks, MRI showed improvement but there was new and progressing high T2 signal in the left temporal white matter. She was developing neutropenia (absolute neutrophils 0.4) from prolonged ceftriaxone use. Outpatient antibiotics were changed to ceftazidime. Antibiotics were discontinued after a follow-up MRI showed improvement in the abscess compared to initial imaging.