Post-neurosurgical Meningitis Research Articles

Whole-Genome Analysis of KPC-Producing Klebsiella Pneumoniae Isolates from Hospital Acquired Post-Neurosurgical Meningitis

Whole-Genome Analysis of KPC-Producing Klebsiella Pneumoniae Isolates from Hospital Acquired Post-Neurosurgical Meningitis

Post-neurosurgical meningitis; gram negative bacilli vs. gram positive cocci.

Background:Post-neurosurgical meningitis is a significant cause of mortality and morbidity. In this study we aimed to compare the differences of clinical, laboratory features and outcomes between the post-neurosurgical meningitis caused by gram-negative bacilli (GNB) and gram-positive cocci (GPC).Methods:Cases of post-neurosurgical meningitis (with positive CSF culture) were included. After classifying patients as GNB and GPC groups, clinical and paraclinical data were compared.Results:Out of 2667 neurosurgical patients, CSF culture was positive in 45 patients. 25 (54.3%) were GNB, 19 (41.3%) GPC. The most common microorganisms were Klebsiella pneumoniae (n=14, 31.1%), Coagulase negative staphylococcus (n=8, 17.8%), Staphylococcus aureus (n=6, 13.3%), Acinetobacter baumannii (n=4, 8.9%), Pseudomonas aeruginosa (n=2, 4.4%), and Escherichia coli (n=2, 4.4%). There were no correlation between CSF Leakage, Surgical site appearance, presence of drain, Age and GCS between two groups (P=0.11, P=0.28, P=0.06, P=0.86, P=0.11 respectively). The only different laboratory indexes were ESR (86.8 mm/h vs. 59.5 mm/h, P=0.01) and PCT (13.1 ng/ml vs. 0.8 ng/ml, P=0.02) which were higher in GNB cases. 20% (n=5) of patients with GNB meningitis received preoperative corticosteroid, while none of GPC cases received (P=0.03). The median length of hospitalization for GNB and GPC cases was 56 and 44.4 days respectively (P=0.3).Conclusion:The GNB antibiotic coverage should be designed more carefully in post-neurosurgical meningitis especially in patients with recent corticosteroid therapy and elevated ESR and procalcitonin.

1111. Therapeutic Drug Monitoring of Colistin in Cerebrospinal Fluid in the Treatment of Neurosurgical Meningitis caused by Pseudomonas aeruginosa and KPC-producing Enterobacterales

BackgroundCentral nervous system (CNS) infections caused by carbapenem-resistant Enterobacterales (CRE) and Difficult-to-treat resistant (DTR)-P. aeruginosa (PA) present a therapeutic dilemma. Therapies are limited due to antibiotic resistance and inadequate CNS diffusion. Intraventricular polymyxins are utilized in this setting despite a lack in pharmacokinetic data after CNS injection. We describe the utilization of intravenous and intrathecal polymyxin E [colistimethate (CMS)] therapeutic drug monitoring (TDM) in 3 cases of post-neurosurgical meningitis. MethodsBacterial identification and susceptibility testing were performed using MicroScan. TDM was employed by dosing CMS at 125,000 IU (i.e., 4.1 mg CBA or 10 mg) administered via external ventricular drain twice daily and 4.5 MIU (133.2 CBA or 360 mg) CMS administered over 30 minutes IV twice daily. Four pairs of CSF and blood samples were collected for each patient (Table 1). Samples were placed on ice to minimize in-vitro conversion of CMS to Colistin. Colistin binding in plasma and CSF was measured using ultracentrifugation. Concentrations of CMS and Colistin in CSF and human plasma were determined by liquid chromatography/mass spectrometry. Patients A, B and C received 20, 15, and 12 doses of CMS, respectively, prior to TDM.ResultsBacterial cultures revealed DTR PA, blaKPCE. cloacae and blaOXA-48K. pneumoniae for patients A, B and C, respectively. Colistin minimum inhibitory concentrations (MIC) were 0.5 µg/ml, 0.125 µg/ml, and 0.125 µg/ml, respectively. The measured CSF and plasma concentrations of CMS, Colistin, and binding are shown in Table 1. Clinical resolution and microbiological cure were attained in all patients. Therapeutic Drug Monitoring of Unchanged CMS and Formed Colistin in CSF samples for patient A, B, and C Therapeutic Drug Monitoring of Unchanged CMS and Formed Colistin in Plasma Samples for patient A, B, and C ConclusionFavorable concentrations of formed Colistin and CMS in CSF were achieved in 3 patients with complicated CNS infection. To the best of our knowledge, this is the first study to report the binding of Colistin in CSF in humans. A TDM method was effectively applied to demonstrate that Colistin achieves and maintains the PK/PD target (fAUC/MIC) [ratio of area under the plasma concentration curve of unbound drug to MIC] that best correlates with killing activity. Overall, our results support intraventricular polymyxins for treating DTR Gram-negative CNS infections.Disclosures Robert A. Bonomo, MD, entasis (Research Grant or Support)Merck (Grant/Research Support)NIH (Grant/Research Support)VA Merit Award (Grant/Research Support)VenatoRx (Grant/Research Support)

Characteristics of Post-Neurosurgical Nosocomial Bacterial Meningitis in Adults: A retrospective Cross-Sectional Study

Aim: To analyze the characteristics of Post-neurosurgical nosocomial bacterial meningitis in adults Study design: A retrospective cross-sectional study Place and duration: Riyadh Care Hospital/ National Care Hospital, from July 2005 to June 2010 then 2013 to 2018. Methodology: Over ten years, sixty-two patients above the age of 16 years who suffered from Post-neurosurgical nosocomial bacterial meningitis were evaluated by collecting clinical data. The cases were divided into two categories, the first one from July 2007 to June 2012 and second one from August 2013 to July 2018. Results: Among the 62 patients, there were 43 males and 19 females with post-neurosurgical nosocomial bacterial meningitis. It was recorded in the first group that the percentage of post-neurosurgical nosocomial meningitis in all culture-proven adult bacterial meningitis was 12 percent and for the second group it was seen to be 27 percent. The most constant clinical characteristics were fever and gradual consciousness disruption, which may be related to various postoperative neurosurgery issues. The most prevalent pathogens were recorded to be pseudomonas aeruginosa, staphylococcus aureus, coagulase-negative staphylococcus, Acinetobacter baumannii, and lastly, Escherichia coli. During the second era, there was a rise in polymicrobial illnesses and multi antibiotic resistance. Mortality was 22% in the first group of the study and 36% in the second group of the study. Conclusion: The selection of appropriate empirical antibiotics is complex and is necessary to be guided by knowledge of the comparative ratio of multiple diseases as well as the rising prevalence of resistant strains. To increase the likelihood of survival, early diagnosis is suggested with optimal antibiotic selection based on in vitro susceptibility testing, epidemiologic patterns, and lastly, metabolic derangement treatment to be advised and required. Keywords: Bacterial Meningitis, adults, post-neurosurgery

Predictive Value of Cerebrospinal Fluid Lactate Level for the Diagnosis of Bacterial Meningitis following Cranial Surgery

Background:To distinguish post-neurosurgical bacterial meningitis (PNBM) from aseptic meningitis is difficult. Inflammatory and biochemical cerebrospinal fluid (CSF) changes mimic those classically observed after CNS surgery. CSF lactate assay has therefore been proposed as a useful PNBM marker. Objective:To determine the value of cerebrospinal fluid (CSF) lactate level for the identification of bacterial meningitis following cranial surgery. Methods:Between January 2016 and December 2016, a prospective clinical study was done in Department of Neurosurgery, in which all patients with clinical suspicion of PNBM were enrolled. Patients with clinical suspicion of bacterial meningitis BM were categorized, according to preset criteria, into 3 groups: (1) proven BM; (2) presumed BM, and (3) nonbacterial meningeal syndrome. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy. Results:The study included 70 patients. We obtained 65 CSF samples from patients with clinical suspicion of BM by CSF analysis. 20 corresponded to proven BM, 7 to probable BM and 38 to excluded BM. Mean lactate in CSF was: 8.4 ±3.0 mmol /l for proven BM, 4.8 ± 0.99 mmol /l for probable BM and 2.08 ± 0.822 mmol/l for excluded BM (P < .001). Conclusion: CSF lactate level has good predictive value to distinguish BM from aseptic meningitis with sensitivity of 90% and specificity: 87% at cut-off value: 4.0 mmol/l.

Using Therapeutic Drug Monitoring to Treat KPC-Producing Klebsiella pneumoniae Central Nervous System Infection With Ceftazidime/Avibactam.

This report describes the treatment of Klebsiella pneumoniae carbapenemase (KPC)–3–producing multidrug-resistant K. pneumoniae with ceftazidime/avibactam (CAZ-AVI) in a patient who developed postneurosurgical meningitis and bacteremia. Therapeutic drug monitoring of cerebrospinal fluid and blood samples demonstrated CAZ-AVI concentration levels 20-fold greater than the minimum inhibitory concentration in the first 60 minutes postinfusion, providing evidence for the utility of CAZ-AVI in treating KPC–Klebsiella pneumoniae central nervous system infections.

Polymyxin for the treatment of intracranial infections of extensively drug-resistant bacteria in children after neurosurgical operation.

Increased meningitis caused by extensively drug-resistant bacillary presents a significant challenge in antibiotic selection. The aim of our study was to evaluatethe efficacy and safety of polymyxin in the treatment of post-neurosurgical meningitis due to the extensively drug-resistant bacillary in children. We performed a retrospective study on post-neurosurgical meningitis caused by the extensively drug-resistant bacillary in children, who were treated with polymyxin for ≥ 3days. Among five post-neurosurgical meningitis cases that were included, the children were infected by Acinetobacter baumannii (n = 3), Klebsiella pneumonia (n = 1), and Pseudomonas aeruginosa (n = 1). The drug susceptibility test showed that they were extensively drug-resistant bacillary. Two patients received intravenous polymyxin E. Three children received intravenous combined with intraventricular injection of polymyxin B. One patient infected by Klebsiella pneumonia eventually died of septic shock. No serious adverse effects of polymyxin were observed. Polymyxin is a safe and effective therapy for post-neurosurgical, multidrug-resistant bacillary meningitis in children.

Clinical and pathogenesis overview of Enterobacter infections

Enterobacter spp. is a gram-negative environmental bacterium, which belongs to the Enterobacteriaceae family and is found in water, sewage, soil, and plants. These bacteria are common among humans and animals, and the most frequently isolated species is Enterobacter cloacae. The species of this genus are often opportunistic pathogens with expanding significance in nosocomial infections, particularly in neonates, immunocompromised patients in intensive care units, emergency sections, skin and soft tissue infection wards, and urology wards. With the unexpected and rapid increase in antibiotic resistance in various bacterial species, there has been a new alarm for the health of the human community. Enterobacter species cause pneumonitis, bacteremia, post-neurosurgical meningitis, neonatal meningitis, skin and soft tissue infections, and urinary tract infections. Some of the main risk factors for the occurrence and dissemination of Enterobacter spp. infections are poor hand hygiene, crowding, low birth weight, premature birth, intubation of patients, prolonged hospital stay, contaminated infant formula, intravenous feeding, use of extended-spectrum antibiotics and use of intravenous catheters.

Development and verification of a discriminate algorithm for diagnosing post-neurosurgical bacterial meningitis-A multicenter observational study.

ObjectiveTo evaluate the diagnostic accuracy of cerebrospinal fluid (CSF)–based routine clinical examinations for post‐neurosurgical bacterial meningitis (PNBM) in multicenter post‐neurosurgical patients.MethodsThe diagnostic accuracies of routine examinations to distinguish between PNBM and post‐neurosurgical aseptic meningitis (PNAM) were evaluated by determining the values of the area under the curve (AUC) of the receiver operating characteristic curve in a retrospective analysis of post‐neurosurgical patients in four centers.ResultsAn algorithm was constructed using the logistic analysis as a classical method to maximize the capacity for differentiating the two classes by integrating the measurements of five variables. The AUC value of this algorithm was 0.907, which was significantly higher than those of individual routine blood/CSF examinations. The predicted value from 70 PNBM patients was greater than the cutoff value, and the diagnostic accuracy rate was 75.3%. The results of 181 patients with PNAM showed that 172 patients could be correctly identified with specificity of 95.3%, while the overall correctness rate of the algorithm was 88.6%.ConclusionsRoutine biomarkers such as CSF/blood glucose ratio (C/B‐Glu), CSF lactate (C‐Lac), CSF glucose concentration (C‐Glu), CSF leukocyte count (C‐Leu), and blood glucose concentration (B‐Glu) can be used for auxiliary diagnosis of PNBM. The multicenter retrospective research revealed that the combination of the five abovementioned biomarkers can effectively improve the efficacy of the PNBM diagnosis.

Outcome following postneurosurgical Acinetobacter meningitis: an institutional experience of 72 cases.

The authors aimed to evaluate the antimicrobial susceptibility pattern of Acinetobacter isolates responsible for nosocomial meningitis/ventriculitis in the neurosurgical ICU. The authors also sought to identify the risk factors for mortality following Acinetobacter meningitis/ventriculitis. This was a retrospective study of 72 patients admitted to the neurosurgical ICU between January 2014 and December 2018 with clinical and microbiological diagnosis of nosocomial postneurosurgical Acinetobacter baumanii meningitis/ventriculitis. Electronic medical data on clinical characteristics, underlying pathology, CSF cytology, antibiotic susceptibilities, and mortality were recorded. To evaluate the outcome following nosocomial postneurosurgical Acinetobacter meningitis/ventriculitis, patients were followed up until discharge or death in the hospital. Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to compute factors affecting survival. The study population was divided into two groups depending on the final outcome of whether the patient died or survived. Forty-three patients (59.7%) were included in the survivor group and 29 patients (40.3%) were included in the nonsurvivor group. Total in-hospital mortality due to Acinetobacter meningitis/ventriculitis was 40.3% (29 cases), with a 14-day mortality of 15.3% and a 30-day mortality of 25%. The 43 (59.7%) patients who survived had a mean length of hospital stay of 44 ± 4 days with a median Glasgow Outcome Scale-Extended score at discharge of 6. On univariate analysis, age > 40 years (p = 0.078), admission Glasgow Coma Scale (GCS) score ≤ 8 (p = 0.003), presence of septic shock (p = 0.011), presence of external ventricular drain (EVD) (p = 0.03), CSF white blood cell (WBC) count > 200 cells/mm3 (p = 0.084), and comorbidities (diabetes, p = 0.036; hypertension, p = 0.01) were associated with poor outcome. Carbapenem resistance was not a risk factor for mortality. According to a multivariable Cox proportional hazards model, age cutoff of 40 years (p = 0.016, HR 3.21), GCS score cutoff of 8 (p = 0.006, HR 0.29), CSF WBC count > 200 cells/mm3 (p = 0.01, HR 2.76), presence of EVD (p = 0.001, HR 5.42), and comorbidities (p = 0.017, HR 2.8) were found to be significant risk factors for mortality. This study is the largest case series reported to date of postneurosurgical Acinetobacter meningitis/ventriculitis. In-hospital mortality due to Acinetobacter meningitis/ventriculitis was high. Age older than 40 years, GCS score less than 8, presence of EVD, raised CSF WBC count, and presence of comorbidities were risk factors for mortality.

Platelet Indices for Predicting Patient Outcomes in Post-Neurosurgical Meningitis

Background: Platelet volume indices (PVIs) are inexpensive and readily available parameters in intensive care units (ICUs). However, their association with mortality has never been investigated in the post-neurosurgical meningitis (PNM). Objectives: This study was designed to investigate the association of PVIs with mortality in PNM patients. Methods: This retrospective study was conducted in the adult patients undergone various neurosurgical procedures in a neurosurgery department at a tertiary educational medical center in Tehran from 2016 to 2017. In this study, platelet indices including mean platelet volume (MPV), platelet distribution width (PDW), and platelet count were measured on ICU admission. Results: A total of 37 patients were included, 18 of whom survived (mortality rate: 50%). PDW and MPV values were significantly higher in non-survivors than in survivors. In non-survivor patients, platelet count was significantly lower and PDW was higher at diagnosis and discharge when compared to on admission. Also, there was no significant linear correlation between Charlson comorbidity index (CCI) and platelet indices. The means of these parameters showed no significant differences in CCI categories between the two patient subgroups. Conclusions: The obtained data revealed that the high levels of MPV and PDW in PNM are not associated with the increased risk of mortality, whereas the decrease in plateletcrit was not associated with increased risk of mortality.

The Role of Cerebrospinal Fluid Biomarkers in the Diagnosis of Post-Neurosurgical Meningitis.

To measure cytokine and lactate levels in the cerebrospinal fluid (CSF) of patients with suspected post-neurosurgical meningitis. Interleukin (IL)-8,-12, and -13, interferon (IFN) gamma, and lactate concentrations were determined in the CSF of patients diagnosed with meningitis, who were undergoing follow-up after neurosurgical procedures at the Neurosurgery Clinic between May 2016 and November 2017. The demographic, clinical, biochemical, CSF cell count, CSF biochemistry, and CSF culture results of 119 patients were recorded. The study group consisted of 39 patients diagnosed with post-neurosurgical meningitis. The control group comprised of 80 patients without pleocytosis, who had undergone lumbar puncture due to various indications. In the study group, 59% of the patients had fever, 66.7% had deterioration in the level of consciousness, and 35.9% had neck stiffness. The levels of IL-8 (96.5 ng/L vs. 86.6 ng/L, p < 0.001), IL-12 (10.1 ng/L vs. 3 ng/L, p < 0.001), and lactate (5.9 mmol/L vs. 2.1 mmol/L, p < 0.001) were higher in the CSF of the patient group compared to the control group. However, IL-13 (32.7 ng/L vs. 42.5 ng/L, p=0.003) and IFN gamma (73.3 ng/L vs. 260.4 ng/L, p < 0.001) levels were lower in patients compared to controls. The mortality rate in post-neurosurgical meningitis patients was estimated to be 35.9%. Post-neurosurgical meningitis prolongs the duration of hospital stay and causes long-term sequelae. Therefore, measurement of CSF cytokine and lactate levels alongside meningitis diagnostic processes may facilitate early and accurate diagnosis. Measuring CSF lactate is inexpensive and cost effective, particularly in post-neurosurgical patients.

Cerebrospinal Fluid Lactate as an Indicator for Post-neurosurgical Bacterial Meningitis.

ABSTRACTObjectiveTo evaluate the interest of cerebrospinal fluid (CSF) lactate assay for the diagnosis of post-neurosurgical bacterial meningitis (PBM).MethodsWe conducted at our neurosurgical resuscitation unit a prospective study of patients who underwent elective or emergency craniotomy. Lumbar puncture was performed in all patients who had clinical suspicion of PBM for CSF culture and cytological and chemical analysis (glucose, protein, lactate). The diagnosis of PBM is made according to the criteria proposed by the Center for Disease Control and Prevention (CDC). Receiver Operating Characteristic (ROC) was used to determine the diagnostic accuracy of CSF lactate.Results72 patients were studied and only 32 of them had the clinical and biological criteria of the diagnosis of PBM. Median CSF lactate was 6.18 mmol/L for PBM vs 2.63 mmol/L for no PBM (p < 0.001). CSF lactate may predict the presence PBM, with a AUC of 0.98 and NPV of 99.1. The analysis of Youden's index also confirms the good diagnostic power of CSF lactate with a value of 83 at a cut-off value of 4 mmol/L and a sensitivity of 92.3% and specificity of 91.6%.ConclusionOur study shows that the CSF lactate as an indicator for PBM. It is a fast and simple test that can help the clinician to optimize the management of PBM and decrease premature cessation of antibiotics.How to cite this articleLotfi R, Ines B, et al. Cerebrospinal Fluid Lactate as an Indicator for Post-neurosurgical Bacterial Meningitis. Indian J Crit Care Med 2019;23(3):127-130.

Administration of Vancomycin at High Doses in Patients with Post Neurosurgical Meningitis: A Comprehensive Comparison between Continuous Infusion and Intermittent Infusion.

Poor penetration of vancomycin into Central Nervous System (CNS) can lead to treatment failure. The aim of this study was to evaluate and compare CSF concentration and serum pharmacokinetics of high dose vancomycin by continuous infusion vs. intermittent infusion in post neurosurgical meningitis patients. Twenty patients were divided into two groups. Patients in intermittent infusion group received vancomycin as a loading dose of 25 mg/kg over two hours, followed by 25 mg/kg over two hours every 12 h. In the Continuous Infusion group, patients received vancomycin as a loading dose of 25 mg/kg over two hours, followed by 50 mg/kg/day by continuous infusion. In the intermittent infusion group, mean ± SD of serum trough, peak and CSF concentrations were 17.49 ± 2.46 mg/L, 41.33 ± 2.73 mg/L, and 4.83 ± 1.05 mg/L, respectively. Mean of CSF/trough% ratio was 27.39 ± 2.43%. A positive linear correlation was found between the serum trough levels and CSF levels (r = 0.970, P < 0.001). In continuous infusion group, mean ± SD of serum and CSF concentrations were 24.76 ± 2.02 mg/L and 6.20 ± 1.31 mg/L respectively. Mean ± SD of CSF/serum% ratio was 24.84% ± 3.54%. The serum and CSF levels revealed positive linear correlation (r = 0.902, P < 0.001). The mean of CSF concentration in CI group was 6.20 ± 1.31 mg/L which was significantly higher than II group (4.83 ± 1.05 mg/L, P < 0.019). CSF/serum ratio did not show any significant difference between the two groups. Continuous infusion of vancomycin makes it possible to achieve faster and constant target level in serum but did not have any significant effect on the penetration (CSF/Serum ratio) of vancomycin in to the CNS.

CSF leukocyte, polykaryocyte, protein and glucose: Their cut-offs of judging whether post-neurosurgical bacterial meningitis has been cured

ObjectThis paper is aimed to explore a reasonable guideline for distinguishing whether post-neurosurgical bacterial meningitis has completely been cured, so as to avoid the deficient or excessive treatment for post-neurosurgical bacterial meningitis. Patients and methodsWe conducted a retrospective analysis of 46 patients who attended General Hospital of Chinese People’s Armed Police Force in Beijing, China, from January 1, 2014 to April 30, 2016. The CSF leukocyte, polykaryocyte, protein and glucose had been tested when their antibiotic treatments were empirically stopped. Between the non-relapse and relapse groups, Wilcoxon Rank Sum test was used to compare the differences of CSF leukocyte and polykaryocyte, and t-test was applied to contrast the distinctions of CSF protein and glucose, then, the thresholds of significant items were estimated by ROC curve. ResultsThe CSF leukocyte counts in non-relapse group are 23.72 ± 14.12/mm3, which are statistically less than the relapse group’s (47.00 ± 1.00/mm3, P = 0.014), so does the CSF polykaryocyte counts (1.74 ± 4.84/mm3 &4.67 ± 1.15/mm3, P = 0.012). Between the two groups, the AUCs of leucocyte and polykaryocyte are 0.926 (95% CI = 0.845–1.0, P = 0.014) and 0.884 (95%CI = 0.786–0.982, P = 0.028), respectively. Their critical values are 44/mm3 (sensitivity = 1, specificity = 0.907) and 3/mm3 (sensitivity = 1, specificity = 0.837). Conversely, CSF protein and glucose have no statistic differences between the two groups. ConclusionBoth CSF leukocyte and polykaryocyte can satisfactorily indicate whether the post-neurosurgical bacterial meningitis has completely been cured, 0–44/mm3 is recommended as the reference range of CSF leukocyte, and the CSF polykaryocyte’ s is 0–3/mm3.

The combination of cerebrospinal fluid procalcitonin, lactate, interleukin-8 and interleukin-10 concentrations for the diagnosis of postneurosurgical bacterial meningitis: A prospective study.

The differential diagnosis between postneurosurgical bacterial meningitis and aseptic meningitis remains challenging both for the clinician and the laboratory. Combinations of markers, as opposed to single ones, may improve diagnosis and thereby survival. This prospective cohort study included patients with suspected bacterial meningitis after neurosurgery. The patients were divided into two groups according to the diagnostic criteria of meningitis involving a postneurosurgical bacterial meningitis group and a postneurosurgical aseptic meningitis group. Four biomarkers, including cerebrospinal fluid procalcitonin, lactate, interleukin-8 and interleukin-10 were assayed separately, and three algorithms were constructed using a linear combination. The area under the receiver operating characteristic curve was used to compare their performances. A cohort of 112 patients was enrolled in our study. Forty-three patients were diagnosed with postneurosurgical bacterial meningitis, and the cerebrospinal fluid values of their biomarkers were higher in patients with postneurosurgical bacterial meningitis than with postneurosurgical aseptic meningitis. The area under the receiver operating characteristic curves for the detection of postneurosurgical bacterial meningitis were 0.803 (95% confidence interval [CI], 0.724-0.883) for procalcitonin; 0.936 (95% CI, 0.895-0.977) for lactate; 0.771 (95% CI, 0.683-0.860) for interleukin-8; 0.860 (95% CI, 0.797-0.929) for interleukin-10; 0.937 (95% CI, 0.897-0.977) for the composite two-marker test; 0.945 (95% CI, 0.908-0.982) for the composite three-marker test and 0.954 (95% CI, 0.922-0.989) for the composite of all tests. The area under the receiver operating characteristic curves of the combination tests were greater than those of the single markers. Combining information from several markers improved the diagnostic accuracy in detecting postneurosurgical bacterial meningitis.

Evaluation of a micro/nanofluidic chip platform for the high-throughput detection of bacteria and their antibiotic resistance genes in post-neurosurgical meningitis

BackgroundPost-neurosurgical meningitis (PNM) is one of the most severe hospital-acquired infections worldwide, and a large number of pathogens, especially those possessing multi-resistance genes, are related to these infections. Existing methods for detecting bacteria and measuring their response to antibiotics lack sensitivity and stability, and laboratory-based detection methods are inconvenient, requiring at least 24h to complete. Rapid identification of bacteria and the determination of their susceptibility to antibiotics are urgently needed, in order to combat the emergence of multi-resistant bacterial strains. MethodsThis study evaluated a novel, fast, and easy-to-use micro/nanofluidic chip platform (MNCP), which overcomes the difficulties of diagnosing bacterial infections in neurosurgery. This platform can identify 10 genus or species targets and 13 genetic resistance determinants within 1h, and it is very simple to operate.A total of 108 bacterium-containing cerebrospinal fluid (CSF) cultures were tested using the MNCP for the identification of bacteria and determinants of genetic resistance. The results were compared to those obtained with conventional identification and antimicrobial susceptibility testing methods. ResultsFor the 108 CSF cultures, the concordance rate between the MNCP and the conventional identification method was 94.44%; six species attained 100% consistency. For the production of carbapenemase- and extended-spectrum beta-lactamase (ESBL)-related antibiotic resistance genes, both the sensitivity and specificity of the MNCP tests were high (>90.0%) and could fully meet the requirements of clinical diagnosis. ConclusionsThe MNCP is fast, accurate, and easy to use, and has great clinical potential in the treatment of post-neurosurgical meningitis.

Cerebrospinal fluid lactate as a prognostic indicator in postneurosurgical bacterial meningitis and use of intrathecal colistin

Postneurosurgical bacterial meningitis (PNBM) is an emergency and requires early diagnosis and treatment with appropriate antibiotics. The cornerstone of diagnosis is microbiological analysis of the cerebrospinal fluid (CSF) cytochemical characteristics such as leucocyte count, CSF glucose, and protein concentration and CSF: Serum glucose ratio. However, this is often misleading in PNBM. The role of CSF lactate assay for diagnosis and prognosis has been debated. This case report looks into the serial measurement of CSF lactates in PNBM. It also looks into the role of intrathecal colistin. CSF lactate showed a steady decrease corresponding to improvement in clinical condition. Hence, CSF lactate could have a better prognostic value than other conventional markers in PNBM. Intrathecal colistin, in conjunction with the standard antibiotics, can contribute to a quick resolution of the condition.

Outcomes of adjunctive therapy with intrathecal or intraventricular administration of colistin for post-neurosurgical meningitis and ventriculitis due to carbapenem-resistant acinetobacter baumannii

The efficacy and safety of intrathecal (ITH) or intraventricular (IVT) colistin in addition to intravenous (IV) colistin for meningitis and ventriculitis due to carbapenem-resistant Acinetobacter baumannii (CRAB) is unclear. In this retrospective observational study of 40 patients with post-neurosurgical meningitis and ventriculitis due to CRAB, 33 patients without concomitant infection received appropriate dosage regimens of IV colistin. Of the 33 patients, 17 received additional ITH/IVT colistin and 16 received only IV colistin. The 14-day, 30-day and in-hospital mortality rates were nominally lower for patients who received ITH/IVT colistin adjunctive therapy versus patients who received only IV colistin (24% vs. 38%, 29% vs. 56% and 29% vs. 56%, respectively). The costs of treatment were significantly lower, the lengths of hospital and intensive care unit (ICU) stay were significantly shorter, and the number of ventilator days was significantly less among patients who received ITH/IVT colistin compared with patients who did not receive ITH/IVT colistin. The initial Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow Coma Scale (GCS) scores were associated with 30-day mortality with odds ratios (95% confidence intervals) of 1.21 (1.08–1.46) and 0.77 (0.44–0.85), respectively. Chemical meningitis from ITH/IVT colistin was mild and resolved spontaneously. Treatment of post-neurosurgical CRAB meningitis and ventriculitis with ITH/IVT colistin as an adjunct to IV colistin was associated with shorter lengths of hospital and ICU stay and a trend to lower mortality, especially among severely ill patients.

The use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry for rapid bacterial identification in patients with smear-positive bacterial meningitis

ObjectivesTo assess the potential of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) in rapid identification of bacteria from smear-positive cerebrospinal fluid (CSF) in a cohort of patients with meningitis. MethodsSingle-centre observational study, including adults and children with community-acquired or postneurosurgical bacterial meningitis. Meningitis was defined using established criteria. Samples of CSF that had a positive CSF Gram stain were directly examined by MALDI-TOF-MS. Identification was considered accurate when identical to the CSF culture or PCR results (species and genus level). Laboratory workers performing the MALDI-TOF-MS and interpreting its results were blinded to the direct smear results, except for the fact that it was positive. MALDI-TOF-MS results were not conveyed to clinicians. ResultsMALDI-TOF-MS was tested on 44 CSF samples; ten samples were obtained from patients with community-acquired meningitis, and 34 samples were from patients with postneurosurgical meningitis. The assay identified bacteria correctly in 17/21 of the samples with Gram-negative rods observed on the direct smear, all obtained from patients who had undergone neurosurgery, (sensitivity 81%, 95% CI 64.2%–97.7%). In the postneurosurgical group, Gram-positive cocci were identified correctly in only 1/11 (9.1%) of the samples, and Candida species were not identified in two samples. Among patients with community-acquired meningitis, the assay did not identify Streptococcus pneumoniae in eight of eight samples, Neisseria meningitidis in one sample (1/1), and Streptococcus agalactiae in one sample (1/1). ConclusionsWe found MALDI-TOF-MS to be useful in the rapid identification of Gram-negative rods directly from smear-positive CSF samples, but not of Gram-positive bacteria.