Negative Cerebrospinal Fluid Cultures Research Articles

Association between neuroimaging and clinical outcomes in individuals with central nervous system cryptococcosis.

The radiological manifestations of central nervous system (CNS) cryptococcosis are diverse and often subtle. There is heterogeneity on how different neuroimaging patterns impact prognosis. This study aims to assess the association between the neuroimaging and clinical outcomes of CNS cryptococcosis. All patients with CNS cryptococcosis between July 2017 and April 2023 who underwent brain magnetic resonance imaging (MRI) were included. The primary outcome was mortality during hospitalisation. Secondary outcomes were readmission, ventricular shunting, duration of hospitalisation and time to the first negative cerebrospinal fluid culture. We compared the outcomes for each of the five main radiological findings on the brain MRI scan. We included 46 proven CNS cryptococcosis cases. The two main comorbidity groups were HIV infection (20, 43%) and solid organ transplantation (10, 22%), respectively. Thirty-nine patients exhibited at least one radiological abnormality (85%), with the most common being meningeal enhancement (34, 74%). The mortality rates occurred at 11% (5/46) during hospitalisation. We found no significant disparities in mortality related to distinct radiological patterns. The presence of pseudocysts was significantly associated with the need for readmission (p = .027). The ventricular shunting was significantly associated with the presence of pseudocysts (p = .005) and hydrocephalus (p = .044). In this study, there is no association between brain MRI findings and mortality. Larger studies are needed to evaluate this important issue.

Cerebrospinal Fluid Shunt Reinfection and Malfunction in Ecuadorian Children with Different Reshunting Criteria After Infection. “Is It Just One Shunt After Another?”

There is no firm evidence regarding cerebrospinal fluid (CSF) shunt reimplantation after infection in the pediatric population. The purpose of this study was to compare different criteria and analyze new shunt failure. A cross-sectional retrospective multicenter study was performed over 6 years to study patients and each infected shunt at diagnosis, reimplantation, and after reimplantation. The patients were divided into 2 groups: group 1 (G1), reimplantation after negative serial CSF cultures during antibiotic treatment; group 2 (G2), reimplantation after negative serial pancultures after completion of antibiotics. The differences were measured with Mann-Whitney and Χ2 tests; multivariate analysis and associations were calculated using odds ratios (ORs) based on logistic regression. There were 137 shunt infection events in 110 patients: 28 events in G1 and 109 in G2. Significant differences were observed in the diagnosis and reimplantation. Reimplantation dysfunction in G1 was 16 (55.17%) versus 30 (27.78%) in G2 (P= 0.006). The risk of shunt malfunction after reimplantation increased for G1 reimplantation criteria (P= 0.018; OR, 3.34; confidence interval [CI], 1.23-9.05): pleocytosis at diagnosis >17 cells (P= 0.036; OR, 2.41; CI, 1.06-5.47), CSF proteins at diagnosis >182 mg/dL (P= 0.049; OR, 2.21; CI, 1.00-4.89). G2 reimplantation criteria were related to improved pleocytosis, CSF proteins, and blood neutrophils compared with G1. Mechanical and infectious dysfunction of the new shunt was 3 times more prevalent in G1 than in G2, considering the differences between the groups at diagnosis. Increased parameters of infection at diagnosis were associated with future malfunction more than parameters before reimplantation in both groups.

Tubercular Meningitis Mimicking Acute Disseminated Encephalomyelitis (ADEM)- A Case Report

Tuberculosis remains endemic in India, and its manifestation in the central nervous system (CNS) poses significant challenges in diagnosis and management. We present a rare case of a 65-year-old male with tubercular meningitis exhibiting atypical features of acute disseminated encephalomyelitis (ADEM). The patient presented with a month-long history of fever, severe headache, altered sensorium, and neurological signs including brisk reflexes, neck rigidity, and bilateral motor weakness. Initial investigations revealed elevated inflammatory markers and abnormal cerebrospinal fluid (CSF) findings consistent with tubercular meningitis. Despite negative CSF culture and nucleic acid amplification tests (NAATs) for Mycobacterium tuberculosis, the patient displayed characteristic asymmetrical bilateral cerebral lesions on MRI suggestive of ADEM. Given the diagnostic ambiguity and a high suspicion of CNS tuberculosis with concurrent ADEM, the patient was treated with anti-tubercular therapy (ATT) and a course of intravenous methylprednisolone followed by oral prednisolone. Subsequent clinical improvement prompted gradual tapering of prednisolone, leading to a full recovery at discharge. This case highlights the complexity of diagnosing CNS tuberculosis coexisting with ADEM, emphasizing the importance of a comprehensive clinical assessment and tailored therapeutic interventions in managing such intricate neurological presentations.

Broad Range Eubacterial Polymerase Chain Reaction of Cerebrospinal Fluid Reduces the Time to Exclusion of and Costs Associated with Ventriculostomy-Related Infection in Hemorrhagic Stroke

BackgroundPatients with hemorrhagic stroke and an external ventricular drain in situ are at risk for ventriculostomy-related-infections (VRI). Because of the contamination of the cerebrospinal fluid (CSF) with blood and the high frequency of false negative CSF culture, the diagnosis of VRI remains challenging. This study investigated the introduction of CSF broad range eubacterial polymerase chain reaction (ePCR) and its effect on frequency and duration of antibiotic therapy for VRI, neurocritical care unit (NCCU) length of stay, related costs, and outcome.MethodsBetween 2020 and 2022, we prospectively included 193 patients admitted to the NCCU of the University Hospital of Zürich with hemorrhagic stroke and an external ventricular drain for more than 48 h. Patient characteristics, serum inflammatory markers, white blood cell count in CSF, use and duration of antibiotic treatment for VRI, microbiological findings (CSF cultures and ePCR tests), and NCCU length of stay were compared in patients with no infection, noncerebral infection, suspected VRI, and confirmed VRI. Data of patients with suspected VRI of this cohort were compared with a retrospective cohort of patients with suspected VRI treated at our NCCU before the introduction of CSF ePCR testing (2013–2019).ResultsOut of 193 patients, 12 (6%) were diagnosed with a confirmed VRI, 66 (34%) with suspected VRI, 90 (47%) with a noncerebral infection, and 25 (13%) had no infection at all. Compared with the retrospective cohort of patients, the use of CSF ePCR resulted in a reduction of patients treated for suspected VRI for the whole duration of 14 days (from 51 to 11%). Furthermore, compared with the retrospective group of patients with suspected VRI (n = 67), after the introduction of CSF ePCR, patients with suspected VRI had shorter antibiotic treatment duration of almost 10 days and, hence, lower related costs with comparable outcome at 3 months.ConclusionsThe use of CSF ePCR to identify VRI resulted in shorter antibiotic treatment duration without changing the outcome, as compared with a retrospective cohort of patients with suspected VRI.

A new adjunct in the differentiation of encephalitis and meningitis after negative cerebrospinal fluid culture: systemic inflammatory immune index

Objectives: Encephalitis and meningitis can have serious and potentially life-threatening consequences. This study aims to investigate whether the effects of systemic immune inflammation index (SII) and neutrophil/lymphocyte (N/L) ratio on differential diagnosis, severity, and clinical outcomes are superior to each other in patients diagnosed with encephalitis and meningitis in the emergency department. Methods: Patients aged 18 years and older who presented to the adult emergency department of the hospital and were diagnosed with meningitis or encephalitis between January and December 2022 were included in the study. Patients under 18 and those with missing data in their files were excluded from the study. N/L ratio, SII values, and other associated parameters were compared between the group with mortality and the group who survived both diseases. Results: There were significant differences in neutrophil, lymphocyte, N/L ratio, SII, and C-reactive protein (CRP) values between meningitis and encephalitis patients. N/L ratio and SII values were significantly lower in encephalitis patients than in meningitis patients. There was no significant difference in any of the parameters between surviving and deceased patients. Conclusions: Simple calculable ratios such as SII and N/L ratio can be a supportive parameter in the differential diagnosis of the disease. However, it has been observed that using these indices is not a useful tool in determining the severity and prognosis of patients with encephalitis and meningitis.

Device-associated Meningitis due to Elizabethkingia meningoseptica: A Therapeutic Challenge.

To the Editors: Elizabethkingia meningoseptica causes life-threatening infections in humans, especially in immunocompromised patients and infants with low birth weights. It is one of the main causes of meningitis in pediatric and immunocompromised patients in the context of nosocomial diseases associated with devices and is also related to low-birth-weight infants and prematurity1 Due to their resistance to many commonly used antibiotics (beta-lactams, carbapenemics, aminoglycosides, etc.), clinicians face treatment challenges.2 There are currently few publications on pediatric cases regarding E. meningoseptica device-associated meningitis with breakthrough resistance to trimethoprim-sulfamethoxazole (TMP/SMX) while treatment with dual intravenous (IV) therapy with TMP/SMX and high-dose ciprofloxacin requiring intraventricular ciprofloxacin for eradication. This letter is written to describe a case that posed a diagnostic challenge in our center. A 1-month-old female patient with hydrocephalus secondary to a history of myelomeningocele that required correction at birth with a ventriculoperitoneal (VP) shunt system presented during her prolonged hospitalization with device-associated meningitis due to E. meningoseptica initially susceptible to TMP/SMX MIC <16 µg/L, follow-up cerebrospinal fluid (CSF) cultures remained positive for the same pathogen with TMP/SMX breakthrough resistance acquired (MIC > 64 µg/L) (Table 1). Different antibiotics were tested in vitro and showed resistance to vancomycin, minocycline, and rifampicin, maintaining only susceptibility to ciprofloxacin without achieving eradication with systemic dual high-dose IV therapy. TABLE 1. - Cerebrospinal Fluid Culture Analyzed in Vitek2 System (Biomérieux) Initial Control Antibiotic Value/Interpretation Value/Interpretation Amikacin ≥64 µg/mL (R) ≥64 µg/mL (R) Aztreonam ≥64 µg/mL (R)) Cefazolin ≥64 µg/mL (R) Cefepime ≥64 µg/mL (R) ≥64 µg/mL (R) Ceftazidime ≥64 µg/mL (R) ≥64 µg/mL (R) Ceftriaxone ≥64 µg/mL (R) Ciprofloxacin ≥1 µg/mL (Susceptible) ≥1 µg/mL (S) Gentamicin ≥16 µg/mL (Resistant) ≥16 µg/mL (R) Meropenem ≥64 µg/mL (Resistant) ≥64 µg/mL (R) Piperacillin/tazobactam 32 µg/mL (Susceptible) ≥128 µg/mL (R) Tigecycline 1 µg/mL (S) ≥8 µg/mL (R) Trimethoprim/sulfamethoxazole (TMP/SMX) 40 µg/mL (S) ≥320 µg/mL (R) Colistin ≥16 µg/mL (R) Doripenem ≥8 µg/mL (R) Imipenem ≥16 µg/mL (R) (R), resistant; (S), susceptible. Intraventricular antimicrobial therapy with ciprofloxacin was proposed based on a case report in the literature: 21 days of systemic treatment combined with Intrathecal therapy, and another 21 days of systemic therapy alone. Negative CSF cultures were obtained after 6 days of dual therapy plus intraventricular ciprofloxacin with clinical improvement in the patient and replacement of the VP shunt. Although recent literature suggests that antibiotics such as fluoroquinolones can achieve good concentrations in the CSF fluid after IV administration and do not suggest their use in intraventricular or intrathecal routes,3 and that the FDA has not approved any antimicrobial agent for intraventricular use,3,4 when therapeutic options are limited due to multidrug-resistant pathogens in central nervous system infections, intraventricular/intrathecal antibiotic therapy with fluoroquinolones appears to be a viable option in the absence of other available treatments. More studies are required, particularly in cases, such as the one presented for antibiotics that theoretically achieve adequate CSF concentrations when only IV route is used.

Ataxic variant of Guillain-Barre syndrome, with positive GD1b antibodies in an elderly male: a case report (P10-5.005)

<h3>Objective:</h3> Discuss an atypical presentation of ataxic GBS with positive GD1b antibody. <h3>Background:</h3> The clinical spectrum of Guillain-Barre syndrome (GBS) ranges from asymptomatic to rapidly progressive and fatal. Ataxic GBS is one of the rare presentations. It is characterized by profound ataxia without ophthalmoplegia. We report a case of atypical presentation of GBS with rapidly progressive neurological deficits in an elderly male. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 73-year-old right-handed male with past medical history of hypertension and hyperlipidemia presented with gait imbalance and distal extremity numbness for five days prior to presentation. He noted he was having difficulty walking but denied weakness. He reported “electricity” type pain in his arms and legs and perioral tingling. He denied any other neurological deficits. He denied recent illness or vaccination. Physical exam was remarkable for severe ataxia, areflexia, and mild nystagmus. An MRI of the brain, cervical and thoracic spine showed no pathology. Cerebrospinal fluid (CSF) sampling showed protein of 46 mg/dL and no cells with a negative CSF culture. An electromyogram showed motor-sensory non-length dependant non-axonal loss without demyelination. A diagnosis of variant Guillain-Barre syndrome was suspected, and the patient received a 5-day course of intravenous immunoglobulins (IVIG). Despite this the patient developed neuromuscular respiratory failure necessitating intubation. GD1b antibody titter was found to be elevated at 1:800 (reference &lt;1:100) <h3>Conclusions:</h3> The ataxic variant of GBS is a very uncommon disease pathology. This case highlights the importance of considering different subtypes and presentations of GBS and related disorders. Early diagnosis and treatment with IVIG are important for a good outcome. <b>Disclosure:</b> Dr. Valhuerdi Porto has nothing to disclose. Dr. Shnawa has nothing to disclose. Dr. Joseph has nothing to disclose. Dr. Scott has nothing to disclose.

The First Report of Chryseobacterium gleum Caused Ventriculoperitoneal-shunt Infection in a Child.

To The Editors: Ventriculoperitoneal (VP) shunt is one of the most widely used and effective methods in the treatment of hydrocephalus in childhood. VP shunt infections have been observed in approximately 3.2%–25%, and Chryseobacterium spp. is a rare cause of VP shunt infections.1,2 Herein, we report the first VP shunt infection caused by Chryseobacterium gleum. A 12-month-old female (corrected age 8 months) born via spontaneous vaginal delivery, weighed 700 g at 25 weeks of gestation, was admitted to our emergency department with a fever with a maximum peak temperature of 39°C, projectile vomiting, and decreased oral intake. Her history included long-term ventilation in the neonatal intensive care unit with a diagnosis of moderate bronchopulmonary dysplasia. At 4 months of age, she developed intraventricular hemorrhage and progressive hydrocephalus, and a VP shunt was inserted. She had several episodes of VP shunt infections caused by S. epidermidis and S. aureus. At admission, the patient was febrile, tachycardic (heart rate, 160/min) and tachypneic (respiratory rate of 48/min). Physical examination showed weakness, lethargy and sleepiness. Her total Glasgow Coma Scale score was 12 (E3V4M5). Laboratory tests were as follows: white blood cell (WBC) count: 12.5 × 103/μL (neutrophil 37% and lymphocyte 54%), C-reactive protein: 20 mg/L, procalcitonin: 0.09 μg/L. The cerebrospinal fluid (CSF) WBC count was 120/mm3, protein 107 mg/dL and glucose 42 mg/dL. With the preliminary diagnoses of sepsis and shunt infection, intravenous (IV) cefotaxime (300 mg/kg/day) and IV vancomycin (60 mg/kg/day) was initiated empirically. Peripheral/catheter blood cultures and CSF samples were inoculated into aerobic and anaerobic culture bottles (BacT/ALERT, BioMérieux, Durham, USA). The patient underwent VP shunt externalization. The blood and urine cultures were negative during the patient’s follow-up. Chryseobacterium gleum was isolated in the CSF, shunt and ventricular catheter tip cultures on the 3rd day of treatment. The organism had high-level minimum inhibitory concentration (MIC) levels for meropenem (MIC = 32 μg/mL), imipenem (MIC = 32 μg/mL) and piperacillin-tazobactam (MIC = 250 μg/mL). MIC level of ciprofloxacin was 0.125 μg/mL and trimethoprim-sulfamethoxazole was 0.5 μg/mL. Cefotaxime and vancomycin were switched to IV trimethoprim/sulphamethoxazole (5 mg/kg every 6 hours) and ciprofloxacin (10 mg/kg every 8 hours). On the 5th day of the combined therapy, the patient’s CSF sample was evaluated and showed a WBC count of 30/mm3, glucose 42 mg/dL and protein 360 mg/ dL, and the CSF culture was sterile. Antibiotics were continued for 21 days. The patient was clinically stable, and no adverse effects or seizures were observed during or after the treatment. The extra ventricular drainage was removed, the VP shunt was inserted following 2 consecutive negative CSF cultures, and the patient was discharged. Chryseobacterium species are common in nature but are not found in human flora. Most cases are nosocomial and are frequently associated with immunosuppression or implantable devices. Chryseobacterum gleum is typically a low-virulence organism that can cause serious infections. It has been reported that Chryseobacterum gleum can cause infections such as central-line-associated bloodstream infection, community-acquired pneumonia and urinary tract infection in adults.3–5 Unlike previous reports, Chryseobacterium was isolated in the cerebrospinal fluid in our study. Chryseobacterum gleum commonly colonizes mechanical devices, causing device-associated infections, and can form biofilm. According to this study, VP shunt may be a risk factor for Chryseobacterium gleum infections. This report emphasizes the significance of Chryseobacterium species as a causative agent of a wide range of infections, and VP shunts can pose a risk for this agent. Data on the management of Chryseobacterium is limited. Antimicrobial susceptibility testing guidelines for Chryseobacterium infections should be developed for more effective and accurate treatment.

Nosocomial outbreaks of aseptic meningitis: A public health concern

Nosocomial outbreaks of aseptic meningitis: A public health concern

Investigation of Concurrent Pneumococcal Meningitis in Two Children Attending the Same Day-Care Center

Only a few clusters of invasive pneumococcal disease have been described globally in children, and most of these cases occurred before pneumococcal vaccination implementation. Two unusual cases of pneumococcal meningitis, occurring in the same daycare center over a 3-day period, were reported. Both cerebrospinal fluid (CSF) were sent to the National reference center for pneumococci. In addition, we decided to perform a pneumococcal carriage study on all children and staff of the daycare center to analyze the pneumococcal serotypes circulating in this DCC and to discuss an antibiotic chemoprophylaxis. CSF culture was positive for pneumococcus, and serotype 25A was identified by latex agglutination. The second case had negative CSF culture, but CSF antigen test and gene amplification results were positive for Streptococcus pneumoniae. Serotype 12F was identified by using molecular biology. The absence of correlation between these strains was confirmed by multi-locus sequence typing. In the carriage study, we included 29 children (median age 1.9 years, interquartile range 1.4–2.5) and 10 adults. Among the children, 24 carried Streptococcus pneumoniae (83%). The main serotypes isolated were 23A for 6 children and 25A for 5 children; serotypes were non-typeable for 3 children. Only 1 of 10 adults tested carried Streptococcus pneumoniae (serotype 12F). Despite this temporo-spatial pattern, the cases were unrelated and not due to carriage of a particular serotype. No specific action has been taken for the other children attending this DCC, and no other case of bacterial meningitis occurred.

Fast and Sensitive Multiplex Real-Time Quantitative PCR to Detect Cutibacterium Periprosthetic Joint Infections

Diagnosis of Cutibacterium periprosthetic joint infections (PJIs) is challenging due to a long cultivation time of up to 14 days. Faster culture-independent diagnosis would improve patient care with early and accurate treatment. Specific primers and probes were designed for Cutibacterium acnes, Cutibacterium avidum, and Cutibacterium granulosum and evaluated in a multiplex TaqMan real-time quantitative PCR (qPCR) format on 57 skin swabs and 20 culture-negative cerebrospinal fluid samples. The multiplex qPCR was tested in a PJI cohort of 41 sonication fluid samples from removed implants infected with different pathogens. All five culture-positive Cutibacterium PJIs were detected with the corresponding Cutibacterium-specific probe (100% positive percent agreement). The multiplex qPCR additionally detected C. avidum in two PJI sonication fluid samples that were diagnosed as Staphylococcus species infections according to culture (95% negative percent agreement). The new multiplex qPCR can provide a Cutibacterium PJI diagnosis within 1 day, allowing early and accurate antibiotic treatment. A prospective diagnostic trial in PJI with a high number of Cutibacterium species infections (shoulder PJI) is needed for further evaluation.

Evaluation of Real-Time Polymerase Chain Reaction in Culture-Negative Cerebrospinal Fluid Samples of Bacterial meningitis Patients

Background: Meningitis is a rigorous childhood disease with high morbidity and mortality. It is the main cause of under five mortality in India. Mainly three bacteria Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae are responsible. In low economic set up country like India, documented bacterial meningitis mainly depend on gram staining, cerebrospinal fluid (CSF) culture results or latex agglutination test resulting in less number of positive due to the prior antimicrobial intake which affects culture and latex agglutination test results. This study was taken up rapid and accurate molecular method like RT PCR to diagnose bacterial meningitis in culture-negative CSF samples.&#x0D; Materials and Methods: Fifty culture-negative CSF samples from suspected cases of bacterial meningitis were examined by real-time polymerase chain reaction (real-time PCR) for the presence of lytA, bexA, and ctrA genes specific for Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis respectively.&#x0D; Results: Positive real-time PCR results for Streptococcus pneumoniae were detected in 36 (72%) of culture-negative CSF samples while 10% positive results for Haemophilus influenzae type b. Nine (18%) samples were negative by real-time PCR for all tested organisms.&#x0D; Conclusion: The use of molecular techniques as real-time PCR can provide a valuable addition to the proportion of diagnosed cases of bacterial meningitis especially in settings with high rates of culture-negative results.

Bone Cement Internal Auditory Canal Reconstruction to Reduce CSF Leak After Vestibular Schwannoma Retrosigmoid Approach.

To describe rates of cerebrospinal fluid (CSF) rhinorrhea after reconstruction of the IAC with calcium phosphate bone cement during retrosigmoid resections of vestibular schwannomas. A retrospective chart review of 177 patients who underwent retrosigmoid craniotomy and opening of the internal auditory canal for resection of a vestibular schwannoma between January 2016 and September 2019 at a tertiary referral center. Patients with other cerebellopontine angle tumor histology, neurofibromatosis type II, or those undergoing revision surgeries were excluded. Out of 177 patients, six patients (3.4%) developed postoperative rhinorrhea. Four patients (2.3%) were taken back to the OR for mastoidectomy and repair of CSF leak. Three of these patients were noted to have a CSF leak from the peri-labyrinthine air cells, and one was found to have a leak from the craniotomy site communicating with the mastoid air cells. Two patients were conservatively managed with diuretics and had resolution of their CSF leak. Six patients (3.4%) were readmitted for postoperative infection. Two patients were diagnosed with meningitis (1.1%), one aseptic and one H. Influenza, and three patients developed surgical site infections (1.6%). One patient was empirically treated with antibiotics and ultimately had a negative CSF culture. Our results demonstrate that the use of calcium phosphate bone cement for IAC closure in retrosigmoid resection of vestibular schwannomas is a safe and effective technique with low rates of postoperative CSF rhinorrhea.

Meningitis due to Roseomonas in an immunocompetent adolescent

Both bacterial and aseptic meningitis can complicate neurosurgery, but they are often difficult to distinguish clinically or by cerebrospinal fluid (CSF) analysis. We present an adolescent with subacute meningitis after neurosurgery, eventually diagnosed with meningitis caused by Roseomonas mucosa via 16S rRNA gene sequencing after two negative CSF cultures. He was treated successfully with intravenous meropenem with full recovery. This case shows that distinguishing bacterial from aseptic meningitis is important to allow directed antibiotic therapy. We recommend considering bacterial meningitis in the differential diagnosis of aseptic meningitis complicating neurosurgery, and to perform molecular diagnostics such as bacterial sequencing if the suspicion of bacterial meningitis is high.

Detection of Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae in Culture Negative Cerebrospinal Fluid Samples from Meningitis Patients Using a Multiplex Polymerase Chain Reaction in Nepal.

The rapid identification of bacteria causing meningitis is crucial as delays in the treatment increase mortality rate. Though considered as the gold standard for the laboratory diagnosis of bacterial meningitis, culture might give false negative results in a case of patients under antibiotics prior to lumbar puncture. This study aimed to detect Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae by a multiplex polymerase chain reaction (PCR) in culture-negative cerebrospinal fluid samples collected from clinically suspected meningitis cases attending different hospitals in Kathmandu, Nepal from January 2017 to December 2019. S. pneumoniae, N. meningitidis and H. influenzae were detected in 8.59% (33/384) of the specimens by PCR and 7.55% (29/384) of the specimens by culture. Correlation between culture and PCR of the same sample was good (Spearman’s rho correlation coefficient = 0.932). However, the difference in positivity between culture and PCR was statistically not significant (p value > 0.05). In four specimens, culture could not detect any of the targeted bacteria whereas PCR could detect presence of H. influenzae. PCR increases the diagnostic yield for bacterial meningitis. PCR may be considered as an adjunctive test for establishing the cause of infection in culture negative clinically suspected meningitis cases.

Neonates and Young Infants With COVID-19 Presented With Sepsis-Like Syndrome: A Retrospective Case Controlled Study.

Objective: We aimed to describe the presentations and biochemical characteristics of sepsis-like syndrome (SLS) in infants aged <2 months who tested positive for SARS-CoV-2-in comparison to those in the same age group who were SARS-CoV-2-negative.Background: COVID-19 presents with a spectrum of manifestations, and children seem to have a favorable clinical course compared to other age groups. Limited data are available for symptomatic infants.Design: This was a case-controlled single-institution retrospective study on infants aged <2 months admitted with SLS between 1 April 2020 and 1 July 2020. These infants were divided into 2 groups: Group 1 (n = 41), infants with positive nasal/oropharyngeal swab polymerase chain reaction (PCR) results for SARS-CoV-2; and Group 2 (n = 40), infants with negative PCR results for SARS-CoV-2 (control group). Details between both groups were reviewed and analyzed.Outcome: The clinical and laboratory data for SARS-CoV-2 -positive infants who presented with SLS may differ from those for infants with SLS who tested negative for SARS-CoV-2.Results: Overall, 105 infants were admitted with clinical sepsis: 41 were SARS-CoV-2-positive, and 64 were negative. Fever was present in 90% of SARS-CoV-2-positive infants vs. 80% of the negative group. SARS-CoV-2-positive infants had a higher incidence of nasal congestion and cough (39 and 29%, respectively) compared to the SARS-CoV-2-negative group (20 and 3%, respectively) (P < 0.05). Poor feeding and hypoactivity occurred more frequently in the SARS-CoV-2-negative group (58 and 45%, respectively) than in the SARS-CoV-2-positive group (22 and 12%, respectively, P < 0.004). Sepsis workup, including lumbar puncture, was performed in 67% and partial septic workup was performed in 23% of the SARS-CoV-2-positive infants. Full sepsis workup was performed in 92% of the SARS-CoV-2-negative group. Cerebrospinal fluid (CSF) cultures were negative in 26/27SARS-CoV-2-positive infants (an infant had Klebsiella meningitis). All the SARS-CoV-2-negative infants had negative CSF cultures. Blood culture was negative in both groups. Urine culture showed bacterial growth in 9 infants with SARS-CoV-2-negative sepsis.Conclusions: Our study showed that respiratory symptoms (cough and nasal congestion) were more prominent in the SARS-CoV-2-positive group, while poor feeding and hypoactivity were reported more frequently in the negative group. However, the clinical differentiation between COVID-19 disease and sepsis in such age groups is difficult. Therefore, screening young infants with SLS for SARS-CoV-2- is necessary during this pandemic.

Arbovirus, herpesvirus, and enterovirus associated with neurological syndromes in adult patients of a university hospital, 2017-2018.

INTRODUCTION: Herpesviruses, enteroviruses, and arboviruses are important because of their clinical relevance and ability to cause meningitis, encephalitis, meningoencephalitis, and other diseases. The clinical virology associated with diagnostic technologies can reduce the morbidity and mortality of such neurological manifestations. Here we aimed to identify the genomes of agents that cause neurological syndromes in cerebrospinal fluid (CSF) samples from patients with suspected nervous system infections admitted to the University Hospital of the University of Campinas, São Paulo, Brazil, in 2017-2018. METHODS: CSF samples collected from adult patients with neurological syndrome symptoms and negative CSF culture results were analyzed using polymerase chain reaction (PCR), reverse transcriptase-PCR, and real-time PCR, and their results were compared with their clinical symptoms. One CSF sample was obtained from each patient. RESULTS: Viral genomes were detected in 148/420 (35.2%) CSF samples: one of 148 (0.2%) was positive for herpes simplex virus-1; two (0.5%) for herpes simplex virus-2; eight (1.9%) for varicella-zoster virus; four (1%) for Epstein-Barr virus; one (0.2%) for cytomegalovirus; 32 (7.6%) for human herpesvirus-6; 30 (7.1%) for non-polio enterovirus; 67 (16.0%) for dengue virus, three (0.7%) for yellow fever virus, and 21 (5%) for Zika virus. CONCLUSIONS: The viral genomes were found in 35.2% of all analyzed samples, showing the high prevalence of viruses in the nervous system and the importance of using a nucleic acid amplification test to detect viral agents in CSF samples.

A Clinical Study on the Use of Intraventricular Polymyxin B Supplemented by Continuous External Ventricular Drainage in the Treatment of Drug-Resistant Gram-Negative Bacilli Intracranial Infection.

PurposeTo investigate the clinical effect of ventricular polymyxin B supplemented by continuous external ventricular drainage in the treatment of intracranial infection with multidrug-resistant (MDR) or extensively drug-resistant (XDR) Gram-negative (G-) bacilli following neurosurgery.Patients and MethodsA retrospective analysis was performed on 28 patients who had G-bacilli intracranial infection following neurosurgery in our department between January 2017 and December 2019. The patients were treated with intraventricular polymyxin B supplemented by continuous external ventricular drainage. The clinical characteristics, treatment process, cerebrospinal-fluid-related indicators, results and prognosis were analysed.ResultsAll of 28 patients developed an infection subsequent to neurosurgery, and cerebrospinal fluid (CSF) cultures demonstrated MDR/XDR G- bacilli, including Acinetobacter baumannii in 14 cases, Klebsiella pneumoniae in 9 cases, Pseudomonas aeruginosa in 3 cases, and Enterobacter cloacae in 2 cases. The ventricular drainage tube remained unobstructed in all patients during treatment, and intraventricular polymyxin B combined with intravenous antibiotics were administered each day. The duration of treatment with intraventricular polymyxin B was 14.96±4.28 days, and the time required to obtain a negative CSF culture was 8.23±4.02 days. The bacterial clearance rate from cerebrospinal fluid was 92.9% (26/28), and the clinical cure rate was 82.1% (23/28). Among them, 18 patients underwent ventriculoperitoneal shunt insertion for hydrocephalus 82.5 (59.5,114.75) days after the infection was cured, and the mortality rate was 17.6% (5/28). There was no significant change in patient blood creatinine levels before and after treatment. Cured patients were followed up for 4 months to 3 years, and no recurrences were observed.ConclusionTreatment of intracranial infection with MDR/XDR G- bacilli using early intraventricular polymyxin B supplemented by continuous external ventricular drainage treatment may be a safe and effective treatment strategy.

Candida meningitis in neurosurgical patients: a single-institute study of nine cases over 7 years.

Candida meningitis in neurosurgical patients is relatively unusual but is associated with a high mortality rate. We present our experience with this infection and discuss the clinical characteristics, treatment options and outcomes. We retrospectively reviewed neurosurgical patients with multiple positive cerebrospinal fluid (CSF) culture results in our hospital from January 2013 to December 2019. Nine patients were available for review according to our inclusion and exclusion criteria. Four species of Candida were isolated from the CSF samples and Candida albicans accounted for half of all infections. Eight infections were associated with ventricle peritoneal shunt, lumbar cistern peritoneal shunt or external ventricular drain. All of these foreign intracranial materials were removed or changed and all the patients received antifungal treatment, including fluconazole and/or voriconazole. It is associated with severe long-term outcomes in survivors and a mortality rate that reaches 11.1%. Prior treatments with broad-spectrum and high-grade antibiotics and anaemia are possible risk factors for Candida meningitis. We advise that foreign intracranial material should be removed or changed as early as possible and the timing of re-shunt operation can be 1 month after control of Candida meningitis has been achieved, with several negative CSF culture results.

Clinical impact of cerebrospinal fluid Gram stain and culture testing: A retrospective cohort study.

Stewardship of microbiological tests can improve laboratory efficiency. One indicator of appropriate test stewardship is test impact on patient management decisions. We sought to assess the impact of cerebrospinal fluid (CSF) Gram stain and culture results on treatment decisions. Our hypothesis was that CSF Gram stain and culture have low impact on patient management. CSF specimens received at a tertiary microbiology laboratory between January 1, 2013, and December 31, 2013, were included. Clinical information and data on antibiotic treatment before CSF collection, antibiotic treatment after CSF Gram stain results, and antibiotic treatment after CSF culture results were collected. Ethics approval for secondary use of data was obtained. We received 242 CSF specimens for Gram stain and culture during the study period; 120 were excluded (84 from children, 2 from indwelling ventricular drains, 12 collected at outside hospitals, 21 data missing, 1 duplicate). No Gram stains or cultures were positive among patients not already treated empirically. The number needed to test to influence treatment was 17 for Gram stain (11 for abnormal cytochemistry, 29 for normal cytochemistry) and 6 for culture (3 for abnormal cytochemistry, 6 for normal cytochemistry). CSF Gram stain and culture are rarely positive and are being performed on inappropriate specimens. CSF results never prompt physicians to start treatment, so results are affecting not outcome but antibiotic stewardship. Negative CSF culture often leads to discontinuation of antibiotics. Labs could consider rejecting CSF Gram stain if cytochemistry is normal.