Cerebrospinal Fluid Bacterial Culture Research Articles

Analysis of the effect of therapy for severe intracranial infection after craniotomy

ObjectiveTo retrospectively analyze the distribution characteristics of pathogenic bacteria in the cerebrospinal fluid (CSF) of patients with severe intracranial infection after craniotomy and treatment results. The aim was to provide a clinical basis and reference for improving treatment for severe intracranial infections. MethodsThis was a retrospective analysis of the distribution of pathogenic bacteria and the therapeutic effect for 43 patients who developed severe intracranial infections after craniotomy. All patients had positive CSF cultures and were treated in two hospitals in Beijing from May 2015 to May 2020. All patients received an intravenous injection of sensitive antibiotics combined with a CSF lateral ventricle catheter or lumbar cistern drainage. Antibiotic lavage treatment was administered through an external drain. ResultsThe CSF bacterial culture results for the 43 patients showed 34 single-strain infections (26 Gram-positive bacteria and 8 Gram-negative bacteria) and 9 multistrain infections. Fifty-two pathogenic strains were isolated, namely 32 Gram-positive bacteria (61.54%), 18 Gram-negative bacteria (34.61%), and 2 fungi (3.85%). After combined treatment, 29 patients (67.44%) were cured; treatment was effective for 7 patients (16.28%) and ineffective for 7 patients (16.28%). After 6 months of follow-up, the 36 surviving patients were cured of infection. The Glasgow Outcome Scale score results showed that 5 of the 36 (13.9%) patients had a persistent vegetative state; 13 (36.1%) had severe disability; 12 (33.3%) had moderate disability; and 6 (16.7%) had mild disability. ConclusionCSF pathogenic bacteria in patients with intracranial infection after craniotomy were mainly Gram-positive bacteria, primarily Staphylococcus epidermidis. A small number of patients had mixed bacterial infections. Owing to the presence of implanted devices in patients who underwent ventriculoperitoneal shunt surgery, the antibacterial therapeutic effect was worse than that for other types of postoperative infections. Therefore, when initial intravenous antibiotics are ineffective, the shunt device should be removed or replaced as soon as possible. When initial intravenous antibiotics are ineffective and severe intracranial infection occurs, a combined treatment plan should be adopted. That is, CSF drainage and antibiotic lavage should be performed cautiously with the intravenous injection of sensitive antibiotics. Our clinical data confirmed that postoperative neurosurgical infection could lead to different degrees of nerve dysfunction, which should be considered.

Clinical Performance of FilmArray Meningitis/Encephalitis Multiplex Polymerase Chain Reaction Panel in Central Nervous System Infections.

IntroductionEarly identification of etiology is very important for initiating appropriate therapy promptly in patients with meningoencephalitis (ME). BioFire FilmArray® meningitis/encephalitis (FA-ME) panel is a fully automated multiplex polymerase chain reaction (PCR) that detects 14 pathogens simultaneously in an hour. There is a dearth of studies highlighting its usefulness in ME syndrome in Indian patients.Materials and methodsWe performed a retrospective analysis of patients, admitted to the Kerala Institute of Medical Sciences Hospital, Thiruvananthapuram, Kerala, South India, with meningitis/encephalitis syndrome who underwent the multiplex PCR test on cerebrospinal fluid (CSF) over a period of 2 years from 2016 to 2018. Patients presenting with clinical diagnosis of acute meningitis, encephalitis, or ME who underwent CSF FA-ME panel were studied. The performance of the FA-ME panel was compared to CSF bacterial culture.ResultsTwo-hundred and fifty-nine patients between December 2016 and December 2018 underwent the FA-ME test in CSF. FA-ME test detected pathogens in 61 (23.6%) out of 259 patients with ME syndrome. Among the pathogens detected by FA-ME panel, enterovirus was the commonest accounting for 29 cases (47.5%), followed by varicella in 11 patients (18%) and pneumococci in 9 (14.8%). CSF bacterial culture yield was low, positive only in 8 (3%) out of 259 cases, and matched with FA-ME panel in only one sample that grew Streptococcus pneumoniae. Bacterial culture yielded seven pathogens in those whose FA-ME panels were negative.ConclusionFA-ME panel improves diagnostic yield as compared to bacterial culture (26.3 vs 3%). FA-ME test helps in the early initiation of targeted antibiotic therapy and greater antibiotic de-escalation.How to cite this articleChandran S, Arjun R, Sasidharan A, Niyas VKM, Chandran S. Clinical Performance of FilmArray Meningitis/Encephalitis Multiplex Polymerase Chain Reaction Panel in Central Nervous System Infections. Indian J Crit Care Med 2022;26(1):67–70.

The value of next-generation sequencing for the diagnosis of Streptococcus suis meningitis.

The aim of this study was to investigate the value of next-generation sequencing for the diagnosis of Streptococcus suis meningitis. Patients with meningitis in the Department of Neurology of the Hainan General Hospital were recruited and divided into a next-generation sequencing group and a control group. In the next-generation sequencing group, we used the next-generation sequencing method to detect the specific pathogenic bacteria in the patients. In the control group, we used the cerebrospinal fluid bacterial culture method to detect the specific pathogenic bacteria in the patients. A total of 28 participants were recruited for this study, with 14 participants in each group. The results showed similarities in both the average age and average course of the disease between the two groups (p>0.05). The white blood cell count, percentage of neutrophils, and level of C-reactive protein in the next-generation sequencing group were significantly higher than those in the control group (p<0.05). There were similarities in both the temperature and intracranial pressure between the two groups (p>0.05). In the next-generation sequencing group, all patients (100%) were detected as having had the S. suis meningitis infection by next-generation sequencing, while only 6 (43%) patients in the control group had been detected as having the S. suis meningitis infection by cerebrospinal fluid bacterial culture. The positive detection rate of S. suis by the next-generation sequencing method was significantly higher compared with using a cerebrospinal fluid bacterial culture. Therefore, the next-generation sequencing method is valuable for the diagnosis of S. suis meningitis and is worthy of clinical application.

Clinical profile of children with parechovirus meningitis in Singapore

Human parechovirus (HPeV) is one of the most common causes of aseptic meningitis in children worldwide. This study aims to review the epidemiology, clinical presentation, and cerebrospinal fluid (CSF) findings in HPeV meningitis and compare these with Enterovirus (EV) meningitis. This is a retrospective study of children aged ≤ 1year admitted for HPeV meningitis between November 2015 and July 2017, with positive CSF HPeV PCR and negative blood and CSF bacterial cultures. The clinical findings were compared with a historical cohort of children with EV meningitis admitted between July 2008 and July 2011. There were 71 children with HPeV meningitis, aged between 2 and 127days, with the majority (96%) being ≤ 90days old. The most common symptoms reported were poor feeding (42%), tachycardia out of proportion to fever (27%), and lethargy (20%). Only 2 patients (3%) had CSF pleocytosis. Cerebral spinal fluid white blood cell counts ranged from 0 to 28 cells/mm3, with a median of 3 cells/mm3 [interquartile range (IQR) 1-6 cells/mm3]. When compared to our historical cohort of EV meningitis ≤ 90days old, children with HPeV meningitis ≤ 90days old were less likely to have CSF pleocytosis (OR 0.008, 95% CI 0.001-0.057). HPeV and EV meningitis are known to cause sepsis-like illness in infants < 90days old. This study further supports this, with the requirement for fluid bolus therapy for tachycardia or poor perfusion noted to be higher in children with HPeV meningitis ≤ 90days old (OR 6.3, 95% CI 2.7-14.2).

Metagenomic Next Generation Sequencing in the Detection of Pathogens in Cerebrospinal Fluid of Patients After Alternative Donor Transplantation: A Feasibility Analysis.

Central nervous system (CNS) complications can occur in 9%–15% of patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical manifestations of the CNS complications are non-specific, with most of them being disturbances of consciousness, convulsions, headaches, fever, and epilepsy, making it difficult to infer the cause of the complications based on clinical manifestations. We retrospectively analyzed the sensitivity and feasibility of metagenomic next generation sequencing (mNGS) in the diagnosis of CNS infections after allo-HSCT. Lumbar punctures were performed on 20 patients with CNS symptoms after receiving alternative donor HSCT(AD-HSCT) at the Affiliated Cancer Hospital of Zhengzhou University from February 2019 to December 2020, and their cerebrospinal fluid (CSF) was collected. The mNGS technique was used to detect pathogens in the CSF. Routine CSF testing, biochemical analyses, G experiments, GM experiments, ink staining, acid-fast staining, and bacterial cultures were carried out, and quantitative PCR (qPCR) tests were used to detect cytomegalovirus (CMV), Epstein-Barr virus (EBV), BK polyomavirus (BKPyV), and human alphaherpesvirus (HHV). A total of 29 tests were performed with 21 of them being positive. Of the five negative patients, three were diagnosed with a posterior reversible encephalopathy syndrome, one as having transplantation-associated thrombotic microangiopathy, and one with transient seizure caused by hypertension. Fifteen patients tested positive, of which four had single infections and eleven had mixed infections. Five cases of fungal infections, six cases of bacterial infections, and 13 cases of viral infections were detected. Among the 13 cases of viral infections, ten cases were CMV(HHV-5); three were BKPyV; two were Torque teno virus (TTV); Two were HHV-1,two were EBV(HHV4), and one each of HpyV5 and HHV-6B. Thirteen patients tested positive for virus while the qPCR detection method of 6 identical specimens were below the minimum detection limit(<1×103 U/ml). The mNGS technique is highly sensitive, and it can be used to diagnose CNS infections after allo-HSCT.

Prevalence of Invasive Bacterial Infections in Well-Appearing, Febrile Infants.

Data on invasive bacterial infection (IBI), defined as bacteremia and/or bacterial meningitis, in febrile infants aged <60 days old primarily derive from smaller, dated studies conducted at large, university-affiliated medical centers. Our objective with the current study was to determine current prevalence and epidemiology of IBI from a contemporary, national cohort of well-appearing, febrile infants at university-affiliated and community-based hospitals. Retrospective review of well-appearing, febrile infants aged 7 to 60 days was performed across 31 community-based and 44 university-affiliated centers from September 2015 to December 2017. Blood and cerebrospinal fluid bacterial culture results were reviewed and categorized by using a priori criteria for pathogenic organisms. Prevalence estimates and subgroup comparisons were made by using descriptive statistics. A total of 10 618 febrile infants met inclusion criteria; cerebrospinal fluid and blood cultures were tested from 6747 and 10 581 infants, respectively. Overall, meningitis prevalence was 0.4% (95% confidence interval [CI]: 0.2-0.5); bacteremia prevalence was 2.4% (95% CI: 2.1-2.7). Neonates aged 7 to 30 days had significantly higher prevalence of bacteremia, as compared with infants in the second month of life. IBI prevalence did not differ between community-based and university-affiliated hospitals (2.7% [95% CI: 2.3-3.1] vs 2.1% [95% CI: 1.7-2.6]). Escherichia coli and Streptococcus agalactiae were the most commonly identified organisms. This contemporary study of well-appearing, febrile infants supports previous epidemiological estimates of IBI prevalence and suggests that the prevalence of IBI may be similar among community-based and university-affiliated hospitals. These results can be used to aid future clinical guidelines and prediction tool development.

Clinical study on the diagnosis of porcine streptococcal meningitis with negative blood and cerebrospinal fluid culture by next-generation sequencing

BackgroundStreptococcus suis (Ss) is a Gram-positive and anaerobic zoonotic pathogen that is susceptible to all populations and can cause meningitis, septicemia, endocarditis and arthritis in humans.MethodsIn this study, patients with meningitis who were admitted to our hospital with negative blood and cerebrospinal fluid culture were divided into a next-generation sequencing group and a control group. In the next-generation sequencing group, we used the next-generation sequencing method to detect pathogenic bacteria in the patients’ cerebrospinal fluid. In the control group, we used blood and cerebrospinal fluid bacterial culture method to detect pathogenic bacteria in the patients' cerebrospinal fluid. The detection rates of pathogenic bacteria in the cerebrospinal fluid of the two groups were compared and analyzed.ResultsA total of 18 patients were included in this study, including 8 patients in the next-generation sequencing group and 10 patients in the control group. The mean age (P = 0.613) and mean disease duration (P = 0.294) were similar in both groups. Patients in the next-generation sequencing group had a leukocyte count of 13.13 ± 4.79 × 109, a neutrophil percentage of 83.39 ± 10.36%, and a C-reactive protein level of 134.95 ± 107.69 mg/L. Patients in the control group had a temperature of 38.32 ± 1.07, a leukocyte count of 8.00 ± 2.99 × 109, and a neutrophil percentage of 74.61 ± 8.89%, and C-reactive protein level was 4.75 ± 6.8 mg/L. The statistical results showed that the leukocytes (P = 0.013) and C-reactive protein levels (P = 0.001) were significantly higher in the patients of the next-generation sequencing group than in the control group. No statistically significant differences were seen in body temperature and neutrophil percentage between the two groups (P > 0.05). The incidence of intracranial pressure and meningeal irritation signs were similar in the two groups (P > 0.05). The detection rate of Streptococcus suis in the cerebrospinal fluid of patients in the next-generation sequencing group was 100%, and the detection rate of Streptococcus suis in the cerebrospinal fluid of the control group was 0%.ConclusionThe detection rate of Streptococcus suis infection in cerebrospinal fluid by next-generation sequencing was significantly higher than that by blood and cerebrospinal fluid bacterial culture. Therefore, the diagnosis of porcine streptococcal meningitis by next-generation sequencing method is worthy of clinical promotion and application.

Hearing and Neurodevelopmental Outcomes of Young Infants with Parechovirus-A and Enterovirus Meningitis: Cohort Study in Singapore Children and Literature Review

Abstract Parechovirus-A (PeV-A) and Enterovirus (EV) commonly cause childhood aseptic meningitis. Bacterial meningitis in children has been associated with devastating long-term sequelae. However, developmental outcomes are unclear in Parechovirus meningitis. This study aims to review the clinical findings and developmental outcomes of infants with PeV-A and EV meningitis. We performed a retrospective study of infants aged 90 days or younger being admitted to our hospital with PeV-A meningitis between November 2015 and July 2017, with positive cerebrospinal fluid (CSF) PeV-A PCR and negative blood and CSF bacterial cultures. Hearing and neurodevelopmental outcomes were compared with a previous cohort of infants aged 90 days or younger with EV meningitis admitted from January 2015 to December 2015. A total of 161 infants were included in our study, of which 68 infants (42.2%) had PeV-A meningitis and 93 infants (57.8%) had EV meningitis. We assessed their developmental outcome at 6 months, 1 year, and 2 years post-meningitis. At 2 years post-meningitis, three infants with PeV-A meningitis had developmental delay (5.5%), whereas none with EV meningitis had developmental delay. One patient had speech delay and autism spectrum disorder, while two had mild speech delay. When compared with our cohort of EV meningitis ≤90 days old, children with PeV-A meningitis ≤90 days old were more likely to have developmental delay 2 years post-meningitis (odds ratio 2.4, 95% confidence interval 2.0–3.0, p = 0.043). None of the patients with PeV-A or EV meningitis had sensorineural hearing loss or neurological sequelae, such as cortical blindness, oropharyngeal dysphagia, hydrocephalus, epilepsy, or cerebral palsy. Infants with PeV-A meningitis had a significant risk of developmental delay 2 years post-meningitis compared with those with EV meningitis. It is important to follow-up the developmental milestones of infants diagnosed with PeV-A meningitis for at least 2 years; and when they develop developmental delay, to ensure that they receive appropriate intervention.

Accuracy of heparin binding protein: as a new marker in prediction of acute bacterial meningitis.

BackgroundCerebrospinal fluid bacterial culture is the gold-standard for confirmation of acute bacterial meningitis, but many cases are not culture confirmed. Antibiotics reduce the chance of a microbiological diagnosis. Objective to evaluate efficacy of Heparin-binding protein in diagnosis of bacterial meningitis.Patients30 patients diagnosed with acute bacterial meningitis, 30 viral meningitis, and 30 subjects with normal CSF findings.DesignDiagnosis was based on history, clinical criteria, CSF examination, latex agglutination & culture, and sensitivities and response to therapy. HBP was measured using enzyme-linked immunosorbent technique in both serum & CSF.ResultsCerebrospinal fluid HBP levels averaged 0.82 ± 0.3 ng/mL in controls, 3.3 ± 1.7 ng/mL in viral and 174.8 ± 46.7 ng/mL in bacterial meningitis. Mean serum level was 0.84 ± 0.3 ng/mL in the controls, 3.7 ± 1.9 ng/mL in viral, and 192.2 ± 56.6 ng/mL in bacterial meningitis. Both HBP levels were significantly higher in patients with bacterial meningitis. Cut-offs of 56.7 ng/ml and 45.3 ng/ml in cerebrospinal fluid & serum showed 100% overall accuracy. Even in patients who received prior antibiotics, remained elevated.ConclusionSerum Heparin-binding protein serves as a non-invasive potential marker of acute bacterial meningitis even in partially treated cases.

Classification of Pathogenic Bacteria in Cerebrospinal Fluid of Patients with Intracranial Infection After Neurosurgery and Selective Use of Antibacterial Agents

Background: Anti-infective treatment has become troublesome owing to aggravated resistance to antibacterial agents. Objectives: This study aimed at investigating the distribution characteristics and drug resistance changes of pathogenic bacteria in cerebrospinal fluid (CSF) of patients with intracranial infection receiving neurosurgery, and to provide evidence for rational use of antibacterial agents. Methods: Bacteria were collected from CSF cultures of all patients receiving neurosurgery in the hospital of the current research, from January 2013 to December 2015, and the same types of strains cultured from each case during the same infection were combined. A hospital information system (HIS) was then used to analyze the data of 120 patients, who received neurosurgery from January 2015 to June 2016 and had positive CSF bacterial culture results after surgery, and to treat them by rationally selecting antibacterial agents. Results: A total of 845 pathogenic bacterial strains were isolated from the CSF samples and cultured, of which 629 were Gram-negative bacteria, accounting for 74.4%. Particularly, Acinetobacter baumannii had severe pan-resistance. There were 216 Gram-positive bacteria, which accounted for 25.6% of all strains, and were mainly methicillin-resistant staphylococci, being basically resistant to penicillins and only susceptible to vancomycin and linezolid. After rational selection of antibacterial agents using HIS, based on the retrospective analysis results, 101 of the 120 patients were cured by vancomycin and linezolid (cure rate: 84.17%). Conclusions: Since the treatment outcomes after rational selection of antibacterial agents (i.e. vancomycin and linezolid) using HIS were satisfactory, the findings of retrospective analysis are of high clinical value.

Neonatal HSV Disease: Balancing the Low Incidence With the Need to Treat Promptly.

* Abbreviations: ED — : emergency department HSV — : herpes simplex virus LP — : lumbar puncture PCR — : polymerase chain reaction In this issue of Pediatrics , Cruz et al1 address the following clinical question: what is the probability that an infant <60 days of age presenting to the emergency department (ED) who receives a lumbar puncture (LP) for concern of meningitis has a herpes simplex virus (HSV) infection? To answer this question, Cruz et al1 conducted a retrospective observational study and report on the incidence of HSV in infants <60 days old who had cerebrospinal fluid bacterial culture testing performed at 1 of 23 North American, tertiary-care, pediatric EDs over a 9-year period. There were 112 infants who had HSV identified, which amounts to 0.42%, or 42 of 10 000 (95% confidence interval, 35–51 of 10 000) infants evaluated. This estimate serves as the pretest probability of HSV infection in infants presenting to the ED who receive an LP for meningitis. On average, EDs saw ∼1 infant with HSV infection per year. Of neonatal HSV cases, 89.3% occurred in the first 6 weeks, with a median age of presentation of 14 days. Cruz et al1 also bring attention to an important issue on the state of affairs of hospital management of HSV in young infants: there is substantial variation in HSV testing and acyclovir administration across EDs. HSV testing ranged from 14% to 72%, and empirical acyclovir administration ranged from 4% to 53% across EDs. … Address correspondence to Sanjay Mahant, MD, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G1X8. E-mail: sanjay.mahant{at}sickkids.ca

Risk Factors and Microbiology of Meningitis and/or Bacteremia After Transsphenoidal Surgery for Pituitary Adenoma.

To investigate the incidence, bacteriologic features, and risk factors of posttranssphenoidal surgery (post-TSS) meningitis and/or bacteremia. This retrospective study included 3242 patients who underwent TSS for pituitary adenoma at the Department of Neurosurgery of Peking Union Medical College Hospital between January 2012 and December 2016. Clinical data for patients with and without post-TSS meningitis and/or bacteremia were compared and analyzed. Meningitis and bacteremia developed after 27 (0.8%) and 26 (0.8%) procedures, respectively, and 6 patients (0.2%) developed both. Gram-positive organisms (coagulase-negative staphylococci, Streptococcus pneumonia, and Sviridans) predominated in meningitis, whereas gram-negative organisms (Klebsiella pneumonia, Enterobacter aerogenes, and Escherichia coli) predominated in bacteremia. All identified species were sensitive to amikacin, imipenem, and meropenem. Antibiotic treatment cured 52 patients (7 died). In a multivariate analysis, the risk of meningitis and/or bacteremia was independently associated with diabetes (P < 0.001; odds ratio [OR], 6.06), previous surgery at the same location (P < 0.001; OR, 4.23), intraoperative cerebrospinal fluid leakage (P < 0.001l; OR, 4.63), and an endoscopic approach (P= 0.001; OR, 2.50). Meningitis and/or bacteremia remain critical postoperative complications of TSS for pituitary adenoma. The pathogens with drug sensitivity to antibiotics differed between meningitis and bacteremia. Early blood and cerebrospinal fluid bacterial cultures, drug susceptibility analyses, and appropriate antibiotic treatment can help control the rate of infection.

Diagnostic Practices for Suspected Community-Acquired Central Nervous System Infection in the Post-Conjugate Vaccine Era.

The aim of this study was to evaluate diagnostic practices for suspected community-acquired central nervous system (CNS) infection in an urban pediatric population. This is an observational, retrospective single-center review of cerebrospinal fluid (CSF) studies in children, 1 month to 21 years old, evaluated for suspected CNS infection from 2004 to 2014. Cases of suspected nosocomial meningitis were excluded. The frequency of N-methyl-D-aspartate receptor antibody (NMDAR ab) encephalitis was analyzed from 2010 to 2014. A total of 940 unique patient visits with CSF studies were included in the final analysis. There were 940 bacterial cultures sent; 4 (0.42%) grew suspected CSF bacterial pathogens, and 18 (1.9%) grew organisms that were suspected contaminants. Bacterial pathogens included late-onset group B Streptococcus in 3 infants younger than 3 months and Streptococcus pneumoniae in an unvaccinated 9-year-old child. Viral CNS infection was 7.5 times more frequent than bacterial infection. Enterovirus was the only virus isolated. Five cases positive for NMDAR ab were identified since 2010. Bacterial studies were performed more frequently than viral and other studies. Cerebrospinal fluid bacterial culture was nearly 5 times more likely to yield a contaminant than a pathogen. The frequency of viral infection was likely underestimated as only 20% were tested, mainly by culture, which is suboptimal. These data suggest diagnostic practices for the evaluation of suspected community-acquired CNS infections in children need to be modified to reflect current epidemiology and highlight the need for greater accessibility to polymerase chain reaction for viral diagnostics. Furthermore, NMDAR ab-mediated encephalitis should be considered early in children presenting with suggestive symptoms.

26-Year-Old Man With Nausea, Delirium, and Fever

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN (H.L.T.); Advisor to resident and Consultant in Infectious Diseases, Mayo Clinic, Rochester, MN (L.M.B.). A 26-year-old-man who had been living in Indonesia until 4 months previously presented to our hospital for evaluation of fever, agitation, and altered mental status. He had been seen previously at another facility for vague abdominal pain, nausea, and fever. He had become subacutely agitated and was transferred to our institution because of altered mental status and vomiting. On admission, he was febrile (temperature, 39.3 C) and tachycardic (heart rate, 118 beats/ min); his blood pressure was 134/96 mm Hg, and his oxygen saturation was 100% while breathing room air. Physical examination findings were notable for intermittent altered mental status with restlessness, agitation, inattention, and pain with neck flexion and posterior neck palpation. Findings on work-up at the outside facility included a sodium level of 118 mmol/L and no abnormalities detected on head computed tomography (CT) and chest radiography. His pupils were mildly constricted but responded to light. Admission laboratory studies yielded a normal white blood cell count of 10.1 10/L and an improved sodium concentration of 133 mmol/L.

Therapy of the neurosurgical postoperative culture negative meningitis by using external lumbar drainage combined with empirical antibiotics treatment

To evaluate the curative effect of external lumbar drainage combined with empirical antibiotics treatment on the postoperative culture negative meningitis. The clinical data of eighty post-operative meningitis patients with cerebrospinal fluid culture negative were retrospectively analyzed according to inclusive and exclusive criteria from January 2013 to December 2014 in Department of Neurosurgery, Tianjin Huanhu Hospital. All patients were composed of 45 male cases and 35 female cases, aging from 9 to 72 years. All patients were divided into two groups according to receiving the different treatment: one group only receiving a intravenously empirical antibiotics treatment (n=40), another group receiving a combined therapy of external lumbar drainage and intravenously empirical antibiotics treatment (n=40). The volume of drainage of cerebrospinal fluid (CSF) were set up from 200 to 300 ml per day. There was no difference in the dosage and interval of the same antibiotics between two groups. The antibiotics usage and therapeutic effect of two groups of patients were observed and analyzed by t-test, Wilcoxon rank test or χ(2) test. The rate of CSF bacterial culture negative was 62.9% (88/140) in the same period. In group of empirical antibiotics treatment, the time of antibiotics treatment was (12.6±3.1) days, the rate of combined with other antibiotics treatment was 40.0% (16/40), the rate of mortality was 15.0% (6/40). However, in group of external lumbar drainage combined with empirical antibiotics treatment, the 3 data were (5.3±1.2) days, 10.0% (4/40), 7.5% (3/40), respectively. The time of antibiotics of the group of empirical antibiotics was longer (t=3.605, P=0.017), while the rate of combined antibiotics and the rate of mortality were lower (χ(2)=3.971, P=0.035; χ(2)=4.136, P=0.027, respectively). The average drainage time was (5.8±1.5) days, 32 patients gained a complete healing only by their first placement, 5 cases need replacement because of occlusion or drainage time more than 14 days. There were no recurrence cases after 3 months' follow-up. The method of external lumbar drainage combined with empirical antibiotics treatment can significantly reduce the dosage and course of antibiotics treatment. It is a simple, safe, efficacious method for the treatment of neurosurgical postoperative bacterial culture negative meningitis.

Capnocytophaga canimorsus meningitis diagnosed by 16S rRNA PCR

Capnocytophaga canimorsus is a common Gram-negative anaerobic bacterium from the oral flora of dogs, typically transmitted to humans by dog bites. We report a case of C. canimorsus meningitis where...

Diagnosis and treatment of pyogenic ventriculitis caused by gram-negative bacteria in severe neurosurgical patients

Objective To investigate the experiences in diagnosis and treatment pyogenic ventriculitis caused by gram-negative bacteria (G-) in severe neurosurgical patients. Methods Nineteen consecutive patients with pyogenic ventriculitis treated at the Neurosurgical Intensive Care Unit of the Department of Neurosurgery, Beijing Xuanwu Hospital, Capital Medical University from September 2009 to August 2014 were reviewed. Their bacteriological results, clinical treatment, and prognosis were analyzed. Results Ventricular drainage of cerebrospinal fluid bacterial smears in all cases were G-bacteria. Head CT scans confirmed as intraventricular empyema. Eighteen patients were positive in cerebrospinal fluid bacterial culture, 12 of them were Acinetobacter baumannii, 2 were Klebsiella pneumonia, 2 were Serratia marcescens, 1 was Pseudomonas maltophila, and 1 was Escherichia coli. The bacterial culture in one case was negative. The catheters which caused infections were removed and ventricular drainage was conducted in all cases. The patients were treated with intraventricular lavage in combination with intravenous drugs and intraventricular antibiotics according to the conditions. They were followed up for 3 months to 3 years. After treatment for 2 to 8 weeks, 14 patients were cured (74%) and 5 died (26%). In the cured patients, 8 patients underwent ventriculo-peritoneal shunt after the infection being cured in 2 to 6 weeks because of hydrocephalus. No reinfection occurred. Twelve patients came to consciousness, and 2 were in a persistent vegetative state before infection and did not have any improvement. Conclusions Suppurative ventriculitis in severe neurosurgical patients is mainly caused by G-negative bacteria. The mortality is higher. Early diagnosis, especially clarifying pathogens, timely ventricular irrigation, and ventricular drainage in combination with intravenous and intraventricular antibiotic treatment may increase the cure rate and improve the prognosis. Key words: Cerebral ventriculitis; Gram-negative bacteria; Intensive care unit; Acinetobacter baumannii

Cerebrospinal fluid white cell count: discriminatory or otherwise for enteroviral meningitis in infants and young children?

Non-polio enteroviruses (EV) are the most common viruses causing aseptic meningitis in children. We aim to evaluate the cerebrospinal fluid (CSF) characteristics of neonates and children with EV meningitis with a view to determine whether it could be discriminatory or otherwise in making a positive diagnosis. We performed a 3-year (July 2008-July 2011) retrospective study of children ≤16 years, treated at a tertiary children's hospital, with positive CSF EV polymerase chain reaction (PCR) and negative blood and CSF bacterial cultures. A total of 206 children were studied. The median CSF white cell count was 79 cells/mm(3) (range 0-4608 cells/mm(3)). CSF pleocytosis was observed in 99/150 (66%) aged ≤90 days, 3/4 (75%) aged 90 days-1 year, and 49/52 (94%) children ≥3 years. There was a huge variability in CSF pleocytosis in infants ≤90 days, where 34% of them had no pleocytosis, while in 66%, a wide range of pleocytosis that might even suggest bacterial meningitis was noted. CSF red cells were low, and protein or sugar values were not discriminatory. CSF pleocytosis in relation to increasing age was found to be statistically significant (p < 0.001). Early lumbar puncture within 48 h of symptoms and absence of CSF pleocytosis was also statistically significant (p = 0.039). CSF pleocytosis in EV meningitis is commoner in older children. As there was a huge variability in CSF pleocytosis in infants ≤90 days particularly, CSF analysis including EV PCR could avoid unnecessary antibiotic therapy.

High-throughput sequencing of 16S rDNA amplicons characterizes bacterial composition in cerebrospinal fluid samples from patients with purulent meningitis.

Purulent meningitis (PM) is a severe infectious disease that is associated with high rates of morbidity and mortality. It has been recognized that bacterial infection is a major contributing factor to the pathogenesis of PM. However, there is a lack of information on the bacterial composition in PM, due to the low positive rate of cerebrospinal fluid bacterial culture. Herein, we aimed to discriminate and identify the main pathogens and bacterial composition in cerebrospinal fluid sample from PM patients using high-throughput sequencing approach. The cerebrospinal fluid samples were collected from 26 PM patients, and were determined as culture-negative samples. The polymerase chain reaction products of the hypervariable regions of 16S rDNA gene in these 26 samples of PM were sequenced using the 454 GS FLX system. The results showed that there were 71,440 pyrosequencing reads, of which, the predominant phyla were Proteobacteria and Firmicutes; and the predominant genera were Streptococcus, Acinetobacter, Pseudomonas, and Neisseria. The bacterial species in the cerebrospinal fluid were complex, with 61.5% of the samples presenting with mixed pathogens. A significant number of bacteria belonging to a known pathogenic potential was observed. The number of operational taxonomic units for individual samples ranged from six to 75 and there was a comparable difference in the species diversity that was calculated through alpha and beta diversity analysis. Collectively, the data show that high-throughput sequencing approach facilitates the characterization of the pathogens in cerebrospinal fluid and determine the abundance and the composition of bacteria in the cerebrospinal fluid samples of the PM patients, which may provide a better understanding of pathogens in PM and assist clinicians to make rational and effective therapeutic decisions.

Fatal artesunate toxicity in a child

A 5-year-old boy from a malaria endemic region of our country was admitted to our unit after being diagnosed of Plasmodium vivax malaria and treated with rectal artesunate at a dose of 200 mg bid for 4 days (total dose 1,600 mg; 88 mg/kg/day). After a period of improvement, at the fifth day of treatment he developed unconsciousness, seizures, jaundice and gastrointestinal hemorrhage. New tests for Plasmodium were negative (blood smear, bone marrow examination and two rapid diagnostic tests for Plasmodium falciparum). Blood, urine and cerebrospinal fluid bacterial cultures were negative as well as viral tests for central nervous system and liver infections. A computerized tomography scan of the brain demonstrated a diffuse brain swelling. Despite intensive treatment, the clinical condition worsened to status epilepticus, unresponsive hemodynamic collapse, pancytopenia, liver failure, coagulopathy, renal insufficiency and finally death 6 days after admission and 13 days after the first dose of artesunate. The Institutional Review Board waived the need for consent. The safety profile of artemisinin derivatives has been questioned because of their potential neurotoxic effects. In this case, the particular pharmacokinetic profile of artesunate suppositories and prescription error at a dose at seven fold higher than the maximum recommended for the drug, could have caused a protracted central nervous system exposure to very high levels of artesunate leading to toxicity especially to the brain stem, which explains the unresponsive hemodynamic collapse responsible for the death of our patient. To our knowledge, this could be the first reported case of artesunate intoxication in humans. Children are particularly vulnerable to inadvertent prescribing errors. We caution against using adult preparations for pediatric treatment and suggest that hospitals should update their prescribing formulary for pediatric treatment of malaria.