First recorded outbreaks of meningococcal disease in the Israel Defence Force: three clusters due to serogroup C and the emergence of resistance to rifampicin

Molecular characteristics of Neisseria meningitidis in Qatar

The aim of the current study is to review the molecular characteristics of Neisseria meningitidis (N. meningitidis) in Hamad Medical Corporation, which is the provider of secondary and tertiary care in the state of Qatar. A total of 39 isolates of N. meningitidis from the period of 2013 to 2018 were revived and identified by Vitek, and susceptibility on the basis of the E test was retrieved from the patient's files. The revived isolates were subjected to multilocus sequence typing. The most common serogroup (19) of N. meningitidis was W135, of which 12 were isolated from blood and CSF. ST-11 was the most predominant ST clonal complex causing N. meningitidis cases (61.53%). Clonal complex ST-41/44 was the second most observed complex (3, 2 of which were related to serogroup B). The most frequent sequence type was 9596 (8 isolates). Determining the molecular pattern of N. meningitidis in Qatar is helpful for understanding the strains circulating in Qatar, and the study of the resistance trend of such strains may be very helpful for empirical treatment of future patients.

Outbreaks of meningococcal meningitis in non-African countries over the last 50 years: a systematic review

Background

Meningococcal disease is caused by the bacteria Neisseria meningitidis, leading to substantial mortality and severe morbidity; with serogroups A, B, C, W135, X and Y most significant in causing disease. An outbreak is defined as multiple cases of the same serogroup occurring in a population over a short time-period. A systematic review was performed to gain insight into outbreaks of meningococcal disease and to describe the temporal pattern over the last 50 years in non-African countries.

Methods

PubMed and EMBASE were searched for English-language publications on outbreaks of meningococcal disease in non-African countries between January 1966 and July 2017, with an additional grey literature search. Articles and reports were considered eligible if they reported confirmed meningococcal outbreak cases, included the region, number of cases, and the start and end dates of the outbreak. Data on outbreaks was stratified by geographical region in accordance with the World Health Organization (WHO) regional classification, and case-fatality rates (CFRs) were calculated.

Results

Of the identified publications, 3067 were screened and 73 included, reporting data from 83 outbreaks. The majority of outbreaks were identified in the regions of the Americas (41/83 outbreaks), followed by the European region (30/83 outbreaks). In each of the Western Pacific, Eastern Mediterranean, and South-East Asian regions there were <10 outbreaks reported. The predominant serogroup in the majority of outbreaks was serogroup C (61%), followed by serogroup B (29%), serogroup A (5%) and serogroup W135 (4%). Outbreaks showed a peak in the colder months of both the Northern and Southern Hemispheres. Of the 54 outbreaks where CFR was calculable for all outbreak cases, it ranged from 0%-80%.

Conclusions

These data present a retrospective view of the patterns for meningococcal disease outbreaks in non-African countries, and provide valuable data for monitoring future changes in disease epidemiology and informing preventive measures.

Rifaximin in the treatment of irritable bowel syndrome: is there a high risk for development of antimicrobial resistance?

Irritable bowel syndrome (IBS), a chronic, nonfatal illness is commonly encountered in clinical practice; however, treatment options are limited and often ineffectual. Despite this, there is increasing evidence that bacterial overgrowth in the bowel (dysbiosis) may be an etiological factor in IBS. This has lead to studies in which the antibiotic agent rifaximin has been used to reduce the microbial burden in the bowel, to some extent alleviating the symptoms of IBS. Rifaximin is a member of the rifamycin class of antibiotics, which when administered orally has the distinctions of being gut specific coupled with poor systemic absorption, characteristics that are suggested to limit the development of bacterial resistance. The rifamycins are currently used to treat serious human diseases including tuberculosis, meningococcal disease, methicillin-resistant Staphylococcus aureus and Clostridium difficile infections. The use of rifamycins in the treatment of these diseases is associated with the development of antibiotic resistance over time. When considering the importance of the rifamycins in the treatment of serious human diseases, the large number of patients affected by IBS, and the lack of scientific evidence available on the development of antibiotic resistance to rifaximin over the long-term when used in the gut, it is advisable that the use of rifaximin as a therapy for IBS should be limited to single, acute, short-term treatment.

Meningococcal disease in the Middle East and North Africa: an important public health consideration that requires further attention

This paper reviews the epidemiological data describing meningococcal disease in the Middle East and North Africa (MENA). While meningococcal disease remains an important cause of endemic and epidemic disease in many MENA countries, existing published epidemiological data appear limited, fragmented, and collected via disparate methodologies. Children aged 5 years and younger are predominantly affected, though outbreaks of the disease often affect older age groups. Whilst serogroup A remains a main cause of meningococcal disease in the region, cases of serogroup B, W-135, and Y have been increasingly reported over the last two decades in some countries. The Hajj pilgrimage is a key factor influencing outbreaks and transmission, and the use of vaccines has minimized the effects on the home countries of the pilgrims and has decreased global dissemination of disease. Wider use of available polyvalent meningococcal conjugate vaccines may provide broader protection against the range of serogroups causing disease or posing a threat in the region. In addition, strengthening regional surveillance systems and regularly publishing reports with reliable estimates of disease incidence, carriage, disease-related mortality, and sequelae may facilitate the development of appropriate interventions and public health strategies regarding meningococcal disease within the region.

Phenotypic and molecular characterization of serogroup C Neisseria meningitidis associated with an outbreak in Bahia, Brazil

OBJECTIVE

To characterize meningococcal strains isolated from five cases of meningococcal disease (MD) associated with an outbreak in Trancoso - BA, occurred in October 2009. All cases, with the exception of a 39-year-old male, attended a dance party with approximately 1000 youngsters in a rural site.

MATERIALS AND METHODS

The epidemiological investigation was conducted by the Epidemiological Surveillance Service of Bahia State. Meningococcal strains were characterized at Adolfo Lutz Institute, the Brazilian National Reference Laboratory for Bacterial Meningitis by conventional techniques (serotype, serosubtype and antimicrobial susceptibility test) and by molecular methods (Pulsed-field gel electrophoresis - PFGE and Multilocus Sequence Typing - MLST).

RESULTS

The PFGE showed 2 closely related restriction profiles, designated as PFGE types A and A1, having 92% relatedness to each other. MLST characterization showed both A and A1 clones were ST-3780, which belongs to the ST-103 complex. All isolates displayed the phenotype C:23:P1.5 and were susceptible to all antibiotics tested.

CONCLUSIONS

This is the first reported MD outbreak associated with serogroup C ST-103 complex in Brazil, as well as the party and illicit drug-use associated outbreak.

What is the evidence for giving chemoprophylaxis to children or students attending the same preschool, school or college as a case of meningococcal disease?

We performed a systematic literature review to assess the effectiveness of chemoprophylaxis for contacts of sporadic cases of invasive meningococcal disease (IMD) in educational settings. No studies directly compared IMD risk in contacts with/without chemoprophylaxis. However, compared to the background incidence, an elevated IMD risk was identified in settings without a general recommendation for chemoprophylaxis in pre-schools [pooled risk difference (RD) 58·2/10⁵, 95% confidence interval (CI) 27·3-89·0] and primary schools (pooled RD 4·9/10⁵, 95% CI 2·9-6·9) in the ~30 days after contact with a sporadic IMD case, but not in other educational settings. Thus, limited but consistent evidence suggests the risk of IMD in pre-school contacts of sporadic IMD cases is significantly increased above the background risk, but lower than in household contacts (pooled RD for household contacts with no chemoprophylaxis vs. background incidence: 480·1/10⁵, 95% CI 321·5-639·9). We recommend chemoprophylaxis for pre-school contacts depending on an assessment of duration and closeness of contact.

Emerging resistance in Neisseria meningitidis and Neisseria gonorrhoeae

The value of monitoring antimicrobial resistance is particularly significant for Neisseria meningitidis and Neisseria gonorrhoeae diseases, even if it is for different reasons. Although there is no global alert for the spread of resistant meningococcal strains, the emergence of resistance is correlated to the outcome of treatment and the successful prophylaxis of close contacts. Few cases of resistance among meningococci have been recorded worldwide; it remains unclear what intriguing mechanism is responsible for maintaining resistance in these cases in the absence of significant antibiotic selective pressure, as in the case of penicillin; on the contrary, although rifampicin is the antibiotic of choice in the prophylaxis of close contacts, there is a very low rate of resistance. The emergence of multidrug-resistant N. gonorrhoeae is a great challenge in controlling gonorrhea as one of the main sexually transmitted bacterial diseases. International surveillance programs permit the monitoring of the susceptibility of the pathogen and allow the revision of the standardized treatment regimen when the situation changes.

EpiScanGIS: an online geographic surveillance system for meningococcal disease

Background

Surveillance of infectious diseases increasingly relies on Geographic Information Systems (GIS). The integration of pathogen fine typing data in dynamic systems and visualization of spatio-temporal clusters are a technical challenge for system development.

Results

An online geographic information system (EpiScanGIS) based on open source components has been launched in Germany in May 2006 for real time provision of meningococcal typing data in conjunction with demographic information (age, incidence, population density). Spatio-temporal clusters of disease detected by computer assisted cluster analysis (SaTScan™) are visualized on maps. EpiScanGIS enables dynamic generation of animated maps. The system is based on open source components; its architecture is open for other infectious agents and geographic regions. EpiScanGIS is available at , and currently has 80 registered users, mostly from the public health service in Germany. At present more than 2,900 cases of invasive meningococcal disease are stored in the database (data as of June 3, 2008).

Conclusion

EpiScanGIS exemplifies GIS applications and early-warning systems in laboratory surveillance of infectious diseases.

Invasive meningococcal disease in children in Jerusalem

Neisseria meningitidis is an important cause of childhood meningitis and septicaemia. Between 1999 and 2005, 133 invasive meningococcal disease (IMD) cases occurred in Jerusalem, 112 (84.2%) of them in children aged 0-14 years. The annual incidence rate in Jerusalem was higher than the national average (2.45+/-0.6 vs. 1.13+/-0.16/100 000 population, P=0.002). Most of the children (82.1%) were from low socio-economic Arab and Jewish ultra-orthodox communities; mortality was higher among Arab than Jewish children (1.3 vs. 0.22/100 000 person-years, P=0.004). A cluster of 10 children with severe meningococcal sepsis (three fatalities) emerged in the winter of 2003-2004. Compared to the other 102 cases in 1999-2005 both meningococcaemia (100% vs. 51%, P=0.003) and mortality (30% vs. 6.9%, P=0.014) rates were higher. Serogroup B comprised 77.6% of the bacterial isolates. Pulsed-field gel electrophoresis showed considerable variability among cluster isolates, but significant resemblance in Arab cases throughout 1999-2005. The increased susceptibility of specific sub-populations to IMD necessitates further evaluation.

Rifampin-resistant meningococcal disease

Rifampin-resistant meningococcal disease occurred in a child who had completed rifampin chemoprophylaxis for exposure to a sibling with meningococcemia. Susceptibility testing of 331 case isolates found only 1 other case of rifampin-resistant disease in Minnesota, USA, during 11 years of statewide surveillance. Point mutations in the RNA polymerase β subunit (rpoB) gene were found in isolates from each rifampin-resistant case-patient.

Bacterial Meningitis in Children

Acute bacterial meningitis is still an important cause of morbidity and mortality in children worldwide. Recently, Haemophilus influenzae type b (Hib), once a common cause of meningitis, has virtually disappeared in developed nations, reflecting the overwhelming success of Hib vaccination. Unfortunately, Hib remains a significant pathogen in resource-poor countries. The introduction of the conjugated pneumococcal vaccine in 2000 may lead to similar future trends as witnessed with Hib. As the resistance of Streptococcus pneumoniae to penicillin and cephalosporins continues to evolve, vancomycin has become an important antibacterial in the treatment of bacterial meningitis. The unreliable penetration of this agent into cerebrospinal fluid is of concern, which is compounded by the controversial use of corticosteroids in paediatric meningitis. Some data suggest that in certain situations the addition of rifampicin (rifampin) to ceftriaxone may be a better choice. While dexamethasone is now considered the standard adjunctive therapy in the treatment of pneumococcal meningitis in adult patients, the benefit in children is not so clear and remains controversial; thus, there is no definitive paediatric recommendation. Several anti-inflammatory agents currently under investigation may be used in the future as adjunctive therapy for bacterial meningitis. It is clear that the current concepts in the treatment of childhood bacterial meningitis are evolving, and other antibacterial options and possible alternatives such as carbapenems and fluoroquinolones should be considered. Fluid restriction because of the Syndrome of Inappropriate Antidiuretic Hormone Secretion is widely advocated and used. Yet, this practice was recently challenged. It seems that most patients with meningitis do not need fluid restriction. The overwhelming success of the conjugated Hib vaccine and the encouraging results of the new conjugated pneumococcal and meningococcal vaccines suggest that the ideal management of bacterial meningitis is prevention and vaccines development against the most common bacterial agents are the best solution.

New therapies and vaccines for bacterial meningitis

Acute bacterial meningitis remains an important cause of morbidity and mortality worldwide. There have recently been major advances in the prevention of the major causes of bacterial meningitis following improvements in vaccinology. The success of immunisation against Haemophilus influenzae type b infection is being mirrored with serogroup C conjugated meningococcal vaccine and pneumococcal conjugate vaccine. However, there remain major challenges, notably, serogroup B meningococcal infection and shifts in epidemiology caused by vaccine introduction. In addition, much of the world's population is unvaccinated. Therefore, improvements in management of acute bacterial meningitis are vital. In this review we attempt to summarise important advances in both prevention and treatment of acute bacterial meningitis.

Bacterial meningitis: current controversies in approaches to treatment

Acute bacterial meningitis continues to be a disease with unacceptably high mortality and morbidity rates in both adults and children worldwide, despite advances in antibacterial therapy. Death or permanent disability occurs frequently. The causative organism varies with age, immune function and immunisation status. Infection with Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) is associated with the majority of cases, with Listeria monocytogenes and Streptococcus agalactiae being more prevalent pathogens at the extremes of age (<3 months or >50 years). Antibacterial resistance is an increasing problem, particularly in pneumococcal bacteria but increasingly in other organisms. The increasing prevalence of resistance of pneumococcus to penicillin and the cephalosporins complicates therapy and may have an important impact on treatment outcome. Increased understanding of the pathophysiology has allowed advances in diagnosis and therapy. The use of adjunctive corticosteroids remains controversial, but is probably beneficial in reducing neurological sequelae in children. In adults the evidence is less clear. Vaccination has virtually eradicated Hib meningitis in some countries. Recent introduction of a conjugate vaccine against serogroup C meningococci in the UK has caused a dramatic reduction in the incidence of invasive disease due to this organism. A 7-valent pneumococcal vaccine promises a similar reduction in the incidence of invasive pneumococcal disease. In the meantime, the emergence of widespread resistance of organisms to antibacterial agents, in particular among the common organisms causing bacterial meningitis, remains the biggest challenge in therapy.

Secular trends in the epidemiology of pediculosis capitis and pubis among Israeli soldiers: a 27-year follow-up

BACKGROUND

Pediculosis capitis and pubis are not mandatorily reported diseases in most countries. Thus, the reported rates of these diseases in large populations are usually inaccurate and based on estimations.

OBJECTIVE

To describe the global epidemiology of pediculosis capitis and pubis in the Israeli Defense Force.

METHODS

We analyzed the data obtained from the routine and mandatory reporting of every individual case of pediculosis capitis and pubis to the Army Health Branch Epidemiology Department since 1972 and 1973, respectively.

RESULTS

During this period, epidemics of pediculosis capitis and pubis were observed between 1973 and 1985 and 1972 and 1987, with 17.7- and 3.9-fold increases in incidence, respectively. These two epidemics were followed by a sharp decline in morbidity (113.6- and 13.6-fold between 1981 and 1999 and 1984 and 1999, respectively) to the present.

CONCLUSIONS

A number of factors could be responsible for the observed decline in morbidity, e.g. socioeconomic, pharmacologic, environmental, or prevention policy modifications. The rates of pediculosis capitis and pubis have continuously declined since the last epidemic of 1972-1987, indicating the influence of these and possibly other factors.

Antibiotic susceptibility patterns of Neisseria meningitidis isolates from patients and asymptomatic carriers

The activities of seven antimicrobial agents used for treatment and prophylaxis of meningococcal disease was investigated against 901 Neisseria meningitidis isolates, 112 of which were recovered from patients and 789 of which were recovered from asymptomatic carriers. The proportions of isolates with decreased susceptibility to penicillin were 55.3 and 39.0%, respectively. Penicillin- and ampicillin-intermediate strains were more common among serogroup C meningococci than among non-serogroup C meningococci from both patients and carriers.

Emergence of drug resistance. Impact on bacterial meningitis

Antimicrobial resistance has emerged among the three major bacterial pathogens causing meningitis. Chloramphenicol resistance in the meningococcus recently has been described, and although intermediate penicillin resistance is common in some countries, the clinical importance of penicillin resistance in the meningococcus has yet to be established. Beta-lactamase-producing Haemophilus influenzae are relatively common, and chloramphenicol resistance is emerging. Third-generation cephalosporins are required to treat meningitis caused by these resistant strains. Pneumococcus resistance to penicillin and to chloramphenicol is widespread, and resistance to third-generation cephalosporins is found in many parts of the world. Correct management of these strains includes the addition of vancomycin or rifampin to therapy with third-generation cephalosporins.