Gram-negative Bacillary Meningitis Research Articles

Spontaneous Gram-negative Bacterial Meningitis Following Steroid Therapy for Severe COVID-19

Abstract This case demonstrates an unusual case of spontaneous Gram-negative bacillary meningitis (GNBM) due to Serratia following COVID-19 and steroid exposure. A 52-year-old male presented with clinical features of acute meningitis following a prolonged hospitalization for severe COVID-19 pneumonia, during which he was administered corticosteroids. Neuroimaging was normal. Cerebrospinal fluid (CSF) analysis revealed high protein, hypoglycorrhachia, and neutrophilic pleocytosis. The Gram stain showed plenty of neutrophils but no bacteria. CSF culture demonstrated convex 1–2 mm colonies, slightly umbonate with entire margins, and opaque. On VITEK2, this was identified as Serratia marcescens and was susceptible to all tested antibiotics. Clinical improvement was noted after 48 h with the administration of meropenem (2 g q8 h) and levofloxacin (750 mg once daily). After a week of treatment, repeat CSF analysis showed a decrease in the CSF protein and total white blood cells, lymphocytic pleocytosis, and an increase in the CSF glucose. The patient made a complete recovery following 3 weeks of antibiotic therapy. This case report highlights that steroids should be used cautiously and judiciously in the COVID-19 setting. Serratia is a rare cause of spontaneous GNBM.

The Clinical Characteristics, Microbiology and Risk Factors for Adverse Outcomes in Neonates with Gram-Negative Bacillary Meningitis.

Background: We aimed to describe the clinical features of Gram-negative bacillary (GNB) meningitis in neonates and investigate the risk factors associated with final adverse outcomes of neonatal GNB meningitis. Methods: From 2003 to 2020, all neonates (aged ≤ 90 days old) with bacterial meningitis who were hospitalized in four tertiary-level neonatal intensive care units (NICUs) of two medical centers in Taiwan were enrolled. Neonates with GNB meningitis were compared with those with Streptococcus agalactiae (group B streptococcus, GBS) meningitis. Results: During the study period, a total of 153 neonates with bacterial meningitis were identified and enrolled. GNB and GBS accounted for 40.5% (n = 62) and 35.3% (n = 54) of all neonatal bacterial meningitis, respectively. In neonates with GNB meningitis, the final mortality rate was 6.5% (4 neonates died); 48 (77.4%) had neurological complications, and 26 (44.8%) of 58 survivors had neurological sequelae at discharge. Although the final outcomes were comparable between neonates with GNB meningitis and those with GBS meningitis, neonates with GNB meningitis were more likely to have more severe clinical manifestations initially and have ventriculomegaly at follow-up. After multivariate logistic regression analysis, neonates with seizure at onset, early onset sepsis, and requirement of surgical intervention for neurological complications were independently associated with final adverse outcomes. Conclusions: GNB meningitis was associated with a high risk of neurological complications and sequelae, although it did not significantly increase the final mortality rate. Close monitoring of the occurrence of neurological complications and advanced therapeutic strategies to optimize the outcomes are urgently needed in the future.

Spontaneous nosocomial Proteus mirabilis meningitis in a Human Immunodeficiency Virus (HIV)-infected adult patient: a case report

BackgroundGram-negative bacillary meningitis remains a rare occurrence, even in patients with human immunodeficiency virus. Current literature only describes anecdotal cases of spontaneous nosocomial Proteus mirabilis meningitis. This report describes the clinical manifestations and management of a patient with healthcare-associated spontaneous Gram-negative bacillary meningitis in a patient with advanced human immunodeficiency virus disease.Case presentationA 23-year-old Congolese female was hospitalized in a human immunodeficiency virus specialized center for ongoing weight loss, chronic abdominal pain, and vomiting 9 months after initiation of treatment for tuberculosis meningitis. Hospitalization was complicated by healthcare-associated Gram-negative bacillary meningitis on day 18. Blood and cerebrospinal fluid cultures confirmed Proteus mirabilis. Antibiotic susceptibility testing showed extended spectrum beta-lactamase resistant to common antibiotics, and sensitive to meropenem. Despite initiation of high-dose meropenem by intravenous infusion (2 g every 8 hours), the patient did not improve, and died after 4 days of meropenem treatment. Gram-negative bacillary meningitis remains rare and is associated with an unfavorable prognosis.ConclusionsThis case report highlights the importance of microbiological identification of pathogens in resource-limited settings. As Gram-negative bacillary meningitis does not present with pleocytosis in patients with advanced human immunodeficiency virus, a negative lumbar puncture cannot exclude this diagnosis. Access to clinical bacteriology in resource-limited settings is essential to enable correct antibiotic treatment and avoid overuse of antibiotics to which there is already resistance. It further plays an essential role in public health by identifying antibiotic susceptibilities. Infection prevention and control measures must be reinforced in order to protect patients from such avoidable healthcare-associated infections.

Post ventriculoperitoneal shunting S. Maltophilia Meningitis

Background: Leptomeningeal inflammation caused by S. Maltophilia is rare. It is inextricably linked with prior antimicrobial therapy, prolonged ICU stays and antecedent neurosurgical intervention. Case description: We describe a case of a 5-year-old male child with posterior fossa medulloblastoma with obstructive hydrocephalus who underwent ventriculoperitoneal shunt followed by suboccipital midline craniotomy and later presented with S. Maltophilia meningitis. Conclusion: The overall mortality in the cases reviewed was 17 per cent. Inherent resistance to a wide array of antimicrobial agents with a simultaneously increasing number of cases poses a therapeutic challenge. Trimethoprim/sulfamethoxazole is recommended as empirical and as a definitive treatment in patients with S. Maltophilia infection. The optimal duration of therapy for S. Maltophilia meningitis is similar to the treatment of gram-negative bacillary meningitis, which is usually 2 weeks after the culture has been negative.

MULTIFACTORIAL MENINGITIS IN A PATIENT WITH PREVIOUS EPSTEIN BARR VIRUS ENCEPHALITIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gram negative bacillary meningitis is rare and mostly occurs in patients with recent neurosurgery. We present such a case of bacterial meningitis combined with other etiologies in a patient with previous Epstein Barr Virus (EBV) encephalitis. CASE PRESENTATION: 62-year-old male with history of diabetes, stroke and EBV encephalitis (1 month ago) presented with altered mentation. Lumbar puncture (LP) showed neutrophil predominant leukocytosis but cerebrospinal fluid (CSF) culture was negative. Brain imaging showed developing hydrocephalus. He was started on empiric meningitis coverage with antibacterial, antifungal and antitubercular regimen (due to basilar changes on imaging and mildly elevated adenosine deaminase in the CSF). He underwent right craniotomy with ventriculo-peritoneal (VP) shunt placement. Course complicated by worsening mentation requiring intubation for airway protection. Due to concern of hospital acquired pneumonia (HAP), piperacillin-tazobactam was added. Repeat LP showed improved leukocyte count but culture was again negative. He had persistent fevers after finishing piperacillin-tazobactam course; subsequent sputum culture and 3rd CSF culture now grew pseudomonas aeruginosa. He finished 21 days of systemic cefepime and 7 days of intrathecal tobramycin for pseudomonas; and 14 days of empiric amphotericin B (although fungal CSF culture was negative). He remains on empiric antitubercular regimen (isoniazid/rifampin/pyrazinamide/ethambutol) - culture negative. Mentation remains poor and family is currently deciding on aggressive care with tracheostomy or palliative care approach. DISCUSSION: In our case, meningitis on admission was likely some bacterial superinfection after viral encephalitis. After neurosurgery, 2nd CSF culture was negative likely due to ongoing antibiotics for HAP. 3rd CSF culture grew pseudomonas as patient was now off of piperacillin-tazobactam. Pseudomonas meningitis is rare and can occur as complication of neurosurgery, chronic cranial osteomyelitis, mastoiditis or trauma. The mortality rate ranges from 40 to 80%. Complications include hydrocephalus, brain abscesses, seizures, ventriculitis etc. The CSF gram stain is positive in 50% of cases with a positive culture result. Bacteremia is also present in about 50% of the cases. The usual empiric meningitis regimen does not cover pseudomonas and antipseudomonal agents can be added in patients with above risk factors. Cefepime/ceftazidime are empiric therapy and should be adjusted based on sensitivities. Dual therapy with intrathecal/intraventricular regimens can be started in resistant cases. Adjuvant steroids have shown no benefit. CONCLUSIONS: Timely recognition of risk factors for gram negative bacillary meningitis and starting empiric treatment regimen can improve the prognosis of such patients. REFERENCE #1: Berk SL, McCabe WR. Meningitis caused by gram-negative bacilli. Ann Intern Med. 1980;93(2):253. REFERENCE #2: Rahal JJ, Simberkoff MS. Host defense and antimicrobial therapy in adult gram-negative bacillary meningitis. Ann Intern Med. 1982;96(4):468. REFERENCE #3: S. Pai, L. Bedford et al. Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital. An International Journal of Medicine, Volume 109, Issue 2, February 2016, Pages 85–89, https://doi.org/10.1093/qjmed/hcv094 DISCLOSURES: No relevant relationships by Sahib Singh, source. Web Response no disclosure on file for Parth Jamindar

Community-acquired Escherichia coli meningitis with ventriculitis in an adult\u2014a rare case report

BackgroundCommunity-acquired gram-negative bacillary meningitis is rare to occur without preexisting conditions like trauma, organ dysfunction, and immunocompromised state, and very few case reports with Escherichia coli have been described in literature till now. Presence of ventriculitis along with meningitis makes the incidence further sparse.Case presentationA review of literature identified a total of only 45 community-acquired E. coli meningitis from 1945 till to date. Here, we have described a case of community-acquired E. coli meningitis with ventriculitis in an adult with past history of completely repaired CSF leak secondary to trauma nearly 23 years ago, without current radiological evidence of persistent CSF leak and therefore described as spontaneously acquired. Post-contrast T1 images of MRI were suggestive of subtle ependymal enhancement of ventricles, and patient was treated in lines of ventriculitis. Initial CSF was suggestive of acute pyogenic meningitis, and the organism grown was pan-sensitive E. coli. Patient was treated with antibiotics according to the culture sensitivity pattern and was given a prolonged course of 6 weeks of antibiotic therapy in view of ventriculitis.ConclusionCommunity-acquired E. coli meningitis with possible ventriculitis in adults is described as a rare entity and is likely to be underrated and under-recognized.

Postoperative Central Nervous System Infection After Neurosurgery in a Modernized, Resource-Limited Tertiary Neurosurgical Center in South Asia

Postoperative central nervous system infections (PCNSIs) are rare but serious complications after neurosurgery. The purpose of this study was to examine the prevalence and causative pathogens of PCNSIs at a modernized, resource-limited neurosurgical center in South Asia. A retrospective analysis was conducted of the medical records of all 363 neurosurgical cases performed between June 1, 2012, and June 30, 2013, at a neurosurgical center in South Asia. Data from all operative neurosurgical cases during the 13-month period were included. Cerebrospinal fluid (CSF) analysis indicated that 71 of the 363 surgical cases had low CSF glucose or CSF leukocytosis. These 71 cases were categorized as PCNSIs. The PCNSIs with positive CSF cultures (9.86%) all had gram-negative bacteria with Pseudomonas aeruginosa (n = 5), Escherichia coli (n = 1), or Klebsiella pneumoniae (n = 1). The data suggest a higher rate of death (P = 0.031), a higher rate of CSF leak (P < 0.001), and a higher rate of cranial procedures (P < 0.001) among the infected patients and a higher rate of CSF leak among the patients with culture-positive infections (P = 0.038). This study summarizes the prevalence, causative organism of PCNSI, and antibiotic usage for all of the neurosurgical cases over a 13-month period in a modernized yet resource-limited neurosurgical center located in South Asia. The results from this study highlight the PCNSI landscape in an area of the world that is often underreported in the neurosurgical literature because of the paucity of clinical neurosurgical research undertaken there. This study shows an increasing prevalence of gram-negative organisms in CSF cultures from PCNSIs, which supports a trend in the recent literature of increasing gram-negative bacillary meningitis.

Spontaneous adult Gram-negative bacillary meningitis in Soweto, South Africa

Gram-negative bacillary (GNB) meningitis is a rare cause of meningitis in adults and can occur as a spontaneous infection or as a complication of a neurosurgical procedure or trauma. We aimed to describe the characteristics and outcomes of adults with spontaneous GNB meningitis. A retrospective cohort analysis was performed of 26 patients with GNB meningitis seen at a single hospital in Soweto, South Africa. A predisposing condition was found in 24 (92%) patients. The 19 (73%) HIV-infected patients had a median CD4 count of 24/mm(3). Chronic renal disease, diabetes mellitus, myeloma, and alcoholism were other underlying conditions. The HIV-infected had a median cerebrospinal fluid (CSF) neutrophil count of 2/mm(3) compared to the HIV-non-infected of 560/mm(3). Common organisms were Escherichia coli, Klebsiella pneumoniae, and non-typhoidal Salmonella in HIV-positive patients and K. pneumoniae in the HIV-negative group. Ten (38%) isolates were resistant to third-generation cephalosporins. Mortality was 65%. A disproportionate burden of GNB meningitis fell on the HIV-infected, among whom absent or low CSF white cells was common. Management was complicated by high rates of resistance to third-generation cephalosporins.

Spontaneous gram-negative bacillary meningitis in adult patients: characteristics and outcome

BackgroundSpontaneous meningitis caused by gram-negative bacilli in adult patients is uncommon and poorly characterized. Our objective is to describe and compare the characteristics and the outcome of adult patients with spontaneous gram-negative bacilli meningitis (GNBM) and spontaneous meningitis due to other pathogens.MethodsProspective single hospital-based observational cohort study conducted between 1982 and 2006 in a university tertiary hospital in Barcelona (Spain). The Main Outcome Measure: In-hospital mortality.ResultsGram-negative bacilli meningitis was diagnosed in 40 (7%) of 544 episodes of spontaneous acute bacterial meningitis. The most common pathogens were Escherichia coli and Pseudomonas species. On admission, characteristics associated with spontaneous gram-negative bacilli meningitis by multivariate modeling were advanced age, history of cancer, nosocomial acquisition of infection, urinary tract infection as distant focus of infection, absence of rash, hypotension, and a high cerebrospinal fluid white-cell count. Nine (23%) episodes were acquired in the hospital and they were most commonly caused by Pseudomonas. The in-hospital mortality rate was 53%. The mortality rate was higher among patients with Gram-negative bacillary meningitis than among those with other bacterial meningitis and their risk of death was twenty times higher than among patients infected with Neisseria meningitidis (odds ratio 20.47; 95% confidence interval 4.03-103.93; p<0.001).ConclusionsGram-negative bacilli cause 9% of spontaneous bacterial meningitis of known etiology in adults. Characteristics associated with GNBM include advanced age, history of cancer, nosocomial acquisition, and urinary tract infection as distant focus of infection. The mortality rate is higher among patients with gram-negative bacillary meningitis than among those with other bacterial meningitides.

Salmonella entericaSerotype Arizonae Meningitis in a Neonate

Typhoidal and nontyphoidal salmonella infections are common causes of gastroenteritis in the community. However, salmonella only rarely causes invasive infections like meningitis. We report a 13-day-old female neonate with signs and symptoms of meningitis whose cerebrospinal fluid (CSF) culture showed Salmonella enterica serotype Arizonae that was sensitive to ceftriaxone. She presented with fever and failure to feed for 2 days. Despite prompt treatment with ampicillin, gentamicin, and ceftriaxone, she developed communicating hydrocephalus, frequent seizures, and coma that progressed to death after 2 weeks of hospitalization. Salmonella enterica serotype Arizonae is a rare cause of human infection known to leading to meningitis symptoms similar to those caused by other salmonella species. This is the first report of it as a cause of meningitis in a child under one month of age. Therefore, it should be included in the differential diagnosis of Gram-negative bacillary meningitis in immunocompromised children, neonates, and those with contacts with reptiles.

Intraventricular antimicrobial therapy in postneurosurgical Gram-negative bacillary meningitis or ventriculitis: A hospital-based retrospective study

Postneurosurgical Gram-negative bacillary meningitis (GNBM) or ventriculitis is a serious issue. Intraventricular (IVT) therapy has been applied; however, its effectiveness remains controversial, and the adverse drug effects are considerable. The demographic data, treatment strategies, and clinical outcomes of patients with postneurosurgical GNBM or ventriculitis were recorded. From 2003 to 2011, data on 127 episodes of infection in 109 patients were collected, and 15 episodes in 14 patients were treated using a sequential combination of intravenous antibiotics and IVT therapy; others received intravenous antibiotics alone. The average age of patients who received a sequential combination with IVT therapy was 48.9 years, and 71.4% of the patients were men. The regimens used for IVT therapies included gentamicin (n = 4), amikacin (n = 7), and colistin (n = 4). After meningitis had been diagnosed, the average period that elapsed before initiation of IVT therapy was 25.4 days, and the average duration of IVT therapy was 13.3 days. The most frequently isolated pathogen from cerebrospinal fluid (CSF) was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Serratia marcescens. The cure rate was 73.3%. Of note, the mean period to sterilize the CSF after appropriate IVT antibiotic treatment was 6.6 days. There were no incidents of seizure or chemical ventriculitis during this IVT therapy. The findings of this study suggest that IVT antibiotic therapy is a useful option in the treatment of postneurosurgical GNBM or ventriculitis, especially for those with a treatment-refractory state.

Neurosurgical Gram-Negative Bacillary Ventriculitis and Meningitis: A Retrospective Study Evaluating the Efficacy of Intraventricular Gentamicin Therapy in 31 Consecutive Cases

Gram-negative bacillary (GNB) ventriculitis and meningitis are rare but serious complications after neurosurgery. Prospective studies on antibiotic treatment for these infections are lacking, and retrospective reports are sparse. At our hospital in Uppsala, Sweden, meropenem has been recommended as empirical therapy since 1996, with the addition of intraventricular gentamicin in cases that do not respond satisfactorily to treatment. In this study, we retrospectively compare the efficacy of combination treatment with intraventricular gentamicin to that of systemic antibiotics alone. In addition, we report our experience of meropenem for the treatment of GNB ventriculomeningitis. Adult consecutive patients with gram-negative bacteria isolated from cerebrospinal fluid during a 10-year period and with postneurosurgical GNB ventriculitis or meningitis were included retrospectively. Data were abstracted from the medical records. Thirty-one patients with neurosurgical GNB ventriculitis or meningitis and follow-up for 3 months were identified. The main intravenous therapies were meropenem (n = 24), cefotaxime (n = 3), ceftazidime (n = 2), imipenem (n = 1), and trimethoprim-sulfamethoxazole (n = 1). Thirteen patients were given combination treatment with appropriate intraventricular gentamicin. These patients had a higher cure rate and a lower relapse rate than did those treated with intravenous antibiotics alone (P = .03). Relapse occurred in 0 of 13 patients treated intraventricularly and in 6 of 18 patients treated with systemic antibiotics alone. The mortality rate was 19%; 3 patients in each group died, but in no case was death considered to be attributable to meningitis. Our results support combination treatment with intraventricular gentamicin for postneurosurgical GNB ventriculomeningitis. Meropenem seems to be an effective and safe alternative for the systemic antibiotic treatment of these neurointensive care infections.

Gram-negative bacillary meningitis in Egypt

Gram-negative bacillary meningitis (GNBM) is a rare disease with a high rate of mortality. The aim of this study was to describe the clinical presentation and outcome of primary and secondary GNBM and to evaluate the efficacy of ceftriaxone (a third-generation cephalosporin) in the treatment of this disease. A retrospective study was conducted including 95 patients with GNBM admitted to the Abbassia and Imbaba fever hospitals' meningitis wards in Egypt during the period from 1993 to the end of the year 2009. Their cerebrospinal fluid samples were subjected to conventional bacteriological methods for isolation of the causative Gram-negative bacilli. Forty-nine patients had primary GNBM (no predisposing cause of meningitis was detected) and 46 patients had secondary GNBM (with a predisposing cause of meningitis). Primary GNBM was characterized by an abrupt onset and was significantly associated with typical signs of meningeal irritation. The most common infecting organisms were Salmonella typhi in 16 (33%) patients and Escherichia coli in 15 (31%) patients. Of the patients with primary GNBM, 26 (53%) were cured, 11 (22%) developed neurological sequalae, and 12 (24%) patients died. Secondary GNBM was characterized by an insidious onset and significantly associated with unarousable coma. The most common infecting organisms were Proteus mirabilis in 17 (37%) patients and Pseudomonas aeruginosa in 16 (35%) patients. The most common predisposing factor of meningitis was otitis media and occurred in 26 (57%) patients. Of the patients with secondary GNBM, 15 (33%) were cured, 15 (33%) developed neurological sequalae, and 16 (35%) died. Primary GNBM was significantly associated with a higher cure rate than secondary GNBM. The duration of symptoms in patients with secondary GNBM was significantly higher than in those with primary GNBM. Ceftriaxone was the initial drug for treatment of these patients until the antibiotic sensitivity tests were reported. The overall resistance rate to the drug was 4%. GNBM still has a high mortality rate and should be managed as a medical emergency. GNBM should be suspected in patients with otitis media, neurosurgical, and head trauma or who underwent spinal anesthesia and have disturbance in their level of consciousness, even if there are no signs of meningeal irritation. Ceftriaxone is still an effective drug and had a low rate of resistance in our study.

Neurosurgically related nosocomial Acinetobacter baumannii meningitis: report of two cases and literature review

Nosocomial meningitis is an uncommon complication of neurosurgical procedures, although nosocomial Gram-negative bacillary meningitis does occur occasionally in neurosurgical intensive care units (NSICUs). Acinetobacter baumannii is a rare cause of nosocomial meningitis, and is an even rarer cause of meningitis outbreaks in NSICUs. We report two cases of A. baumannii meningitis in an NSICU due to suboptimal aseptic technique in obtaining cerebrospinal fluid (CSF) specimens. After institution of infection control measures, i.e. aseptically collecting CSF specimens from distal external ventricular drain ports, there were no further cases. This report also reviews nosocomial Acinetobacter meningitis in adult neurosurgical patients.

Adults with spontaneous aerobic Gram-negative bacillary meningitis admitted to the intensive care unit

The characteristics of spontaneous aerobic Gram-negative bacillary meningitis (AGNBM) were determined in 40 adults requiring admission to an intensive care unit (ICU) during a 16-year period in ten French ICUs. Eight infections were hospital-acquired and most patients had predisposing factors, mainly chronic alcoholism and an immunocompromised status. Three immunosuppressed patients had disseminated strongyloidiasis. Gram's stain, cerebrospinal fluid and blood cultures were positive for 85%, 98% and 80% of cases, respectively. Escherichia coli (57%) and Klebsiella pneumoniae (17%) were the most frequent pathogens. In-ICU mortality was 38%. Spontaneous AGNBM is a rare complication of bacteraemia in adults. The severity of predisposing underlying diseases might explain the poor prognosis despite appropriate antimicrobial therapy.

Third-generation cephalosporin resistance among Gram-negative bacilli causing meningitis in neurosurgical patients: significant challenges in ensuring effective antibiotic therapy

The treatment of meningitis caused by Gram-negative bacilli in neurosurgical patients is a major challenge because of the complexity of these patients, the emergence of antibiotic resistance in many of the causative organisms and the restricted choice of antibiotics suitable for use, owing to a failure to achieve high enough concentrations in the CSF. We reviewed the incidence, aetiology, treatment and outcome of all patients with Gram-negative bacillary meningitis (GNBM) in our centre over a 7 year period. Beaumont Hospital, Dublin is a 720 bed tertiary referral hospital and contains the national neurosurgical centre for the Republic of Ireland. The case notes and microbiological records of all patients with GNBM between 1998 and 2004 inclusive were reviewed retrospectively. Only patients with positive CSF culture and clinical features compatible with meningitis were included. Forty separate episodes of GNBM involving 34 different patients occurred during the study period. The most common causative organisms were Enterobacter spp. (35%), Escherichia coli (22.5%) and Pseudomonas aeruginosa (15%). Twenty-five per cent of isolates were resistant to third-generation cephalosporins. The median duration of treatment was 19.2 days and a combination of intravenous and intraventricular antibiotics was the most common treatment regimen used. Mortality directly related to GNBM was 2.5%. Although the mortality directly related to GNBM was low, the emergence of strains resistant to third-generation cephalosporins represents a therapeutic challenge. Treatment with combined intravenous and intraventricular antibiotics is recommended for 2-3 weeks, but more studies are required to determine the optimal management of this difficult condition.

Meningitis due to Enterobacter aerogenes subsequent to resection of an acoustic neuroma and abdominal fat graft to the mastoid

Meningitis is an uncommon complication of neurosurgical procedures, with an incidence of 1.1% to 2.5%. Although unusual, the frequency of nosocomial Gram-negative meningitis appears to be increasing. Gram-negative meningitis has been documented following disruption of the dura-arachnoid barrier secondary to trauma or surgery. The association of Gram-negative bacillary meningitis with neurosurgical procedures was first reported in the 1940's. Wolff et al. described the association between Enterobacter species and post-neurosurgical infection. More recently, risk factors for nosocomial Enterobacter meningitis have been characterized by Parodi et al. Adipose graft, as an independent risk factor has not yet been reported. A patient with acoustic neuroma resection, who developed bacterial meningitis from an abdominal fat pad graft to a mastoidectomy bed is described. A brief overview was made of post-neurosurgical Gram-negative meningitis.

Adjunctive dexamethasone treatment in acute bacterial meningitis

The initiation of antibiotic treatment on suspicion of bacterial meningitis is important, but it is not enough to improve the prognosis for patients, especially those with pneumococcal meningitis. The mortality and morbidity of pneumococcal meningitis are still devastating, and results of a recent randomised trial have shown evidence in favour of dexamethasone treatment given before or with the first antibiotic dose. Adjuvant dexamethasone is unequivocally recommended in children and adults with haemophilus meningitis or pneumococcal meningitis. The benefit of adjunctive dexamethasone is likely to be greatest in patients who are otherwise healthy and present early with acute bacterial meningitis. Dexamethasone is not currently recommended for the treatment of gram-negative bacillary meningitis and neonatal meningitis. Dexamethasone, before or with the first dose of antibiotic, is likely to be one of the most significant practice changes that will benefit many adults and children with common types of acute bacterial meningitis and has been of proven value in the developed world.

Neonatal Meningitis in the New Millennium

After completing this article, readers should be able to: 1. Describe recent changes in the incidence and outcome of neonatal bacterial meningitis. 2. Characterize the predominant responsible organisms and susceptibility of neonates to bacterial meningitis in developed countries. 3. Discuss whether routine lumbar puncture is indicated in the evaluation for sepsis/meningitis immediately after birth. 4. Characterize the duration of positive cerebrospinal fluid cultures with gram-negative bacillary meningitis. 5. Discuss the usefulness of C-reactive protein in the diagnosis and management of neonatal bacterial meningitis. 6. Describe the best predictors of an adverse outcome in neonatal bacterial meningitis. Although bacterial sepsis and meningitis often are linked closely in neonates, the frequency with which neonatal meningitis occurs relative to neonatal sepsis has decreased in recent years. Instead of one case of meningitis for every three or four cases of sepsis, it is now closer to 1 in 20, at least in developed countries. Indeed, a 1996 report from Australia documented a rate of 1 in 40 (5/209). Reports published in the past decade indicate an incidence of neonatal meningitis of 0.16 to 0.45 per 1,000 live births in developed countries. Rates may be higher in underdeveloped countries. Case fatality (mortality) rates in several recent reports from developed countries have ranged from 3% to 13% compared with 25% to 30% in reports from 15 to 20 years ago, although less developed countries still report rates of 30% to 40%. Case fatality rates vary with the causative organism, but generally are higher for gram-negative organisms. Some recent reports have suggested that the outlook for neonates who have meningitis may be improving regarding case fatality rates and neurodevelopmental outcome. Nevertheless, clinicians need to remain vigilant and investigate when sepsis and meningitis are suspected. Early treatment remains the best hope of preventing long-term deficits, although it is difficult to assess the adverse consequences …

Gram-negative bacillary meningitis in adult post-neurosurgical patients

Background To assess the clinical features and therapeutic outcomes of Gram-negative bacillary meningitis (GNBM) in adult postneurosurgical patients. Methods Thirty adult patients with GNBM were included in this study. Their clinical features, laboratory data, prognostic factors, and therapeutic outcome were analyzed. The patients were 22 males and 8 females, aged 17–72 years. Seven had community-acquired infections and 23 had nosocomial infections. Two patients were associated with brain abscess. Results The pathogens found in the 30 GNBM patients were Pseudomonas aeruginosa, Klebsiella species, Escherichia coli, Acinetobacter baumannii, and some rare pathogens including Citrobacter freundii, Serratia marcescens, Enterobacter cloacae, and Proteus mirabilis. Among these 30 patients, 8 patients with third-generation cephalosporin-resistant GNBM were identified since 1994; all infections were nosocomially acquired. Appropriate antibiotics were given to 22 patients. Eight patients did not receive appropriate antibiotic therapy. All eight died. The mortality rate in those treated with appropriate antibiotics was 14%. Conclusions There has been an increase of GNBM in post-neurosurgical patients in recent years. In addition, the emergence of strains resistant to third-generation cephalosporins in this specific group of patients has also been noted in recent years, and has become a great therapeutic challenge. We noted many prognostic factors in post-neurosurgical patients in this study; however, appropriate antibiotic therapy and initial consciousness level are the most significant ones. Therefore, in cases of post-neurosurgical patients with nosocomially acquired GNBM, the possibility of third-generation cephalosporin resistance should be strongly suspected. Early initiation of appropriate antibiotic therapy is needed in this potentially fatal disease.