Update in the diagnosis and management of central nervous system infections

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt

OBJECTIVE

Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients.

METHODS

A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion.

RESULTS

CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92 mmol/L) compared to the non-CILV group (3.03 mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90 mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%.

CONCLUSIONS

The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

Streptococcus intermedius causing primary bacterial ventriculitis in a patient with severe periodontitis - a case report

BACKGROUND

Streptococcus intermedius is a member of the S. anginosus group and is part of the normal oral microbiota. It can cause pyogenic infections in various organs, primarily in the head and neck area, including brain abscesses and meningitis. However, ventriculitis due to periodontitis has not been reported previously.

CASE PRESENTATION

A 64-year-old male was admitted to the hospital with a headache, fever and later imbalance, blurred vision, and general slowness. Neurological examination revealed nuchal rigidity and general clumsiness. Meningitis was suspected, and the patient was treated with dexamethasone, ceftriaxone and acyclovir. A brain computer tomography (CT) scan was normal, and cerebrospinal fluid (CSF) Gram staining and bacterial cultures remained negative, so the antibacterial treatment was discontinued. Nine days after admission, the patient's condition deteriorated. The antibacterial treatment was restarted, and a brain magnetic resonance imaging revealed ventriculitis. A subsequent CT scan showed hydrocephalus, so a ventriculostomy was performed. In CSF Gram staining, chains of gram-positive cocci were observed. Bacterial cultures remained negative, but a bacterial PCR detected Streptococcus intermedius. An orthopantomography revealed advanced periodontal destruction in several teeth and periapical abscesses, which were subsequently operated on. The patient was discharged in good condition after one month.

CONCLUSIONS

Poor dental health can lead to life-threatening infections in the central nervous system, even in a completely healthy individual. Primary bacterial ventriculitis is a diagnostic challenge, which may result in delayed treatment and increased mortality.

Are cerebrospinal fluid biochemical parameters valid to predict positive results in microbiological molecular diagnostic platforms? A 4-year experience with the FilmArray® Panel Meningitis/Encephalitis for detection of community-acquired bacterial meningitis

OBJECTIVE

To demonstrate whether the use of the FilmArray® Meningitis/Encephalitis panel (M/E) in the diagnosis of bacterial meningitis can be optimized based on the screening of cerebrospinal fluid biochemical parameters and whether there is a correlation between biochemical data and positive results of the technique.

MATERIAL AND METHODS

We used data from La Paz University Hospital between September 5, 2017 and December 1, 2021, from patients who had had the FilmArray® panel M/E performed on cerebrospinal fluid samples.

RESULTS

Bacterial meningitis was suspected in 63.9% of the patients; 38.15% had a positive result on the FilmArray® panel M/E, of which 68.97% were isolated in culture. Of the biochemical parameters studied in cerebrospinal fluid, white blood cell count, lactate, and protein were increased in PCR-positive patients, but glucose was decreased.

DISCUSSION

Only lactate showed a significant contribution to the model, with a cut-off point of 4.65 mmol/L with a sensitivity of 81.5% and a specificity of 96.4%.

The clinical utility of metagenomic next-generation sequencing for the diagnosis of central nervous system infectious diseases

BACKGROUND

To evaluate the clinical utility of metagenomic next-generation sequencing (mNGS) for the diagnosis of central nervous system infections (CNSI).

METHODS

Cerebrospinal fluid (CSF) from 54 patients who were high-level clinical suspicion of CNSI was collected and sent for mNGS and conventional tests from January 2019 to March 2022.

RESULTS

Twenty out of 54 patients were diagnosed with CNSI and 34 non-CNSI. Among the 34 non-CNSI, one was false positive by mNGS. Among the 20 CNSI, 11 had presumed viral encephalitis and/or meningitis, 5 had presumed bacterial meningitis, 2 had presumed TMB, 1 had Crytococcus meningitis and 1 had neurosyphilis. The sensitivity of viral encephalitis and/or meningitis was 0.73 (8/11); 10 virus were detected; 9/10 was dsDNA; 1/10 was ssRNA. SSRN ranged from 1 to 13. The accuracy rate was 0.4, the accuracy rate was positively correlated with SSRN (r = 0.738, P = 0.015), SSRN ≥ 1, the accuracy rate was 0.4; SSRN ≥ 3, the accuracy rate was 0.66; SSRN ≥ 4, the accuracy rate was 0.75; SSRN ≥ 6, the accuracy rate was 1. The sensitivity of bacterial meningitis was 1. Seven kinds of bacteria were detected, among which 3/7 were gram positive, 3/7 were gram negative, and 1/7 was infected NTM (nontuberculous mycobacteria). The accuracy rate was 0.43 (3/7). The sensitivity of TBM was 0.66 (2/3), the accuracy rate was 1. The sensitivity of Crytococcus meningitis was 1, the accuracy rate was 0.5. PPV (positive predictive value) of mNGS was 0.94, NPV (negative predictive value) of mNGS was 0.89, specificity was 0.97 and sensitivity was 0.8. The AUG for CSF mNGS diagnosis of CNSI was 0.89 (95% CI = 0.78-0.99) Headache, meningeal irritation sign and image of meninges abnormal were correlated with the sensitivity of mNGS (r = 0.451, 0.313, 0.446; p = 0.001, 0.021, 0.001); CSF Glucose and CSF Chloride were negatively correlated with sensitivity of mNGS (r = -0.395, -0.462; p = 0.003, ＜ 0.001).

CONCLUSION

mNGS is a detection means with high sensitivity, wide coverage and strong timeliness, which can help clinicians to identify the pathogen diagnosis quickly, conduct targeted anti-infection treatment early and reduce antibiotic abuse. The pathogen which causing low CSF Glucose, low CSF Chloride or meninges infections was more likely to be detected by mNGS. It may be related to growth and structural characteristics of the pathogen and blood-brain barrier damage.

Recent Advances in Pharmaceutical Approaches of Antimicrobial Agents for Selective Delivery in Various Administration Routes

Globally, the increase of pathogenic bacteria with antibiotic-resistant characteristics has become a critical challenge in medical treatment. The misuse of conventional antibiotics to treat an infectious disease often results in increased resistance and a scarcity of effective antimicrobials to be used in the future against the organisms. Here, we discuss the rise of antimicrobial resistance (AMR) and the need to combat it through the discovery of new synthetic or naturally occurring antibacterial compounds, as well as insights into the application of various drug delivery approaches delivered via various routes compared to conventional delivery systems. AMR-related infectious diseases are also discussed, as is the efficiency of various delivery systems. Future considerations in developing highly effective antimicrobial delivery devices to address antibiotic resistance are also presented here, especially on the smart delivery system of antibiotics.

Acute meningitis complicated with ventriculitis caused by Streptococcus dysgalactiae subsp. dysgalactiae

Streptococcus dysgalactiae subspecies dysgalactiae (SDSD), also known as Lancefield group C streptococcus, is a pathogen found in animals. It is known to cause pyogenic infections in animals and is one of the most common pathogens that can cause mastitis in cattle. Very few reports of SDSD causing human diseases to have been reported in the literature, but we report a case of community-acquired meningitis and pyogenic ventriculitis caused by SDSD. This report is the first case of SDSD causing a central nervous system (CNS) infection in humans and aims to raise awareness about the role of SDSD in CNS infections. It also seeks to promote the recognition of this bacteria as a potential cause of invasive diseases.

Preventing Poor Outcomes for Neurosurgical Patients

Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.

Norvancomycin for the Treatment of Central Nervous System MRSA Infections: a Randomized Controlled Trial: Norvancomycin for the Treatment of Central nervous system MRSA infections

Combined intravenous and intrathecal administration of norvancomycin (NVCM) is routinely employed in treating methicillin-resistant Staphylococcus aureus (MRSA) ventriculitis in patients following craniotomy. However, the optimal dosing regimen, the pharmacokinetics (PK) of NVCM in cerebrospinal fluid (CSF), and the clinical outcome are yet to be elucidated. Herein, a single-center randomized controlled trial was conducted in the Neurosurgery Department of the Second Hospital of Hebei Medical University (Shijiazhuang, China). Patients with MRSA ventriculitis after craniotomy were randomly assigned to two groups. The control group received 800 mg NVCM intravenously every 12 h, and the experimental group received 800 mg NVCM intravenously every 12 h and 16 mg NVCM intrathecal administration every 24 h. The primary outcome was the length of therapy, while the secondary outcomes included the area under the concentration-time curve in 0-24 h/minimum inhibitory concentration ratio (AUC_0-24h/MIC) of NVCM in CSF. A total of 29 patients (14 in the experimental group and 15 in the control group) were included in this study. Of these, 24 constituted the final analysis population, with 12 in each group. The average length of therapy in the experimental group was markedly shorter than that of the control group (11.2 ± 2.6 days vs. 16.6 ± 5.2 days, P = 0.005), while the AUC_0-24h/MIC in the experimental group was significantly higher than that in the control group (2306.57 ± 928.58 vs. 46.83 ± 27.48, P <0.001) with no increase in adverse reactions. Combined intravenous and intrathecal administration can shorten the treatment time of intracranial infection without higher adverse reaction risks in our research. Further studies with larger sample size are warranted to verify its safety and efficacy.

Central Nervous System Infections Due to Streptococcus anginosus Group: A Single-Center Case Series

BACKGROUND

The Streptococcus anginosus group is known for its pathogenicity and tendency for abscess formation. The S anginosus group also causes brain abscesses, yet few studies describe this presentation in the pediatric neurology literature. We describe 5 patients with central nervous system infection due to S anginosus group evaluated by child neurologists at the University of Iowa from 2014 to 2020.

METHODS

We performed a retrospective case series review of electronic medical records detailing the clinical presentation and course of pediatric patients with S anginosus group-associated central nervous system infection.

RESULTS

We identified 4 males and 1 female (8, 11, 14, 16, and 21 years). Brain imaging showed abscesses in 4 cases and empyema in 1. All underwent neurosurgical intervention and antibiotic treatment. Cultures obtained during the neurosurgical procedure grew S anginosus group (4 cases with Streptococcus intermedius and 1 with Streptococcus constellatus). An 8-year-old boy with a delayed diagnosis died from brain herniation.

CONCLUSIONS

Central nervous system infections due to the S anginosus group can be life-threatening. Neuroimaging plays a key role in the early identification of abscesses. Prompt surgical intervention and timely initiation of antibiotics are critical for optimal outcomes.

Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update

The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.

Cerebrospinal Fluid Penetration of Vancomycin During Continuous Infusion Therapy in Patients With Nosocomial Ventriculitis

BACKGROUND

This study aimed to evaluate the utility of a commercial kit used to measure serum vancomycin concentrations to determine vancomycin concentrations in cerebrospinal fluid (CSF) samples and evaluate CSF penetration when administered as a continuous high-dose infusion in patients with nosocomial ventriculitis.

METHODS

This study included patients with external ventricular drain infection who were admitted to the intensive care unit between January 2018 and September 2020. After validation, CSF samples from 33 patients were collected. All patients received 30 mg/kg of vancomycin as a loading dose followed by 60 mg/kg as a maintenance dose in continuous infusion; all CSF samples were collected at least 48 hours after the first dose.

RESULTS

Thirty-three patients were enrolled in this study. The median serum creatinine level was 0.66 mg/dL (0.5-0.92; n = 30), and median creatinine clearance was 119.2 mL/min (64.6-138.4; n = 13). The median serum vancomycin 24-hour area under the curve (AUC24h) was 838 mg*h/L (515-1010). The median CSF vancomycin concentration was 5.20 mg/L (1.95-12.4). Median serum vancomycin concentration was 34.9 mg/L (21.47-42.1), and median CSF/serum ratio was 18.6% (8.4-41.5). Acute renal injury occurred in 21% (n = 7) of the patients by the end of the therapy. In addition, the vancomycin CSF/serum ratio was positively correlated with the median serum creatinine level (r = 0.670; P = 0.004).

CONCLUSIONS

Commercial vancomycin kits used to measure serum samples may be used to evaluate vancomycin concentrations in the CSF. Vancomycin penetration into CSF was 18.6%.

[Risk factors of nosocomial meningitis in neurological intensive care unit. Results of a five-year prospective study]

Nosocomial meningitis (NM) is a serious complication in neurosurgery. Understanding the risk factors of nosocomial meningitis is important for their prevention.

OBJECTIVE

To determine the main risk factors of NM in neurological intensive care unit.

MATERIAL AND METHODS

A prospective study included all patients (n=2140) treated at the neurological intensive care unit for more than 48 hours between October 1, 2010 and October 31, 2015. Cases of nosocomial meningitis were registered. We analyzed risk factors in 2 groups of patients (with and without NM).

RESULTS AND DISCUSSION

The incidence of NM in neurological intensive care unit was 8.4% (95% CI 6.8-10.0) (n=180). Relative risk of NM under external ventricular drainage was 3.98 (99 cases of NM, p<0.05). Relative risk of NM in patients with CSF leakage (including nasal CSF leakage after transsphenoidal surgery) was 5.2 (49 cases of NM, p<0.05). The incidence of nosocomial meningitis was significantly higher among patients with surgery time ≥8 hours (17.68%, p<0.01). Nosocomial meningitis was also significantly more common after redo surgery (13.07%, p<0.05). Insertion of intracranial pressure sensor was not a significant risk factor of NM. The risk of meningitis was 2.67% if the above-mentioned factors were absent. Extracranial factors are not specific for NM. No significant relationship between certain neurosurgical disease and NM was found.

CONCLUSION

We found higher risk of NM in ICU patients with the following factors: external ventricular drainage, CSF leakage, redo surgery and surgery time.

Cerebrospinal Fluid Collected by Lumbar Puncture Has a Higher Diagnostic Accuracy than Collected by Ventriculostomy

BACKGROUND

Patients harboring an external ventricular drain (EVD) who develop signs of infection require screening for infection in the central nervous system (CNS). The cerebrospinal fluid (CSF) can be collected by the EVD or by lumbar puncture (LP). If only one sample is analyzed, the diagnosis might be dubious or false-negative. The objective of this study was to compare the diagnosis accuracy of CNS infection of CSF samples collected from EVD and LP.

METHODS

We conducted a transversal study where data were prospectively collected from 2016 to 2019. Patients harboring EVD with signs of infection were submitted to the CSF analysis collected by LP and EVD. Diagnosis sensibility and results correlation were analyzed using the kappa index.

RESULTS

The 141 samples from LP and 141 samples from EVD were collected from 108 patients. Among the 282 samples, a total of 77 had infection. Seventy CSF samples from LP fulfilled infection criteria. However, only 32 EVD samples demonstrated infection. Among the 70 cases of infection based on the LP sample, 25 CSF samples collected from the EVD were also suggestive of infection; but in 45 patients only the CSF samples from LP met infection criteria. Seven patients had diagnosis of infection only in the EVD sample. The kappa correlation index of the results obtained from LP and EVD was 0.260 and the McNemar χ² test was <0.01.

CONCLUSIONS

The CSF analysis exclusive from the EVD has a low sensibility and negative predictive value. CSF collected from LP has a sensibility 2.18 times higher than EVD.

CT-guided drainage of a brainstem abscess in a cat as an emergency treatment procedure

Case summary

A 3-year-old male neutered domestic shorthair cat was presented with a 1-week progressive and rapidly deteriorating history of lethargy and abnormal behaviour. Neurolocalisation indicated multifocal intracranial lesions (right oculomotor nerve, brainstem [obtundation, non-ambulatory tetraparesis, vestibular dysfunction and intermittent decerebrate rigidity] and possibly the thalamus [left-sided pleurothotonus]), or more likely a single brainstem lesion with mass effect. MRI of the brain demonstrated a brainstem abscess causing severe dorsal displacement particularly affecting the pons and the medulla oblongata causing cerebellar vermis herniation through the foramen magnum. CT-guided free-hand technique drainage of the brain abscess was performed and broad spectrum antibiotics were started based on sensitivity results. The cat recovered uneventfully from anaesthesia displaying marked improvement immediately after the procedure. Antibiotics were continued for 8 months; repeat imaging prior to withdrawal found complete resolution of the brainstem abscess.

Relevance and novel information

Free-hand CT-guided drainage of a brainstem abscess is not without risk; however, in this case it led to significant clinical improvement and stabilisation likely owing to reduced intracranial pressure. It also provided a diagnostic sample that allowed successful medical treatment planning and outcome. To our knowledge, this is the first report describing the successful management of a brainstem abscess by CT-guided drainage in the veterinary literature. It suggests that stereotactic drainage followed by medical therapy can be considered a successful therapeutic alternative to brain surgery or medical treatment alone, providing an emergency treatment in cases of acute brainstem dysfunction.

Retrospective evaluation of the clinical presentation, magnetic resonance imaging findings, and outcome of dogs diagnosed with intracranial empyema (2008-2015): 9 cases

OBJECTIVE

To describe the clinical presentation, advanced imaging findings, and short- and long-term outcomes in dogs with intracranial empyema.

DESIGN

Retrospective case series.

ANIMALS

Client-owned dogs diagnosed with intracranial empyema.

METHODS

Medical records from 2 referral hospitals were searched for dogs diagnosed with intracranial empyema. To be included in this study, dogs had to fulfill 1 or more of the following 3 inclusion criteria: a magnetic resonance imaging (MRI) scan with space occupying accumulation of extra-axial material suggestive of empyema, a cerebrospinal fluid analysis suggestive of empyema, or direct visualization of purulent material during intracranial surgery.

RESULTS

Nine dogs with intracranial empyema were included, with a median age of 3.5 years (range: 4 mo-12.5 y). All presented as emergencies with 7 of the 9 dogs showing neurological abnormalities and 2 of the 9 with retrobulbar swelling and exophthalmos. Six had surgical intervention, 1 was medically managed, and the remaining 2 dogs were euthanized. Typical MRI findings included extra-axial, T1-weighted hypo- to isointense, T2-weighted hyperintense material compared to gray matter with varying degrees of contrast enhancement, with 6 of 8 showing evidence of contiguous infection from adjacent structures on MRI. For 7 dogs, ≥1 samples were sent for culture and sensitivity, with Enterococcus (surgical swab), Streptococcus pneumonia (from cerebral spinal fluid), and coagulase positive Staphylococcus (ear swab) being cultured. The median antimicrobial course length was 6 weeks (range: 2-28 wk). All dogs for which treatment was attempted survived to discharge, with a median hospitalization time of 7 days (range: 4-10 d). Four of the 7 are still alive at the time of writing (1 lost to follow-up; 2 euthanized for other reasons) with all 4 considered neurologically normal with a successful long-term outcome.

CONCLUSION

Although intracranial empyema in dogs is a rare condition, excellent outcomes are possible in those cases treated appropriately.

Managing Meningoencephalitis in Indian ICU

How to cite this article: Sapra H, Singhal V. Managing Meningo-encephalitis in Indian ICU. Indian J Crit Care Med 2019;23(Suppl 2):S124-S128.

Infectious causes and outcomes in patients presenting with cerebral spinal fluid pleocytosis

To evaluate the infectious etiologies, clinical features, and outcomes of patients with CNS infections at a tertiary care center. Patients that present with a pleocytosis in the cerebral spinal fluid (CSF), defined as a CSF WBC count > 5 cells/mm³, from July 2015 to June 2016 at a tertiary care hospital were analyzed for this report. Data from patients with confirmed (n = 43) and presumed (n = 51) CNS infections were analyzed. CNS infection was the leading known cause of CSF pleocytosis (n = 43, 18% of all patients with a pleocytosis in the CSF), and HSV-2 was identified as the leading causative pathogen (n = 10) followed by varicella zoster virus (n = 5). Fifty-three percent of patients with a pleocytosis in the CSF did not receive a diagnosis. In the patients that did not receive a diagnosis, CNS infection was presumed to be the cause in 51 patients (21% of patients with CSF pleocytosis). The mean time to diagnosis for patients with confirmed CNS infection was 16 days, but time to diagnosis was highly variable depending on the causative pathogen. There was a significant overlap in CSF parameters and peripheral white blood cell counts in patients diagnosed with a viral, bacterial, or fungal infection. Neuroimaging changes were present in only 44% of CNS infections. The overall mortality was 7% for CNS infections, and 17% of patients with a CNS infection had a severe neurologic deficit at presentation while only 3% had a severe deficit at the last neurologic assessment. This study provides new insights into the infectious causes of disease in a cohort of patients with pleocytosis in the CSF. The study provides new insights into the time to diagnosis and outcomes in patients that present with pleocytosis in the CSF.

Methicillin-resistant Staphylococcus aureus intracranial abscess: An analytical series and review on molecular, surgical and medical aspects

Purpose

Intracranial abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) is rare and unexplored. The aim of the present study is to examine the prevalence, clinical and molecular characteristics, treatment options and outcome of MRSA intracranial abscess over a period of 6 years.

Patientsand Methods

A total of 21 patients were included in this retrospective study. The demographic and clinical details of all the patients were collected. Molecular typing including staphylococcal cassette chromosome mec typing, spa typing and polymerase chain reaction of Panton-Valentine leucocidin toxin (PVL) gene for the latter 6 isolates was performed.

Results

The paediatric population was the most affected group (33.3%). The primary route of infection was post-operative/trauma in 7 (33.3%) cases. All the patients were treated surgically either by aspiration or excision. Fifteen (71%) patients received anti-MRSA treatment with vancomycin or linezolid, where linezolid-treated patients showed better prognosis. Of the 11 patients who were on follow-up, unfavourable outcome was observed in 3 (27.3%) cases and 8 (72.7%) cases improved. The molecular typing of six isolates revealed four community-associated (CA) MRSA, one each of livestock-associated (LA) and healthcare-associated MRSA with PVL gene noted in all.

Conclusion

We propose that timely diagnosis, surgical intervention and appropriate anti-MRSA treatment would contribute to better outcome. The occurrence of CA-MRSA and LA-MRSA infection in the central nervous system signifies the threat from the community and livestock reservoir, thus drawing attention towards surveillance and tracking to understand the epidemiology and implement infection control measures.

Central Nervous System Infections

Infections of the nervous system are potential life-threatening and are caused by pathogens such as bacteria, viruses, and fungi. Prompt recognition and treatment of a central nervous system (CNS) infection is crucial for patient survival, as these infections have a high morbidity and mortality. CNS infections include meningitis, encephalitis, and brain abscesses. This article seeks to detail the etiology, clinical course, diagnostic challenges, and treatment of CNS infections organized by infectious agent.

Penetration of Vancomycin into the Cerebrospinal Fluid: A Systematic Review

INTRODUCTION

Infectious disease and pharmacokinetic textbooks indicate that vancomycin has poor penetration into the central nervous system due to its hydrophilic nature and high molecular weight. Recent literature suggests that penetration of vancomycin into cerebrospinal fluid (CSF) is higher than previously reported; therefore, we conducted a systematic review to assess the penetration of vancomycin into CSF.

METHODS

We searched the MEDLINE, EMBASE, and CENTRAL electronic databases for English-language human studies evaluating serum and CSF concentrations of intravenous vancomycin.

RESULTS

In 13 identified studies, the CSF-to-serum ratio of vancomycin varied from 0.00 to 0.81. CSF penetration ranged 0.06-0.81 in patients with meningitis, 0.05-0.17 in ventriculitis, 0.00-0.36 in other infections, and 0-0.13 in patients without infection. Despite variable CSF penetration, 83% of patients with meningitis and 100% of patients with ventriculitis achieved clinical cure. No factor predicted vancomycin CSF penetration.

CONCLUSION

Contrary to prior belief, studies included in our review did not show universally low penetration of vancomycin into CSF. CSF vancomycin levels were variable and did not predict clinical cure.

Primary bacterial ventriculitis in adults, an emergent diagnosis challenge: report of a meningoccal case and review of the literature

BACKGROUND

Defined by an infection of the ventricular system of the brain, ventriculitis is usually known as a health-care associated infection. In contrast, primary pyogenic ventriculitis complicating community-acquired meningitis is uncommon, and mainly described in infants. Only seven cases that have occured in adults have been found in the international literature.

CASE PRESENTATION

We report here a new case due to Neisseria meningitidis occurring in an 85 year-old-man. The comparison with previous reports allows to drawn several conclusions: (i) cases occurred in relatively old adults (median age: 65 years); (ii) Streptococcus pneumoniae, N. meningitiditis and Staphylococcus aureus are the leading responsible pathogens; (iii) atypical clinical presentation seems the rule in which meningism often lacks; (iv) in absence of clinical or biological specific parameters, modern brain imaging such as magnetic resonance imaging with gadolinium enhancement is of utmost importance for the diagnosis, leading to anticipate an increase of the diagnosis in the near future, thanks to easier access to such exploration; (v) death or serious sequelae commonly occurred; (vi) prolonged antibiotic courses (6 weeks to 3 months) have been used, without strong rational. In the given case, the patient presented with a lack of meningeal irritation signs. The diagnosis was made by MRI considering a lasting confused state. A four-week antibiotic regimen was successful, combining two weeks of intravenous cefotaxime followed by two weeks of oral levofloxacin much easier to administrate and allowing early rehabilitation.

CONCLUSION

Primary bacterial ventriculitis is a real diagnosis challenge. Larger indications of MRI for bacterial meningitis, particularly in cases with an atypical presentation or poor evolution would certainly increase the number of diagnosis.

Magnetic Resonance Imaging in Differentatial Diagnosis of Pyogenic Spondylodiscitis and Tuberculous Spondylodiscitis

BACKGROUND

Infectious spondylodiscitis is characterized by the involvement of two adjacent vertebrae and the intervening disc. Incidence rate of the disease is estimated at 0.4-2 cases per 100000 per year. Staphylococcus aureus is the most common infectious agent causing pyogenic spondylodiscitis. Non-pyogenic infections of the spine are most frequently caused by Mycobacterium tuberculosis, and fungi. Clinical symptoms are nonspecific. Early diagnosis and appropriate treatment can prevent unfavorable irreversible sequela for the patient. Significant developments in techniques of imaging of pathological tissues raised expectations among the clinicians regarding possibility to distinguish between tuberculous spondylodiscitis and pyogenic spondylodiscitis on MR images. The aim of this study was to identify and differentiate between features of tuberculous and pyogenic spondylodiscitis on MR images.

MATERIAL/METHODS

We performed retrospective analysis of MR images obtained from 34 patients with confirmed spondylodiscitis (18 with pyogenic spondylodiscitis, and 16 with tuberculous spondylodiscitis). Data acquisition was performed using 1.5 T MRI scanners where images were obtained using similar protocols. T2 TIRM and T1-weighted images with and without contrast enhancement were subject to assessment in coronal, axial and sagittal planes.

RESULTS

Characteristic features of pyogenic spondylodiscitis include: involvement of the lumbar spine, ill-defined paraspinal abnormal contrast enhancement, diffuse/homogeneous contrast enhancement of vertebral bodies, low-grade destruction of vertebral bodies, hyperintense/homogeneous signal from the vertebral bodies on T2 TIRM images. Prevailing features of tuberculous spondylodiscitis included: involvement of the thoracic spine, involvement of 2 or more adjacent vertebral bodies, severe destruction of the vertebral body, focal/heterogeneous contrast enhancement of vertebral bodies, heterogeneous signal from the vertebral bodies on T2 TIRM images, well-defined paraspinal abnormal contrast enhancement, paraspinal and epidural abscesses, meningeal enhancement at the affected spine level.

CONCLUSIONS

Comparison of MR images of patients diagnosed with pyogenic spondylodiscitis and tuberculous spondylodiscitis allowed identification of individual characteristics for preliminary differentiation between TB and infectious spondylodiscitis and thereby enabling proper treatment.

Management of infections associated with neurocritical care

The reported incidence of hospital-acquired infections (HAIs) in the neurointensive care unit (NICU) ranges from 20% to 30%. HAIs in US hospitals cost between $28 and $45 billion per year in direct medical costs. These infections are associated with increased length of hospital stay and increased morbidity and mortality. Infection risk is increased in NICU patients due to medication side-effects, catheter and line placement, neurosurgical procedures, and acquired immune suppression secondary to steroid/barbiturate use and brain injury itself. Some of these infections may be preventable but many are not. Their appearance do not always constitute a failure of prevention or physician error. Neurointensivists require indepth knowledge of common nosocomial infections, their diagnosis and treatment, and an approach to evidence-based practices that improve processes of care and reduce HAIs.

Spinal Epidural Abscess: A Review with Special Emphasis on Earlier Diagnosis

Spinal epidural abscess (SEA) is an uncommon but serious condition with significant morbidity and mortality. The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases. Although many risk factors for SEA can be found in the published literature, their utility is limited by their frequent lack of objective evidence, numerousness, and absence in a significant proportion of cases. In this review, we call for a more discriminate evidence-based use of the term "risk factor" when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein or erythrocyte sedimentation rate.

C-REACTIVE PROTEIN (CRP) AS A SUPPORTING MARKER OF ANTIBIOTIC EFFECTIVENESS ON CENTRAL NERVOUS SYSTEM (CNS) INFECTIONS

Infection of the central nervous system in pediatric patients have a high mortality as well as acute and chronic neurological sequelae. Signs of the disease are unclear, so cerebrospinal fluid (CSF) test is used as a gold standard for diagnosis, but the investigation has faced many obtacles. Empiric antibiotic therapy is the key factor in reducing morbidity and mortality. Microbiological culture result is obtained within 5-7 days. The effectiveness of empirical antibiotic use is questionable. Therefore, other investigations are conducted to determine the effectiveness of antibiotics by using one marker, the CRP. This study was to analyze CRP level in supporting antibiotic therapy effectiveness in pediatric patients with central nervous system (CNS) infections. A prospective cohort study was conducted to determine the relationship of CRP with other parameters, including clinical, microbiological and laboratory, in pediatric patients with central nervous system infections. Patients meeting blood samples criteria were taken before (H0), the third day (H3) and the fifth day (H5) after antibiotics administration. This study involved 10 patients with central nervous system infections (meningoencephalitis, encephalitis and encephalitis with cerebral edema). Six patients were male, with ages less than a year. Antibiotic treatment effectiveness was associated with improved condition of the patients' CRP level. It was 3.558 ±3.196 before (H0), 3.878±2.813 on the third day (H3) and 3.891±2.204 on the fifth day (H5) after antibiotic administration. Leukocyte levels were 13.680±1.660 before (H0), 17.832±7.213 on the third day (H5), and 10.546±3.671 on the fifth day (H5) after antibiotic administration. Pearson's correlation test analysis performed on CRP and WBC parameters showed H0 p=0.981, CRP and WBC H3 p=0.621, while CRP and WBC H5 obtained significance p=0.644. There was no significant correlation observed between CRP and WBC parameters before and after antibiotic administration. In conclusion, there was no correlation of CRP levels with clinical, laboratory and micobiological parameters in patients with central nervous system infections.

Usefulness of blood and cerebrospinal fluid laboratory testing to predict bacterial meningitis in the emergency department

INTRODUCTION

The classic clinical presentation of bacterial meningitis (BM) is observed in less than half of the cases in adults, and symptoms are less specific in children, the elderly or immunocompromised, and other chronic patients. The usual signs and symptoms do not provide optimal sensitivity and specificity for distinguishing possible BM from viral meningitis (VM), which may lead to a delay in the appropriate antimicrobial therapy. Society therefore stands to benefit from the development of effective, objective, and rapid tools able to predict and identify patients with BM. These tools include laboratory tests for blood and cerebrospinal fluid (CSF). The aim of this review is to summarise recently published scientific evidence in order to clarify existing controversies and compare the usefulness and diagnostic ability of the different parameters used to predict BM.

DEVELOPMENT

Systematic search of the main bibliographic databases and platforms to identify articles published between January 2000 and January 2016. We selected 59 articles that meet the objectives of this review.

CONCLUSIONS

CSF lactate, proportion of polymorphonuclear leukocytes, and CSF glucose, as well as serum procalcitonin (PCT), are the independent factors most predictive of bacterial aetiology. The model that combines serum PCT and CSF lactate achieves the highest predictive power for BM, with a sensitivity and specificity exceeding 99%. We should consider BM when CSF lactate >33 md/dL and/or PCT>0.25ng/mL.

Postneurosurgical Central Nervous System Infection Due to Enterococcus faecalis Successfully Treated With Intraventricular Vancomycin

Infections from Enterococcus faecalis and Enterococcus faecium are uncommon in the post-neurosurgical intervention setting., [1, 2, 3, 4] Intraventricular antibiotics are recommended when standard intravenous therapy fails. [5] Here we present a case of post-neurosurgical ventriculitis, meningitis, and cerebritis in an oncology patient caused by refractory Enterococcus faecalis successfully treated with intraventricular vancomycin.

Ability of procalcitonin to predict bacterial meningitis in the emergency department

INTRODUCTION

The aim of this study was to analyse and compare procalcitonin (PCT) and C-reactive protein (CRP) as tools for detecting bacterial meningitis and predicting bacteraemia.

METHODS

Prospective, observational, and descriptive analytical study of 98 consecutive patients aged ≥15 years and diagnosed with acute meningitis in an emergency department between August 2009 and July 2013.

RESULTS

We analysed 98 patients with AM (66 males [67%]); mean age was 44±21 years. The diagnosis was bacterial meningitis in 38 patients (20 with bacteraemia); viral meningitis in 33; probable viral meningitis in 15; and presumptively diagnosed partially treated acute meningitis in 12. PCT had the highest area under the ROC curve (AUC) (0.996; 95% CI, 0.987-1; p<0.001). With a cutoff of ≥ 0.74 ng/ml, PCT achieved 94.7% sensitivity, 100% specificity, negative predictive value (NPV) of 93.9%, and positive predictive value (PPV) of 100%. The mean levels for PCT were11.47±7.76 ng/ml in bacterial meningitis vs. 0.10±0.15 ng/ml in viral meningitis (p <0.001). The AUC for CRP was 0.916 and a cutoff of ≥ 90 mg/L achieved 67.5% sensitivity, 86.3% specificity, PPV of 89.2%, and NPV of 90.4%. As a predictor of bacteraemia in bacterial meningitis, only PCT delivered a significant difference (14.7±7.1 ng/mL vs. 4.68±3.54 ng/mL, p<0.001). A cutoff of ≥ 1.1 ng/mL achieved 94.6% sensitivity, 72.4% specificity, NPV of 95.4%, and PPV of 69.2%; the AUC was 0.965 (95% CI, 0.921-1; p<0.001).

CONCLUSIONS

PCT has a high diagnostic power for acute meningitis in emergency department patients. PCT outperforms CRP in the detection of bacterial aetiology and is a good predictor of bacteraemia in bacterial meningitis.

A Case of Ventriculitis Associated with Renal Abscess Caused by Serotype K1 Klebsiella pneumoniae

Recently, serotype K1 Klebsiella pneumoniae has been a major agent of an invasive syndrome characterized by liver abscess and its metastatic infection. Extrahepatic infection and its characteristics in patients with renal abscess caused by K. pneumoniae are poorly understood, and few cases of central nervous system infection have been reported. This is a report of 80-year-old woman with uncontrolled type 2 diabetes mellitus with renal abscess caused by serotype K1 K. pneumoniae, complicated with ventriculitis despite of appropriate use of antibiotics. Physicians need to be aware of possibility of metastatic infection in patients with serotype K1 K. pneumoniae infection, if they develop neurologic symptom and focus of infection is still present.

Tubercular ventriculitis: an uncommon entity

Although tubercular meningitis is common in children, tubercular ventriculitis is uncommon. The authors report a 3-mo-old infant who had tubercular ventriculitis secondary to disseminated tuberculosis.

Successful management of severe neuroinvasive eastern equine encephalitis

BACKGROUND

Eastern Equine Encephalitis (EEE) virus is an arbovirus that mostly causes asymptomatic infection in humans; however, some people can develop a neuroinvasive infection associated with a high mortality.

METHODS

We present a case of a patient with severe neuroinvasive EEE.

RESULTS

A 21-year-old man initially presented with headache, fever, and vomiting and was found to have a neutrophilic pleocytosis in his cerebrospinal fluid. He eventually was diagnosed with EEE, treated with high-dose methylprednisolone and intravenous immunoglobulin. His course in the NeuroIntensive Care Unit was complicated by cerebral edema and intracranial hypertension, requiring osmotherapy, pentobarbital and placement of an external ventricular device, and subclinical seizures, necessitating multiple anti-epileptic drugs

CONCLUSIONS

A multifaceted approach including aggressive management of cerebral edema and ICP as well as treatment with immunomodulating agents and cessation of seizures may prevent brain herniation, secondary neurologic injury and death in patients with EEE. Effective management and treatment in our patient contributed to a dramatic recovery and ultimate good outcome.

Non-cephalosporin-susceptible, glucose non-fermentative Gram-negative bacilli meningitis in post-neurosurgical adults: clinical characteristics and therapeutic outcome

OBJECTIVE

The clinical and laboratory characteristics of non-cephalosporin-susceptible (non-CS) glucose non-fermentative Gram-negative (G(-)) infections in adults with postneurosurgical meningitis are rarely examined solely in the literature.

METHODS

The data of 28 post-neurosurgical adults meningitis with glucose non-fermentative G(-) infections, collected during a study period of 5 years (2006-2010), were reviewed. The clinical and laboratory data between the non-cephalosporin-susceptible groups and the cephalosporin-susceptible groups were compared.

RESULTS

A total of 30 G(-) strains were collected from the 28 enrolled cases. Among the implicated glucose non-fermentative G(-) strains, 18 strains, belonging to 17 cases, were non-CS. Among the 18 non-cephalosporin-susceptible strains, Acinetobacter spp. (39%, 7/18) was the most common, followed by Pseudomonas spp. (22%, 4/18), Stenotrophomonas maltophilia (22%, 4/18) and Elizabethkingia meningoseptica (11%, 2/18). With a comparative analysis, there were no significant difference between the non-cephalosporin-susceptible and cephalosporin-susceptible glucose non-fermentative G(-) groups. The clinical and laboratory data were also of no statistical significance between the fatal (n=4) and non-fatal (n=13) non-cephalosporin-susceptible groups.

CONCLUSION

Sixty percent (18/30) of implicated glucose non-fermentative G(-) strains of post-NS meningitis in adults are non-cephalosporin-susceptible. Among the non-cephalosporin-susceptible glucose non-fermentative G(-) strains, Acinetobacter spp., Pseudomonas spp., S. maltophilia and E. meningoseptica are the commonly implicated pathogens, and their emergence in this specific group of meningitis has caused a therapeutic dilemma. The clinical manifestations of non-cephalosporin-susceptible glucose non-fermentative G(-) meningitis were not unique; therefore, only bacterial culture and antimicrobial susceptibility test are the methods for identification confirmation.

Fever and neurologic conditions

Neurologic conditions are categorized as either those that cause a change in mental status or those that create a focal finding on physical examination. Neurologic abnormality associated with fever can be caused by a primary neurologic condition or one that does not originate in the central nervous system. Optimal management of such conditions requires high clinical suspicion and a broad differential diagnosis, which facilitates rapid recognition and effective treatment. A thorough history and physical examination are key determinants in accurately diagnosing neurologic conditions associated with fever, often requiring acquisition of collateral information from persons other than the patient.

A vignette-based survey to assess clinical decision making regarding antibiotic use and hospitalization of patients with probable aseptic meningitis

BACKGROUND

The many etiologies of meningitis influence disease severity - most viral causes are self-limiting, while bacterial etiologies require antibiotics and hospitalization. Aided by laboratory findings, the physician judges whether to admit and empirically treat the patient (presuming a bacterial cause), or to treat supportively as if it were viral.

OBJECTIVE

To determine factors that lead infectious disease specialists to admit and treat in cases of suspected meningitis.

METHODS

A clinical vignette describing a typical case of viral meningitis in the emergency department was presented to clinicians. They were asked to indicate on a Likert scale the likelihood of administering empirical antibiotics and admitting the patient from the vignette and for eight subsequent scenarios (with varied case features). The process was repeated in the context of an inpatient following initial observation and/or treatment.

RESULTS

Participants were unlikely to admit or to administer antibiotics in the baseline scenario, but a low Glasgow Coma Score or a high cerebrospinal fluid (CSF) white blood cell count with a high neutrophil percentage led to empirical treatment and admission. These factors were less influential after a negative bacterial CSF culture. These same clinical variables led to maintaining treatment and hospitalization of the inpatient.

CONCLUSIONS

Most participants chose not to admit or treat the patient in the baseline vignette. Confusion and CSF white blood cell count (and neutrophil predominance) were the main influences in determining treatment and hospitalization. A large range of response scores was likely due to differing regional practices or to different levels of experience.

Acute bacterial meningitis: current review and treatment update

Bacterial meningitis is an infection of the meninges that can be infected by bacteria, virus, or fungus. The classic triad of bacterial meningitis consists of fever, neck stiffness, and altered mental status; headache is also another common symptom. Interventions for bacterial meningitis include prompt diagnosis, and initiation of antimicrobial therapy to optimize bacterial kill and decrease inflammatory response in the subarachnoid space. Nursing management consists of effective delivery of antibiotic therapy, fluid management, and supportive care.

Pharmacokinetics of antibacterial agents in the CSF of children and adolescents

The adequate management of central nervous system (CNS) infections requires that antimicrobial agents penetrate the blood-brain barrier (BBB) and achieve concentrations in the CNS adequate for eradication of the infecting pathogen. This review details the currently available literature on the pharmacokinetics (PK) of antibacterials in the CNS of children. Clinical trials affirm that the physicochemical properties of a drug remain one of the most important factors dictating penetration of antimicrobial agents into the CNS, irrespective of the population being treated (i.e. small, lipophilic drugs with low protein binding exhibit the best translocation across the BBB). These same physicochemical characteristics determine the primary disposition pathways of the drug, and by extension the magnitude and duration of circulating drug concentrations in the plasma, a second major driving force behind achievable CNS drug concentrations. Notably, these disposition pathways can be expected to change during the normal process of growth and development. Finally, CNS drug penetration is influenced by the nature and extent of the infection (i.e. the presence of meningeal inflammation). Aminoglycosides have poor CNS penetration when administered intravenously. Intrathecal gentamicin has been studied in children with more promising results, often exceeding the minimum inhibitory concentration. There are very limited data with intrathecal tobramycin in children. However, in the few patients that have been studied, the CSF concentrations were highly variable. Penicillins generally have good CNS penetration. Aqueous penicillin G reaches greater concentrations than procaine or benzathine penicillin. Concentrations remain detectable for ≥ 12 h. Of the aminopenicillins, both ampicillin and parenteral amoxicillin reach adequate CNS concentrations; however, orally administered amoxicillin resulted in much lower concentrations. Nafcillin and piperacillin are the final two penicillins with pediatric data: their penetration is erratic at best. Cephalosporins vary greatly in regard to their CSF penetration. Few first- and second-generation cephalosporins are able to reach higher CSF concentrations. Cefuroxime is the only exception and is usually avoided due to its adverse effects and slower sterilization of the CSF than third-generation agents. Ceftriaxone, cefotaxime, ceftazidime, cefixime and cefepime have been studied in children and are all able to adequately penetrate the CSF. As with penicillins, concentrations are greatest in the presence of meningeal inflammation. Meropenem and imipenem are the only carbapenems with pediatric data. Imipenem reaches higher CSF concentrations; however, meropenem is preferred due to its lower incidence of seizures. Aztreonam has also demonstrated favorable penetration but only one study has been completed in children. Both chloramphenicol and sulfamethoxazole/trimethoprim (cotrimoxazole) penetrate into the CNS well; however, significant toxicities limit their use. The small size and minimal protein binding of fosfomycin contribute to its favorable CNS PK. Although rarely used, it achieves higher concentrations in the presence of inflammation and accumulation is possible. Linezolid reaches high CSF concentrations; however, more frequent dosing might be required in infants due to their increased elimination. Metronidazole also has very limited information but it demonstrated favorable results similar to adult data; CSF concentrations even exceeded plasma concentrations at certain time points. Rifampin (rifampicin) demonstrated good CNS penetration after oral administration. Vancomycin demonstrates poor CNS penetration after intravenous administration. When combined with intraventricular therapy, CNS concentrations are much greater. Of the antituberculosis agents, isoniazid, pyrazinamide and streptomycin have been studied in children. Isoniazid and pyrazinamide have favorable CSF penetration. Streptomycin appears to produce unpredictable CSF levels. No pediatric-specific data are available for clindamycin, daptomycin, macrolides, tetracyclines, and fluoroquinolones. Daptomycin, fluoroquinolones, and tetracyclines have demonstrated favorable CNS penetration in adults; however, data are limited due to their potential pediatric-specific toxicities and newness within the marketplace. Macrolides and clindamycin have demonstrated poor CNS penetration in adults and thus have not been studied in pediatrics.

Clinical presentation of patients with aseptic meningitis, factors influencing treatment and hospitalization, and consequences of enterovirus cerebrospinal fluid polymerase chain reaction testing

INTRODUCTION

Clinical and laboratory features of enteroviral meningitis may overlap with those of bacterial meningitis. In the present retrospective review, we compared features of enteroviral (EV)-positive and -negative patients to determine those that were most influential in admission, discharge and in anti-infective administration.

METHODS

Data were analyzed from the records of 117 pediatric and adult patients who underwent cerebrospinal fluid (CSF) EV testing over a three-year period.

RESULTS

The oldest EV-positive patient was 34 years of age and the occurrence of the disease was highly seasonal. EV-positive patients were more likely to report fever, rash, photophobia, short onset and exposure to an ill contact. A positive polymerase chain reaction (PCR) result was associated with relatively short hospitalization. Seizure and neurological symptoms were more strongly associated with a negative PCR test result. CSF characteristics did not discriminate well between patients with positive and negative PCR tests. Patients with imperfect Glasgow Coma Scores or with neurological symptoms were more likely to be admitted to hospital than those without. Fever and recent onset predicted determinants of anti-infective use.

CONCLUSION

The present retrospective study confirms previous reports regarding seasonality and the young age of positive patients. Factors that indicate nonenteroviral etiology were appropriately also those that influenced hospitalization. Patients with EV meningitis were likely to be treated with empirical anti-infectives, and a substantial proportion continued to take antibiotics for more than 24 h after receiving the positive EV PCR test result.

INTRODUCTION

Clinical and laboratory features of enteroviral meningitis may overlap with those of bacterial meningitis. In the present retrospective review, we compared features of enteroviral (EV)-positive and -negative patients to determine those that were most influential in admission, discharge and in anti-infective administration.

METHODS

Data were analyzed from the records of 117 pediatric and adult patients who underwent cerebrospinal fluid (CSF) EV testing over a three-year period.

RESULTS

The oldest EV-positive patient was 34 years of age and the occurrence of the disease was highly seasonal. EV-positive patients were more likely to report fever, rash, photophobia, short onset and exposure to an ill contact. A positive polymerase chain reaction (PCR) result was associated with relatively short hospitalization. Seizure and neurological symptoms were more strongly associated with a negative PCR test result. CSF characteristics did not discriminate well between patients with positive and negative PCR tests. Patients with imperfect Glasgow Coma Scores or with neurological symptoms were more likely to be admitted to hospital than those without. Fever and recent onset predicted determinants of anti-infective use.

CONCLUSION

The present retrospective study confirms previous reports regarding seasonality and the young age of positive patients. Factors that indicate nonenteroviral etiology were appropriately also those that influenced hospitalization. Patients with EV meningitis were likely to be treated with empirical anti-infectives, and a substantial proportion continued to take antibiotics for more than 24 h after receiving the positive EV PCR test result.

Assessing the clinical needs for point of care technologies in neurologic emergencies

BACKGROUND

Neurologic emergencies are common, frequently devastating, and benefit from timely diagnosis and treatment. Point of care (POC) technologies have the potential to assist clinicians caring for these patients. In order to prioritize development of new POC testing, a thorough assessment of clinical needs is required. We describe the methods of the clinical needs assessment (CNA) process and provide the initial findings of a CNA for POC technologies in neurologic emergencies performed to support a National Institute of Biomedical Imaging and Bioengineering (NIBIB) initiative.

METHODS

CNA is an iterative process. An initial survey instrument was developed through consensus by a multi-disciplinary panel and underwent internal validation through beta-testing and face-validity assessment. This survey was distributed at the national meetings of several academic medical societies and results were used to redesign of the survey tool for broader distribution. Analysis of responses from the revised survey supported the release of a request for proposals (RFP) in 2010. Survey revision continues, and expanded CNA efforts with focus groups are being designed in anticipation of another RFP in 2012.

RESULTS

The initial survey identified six areas of clinical need and two domains of interest. The revised version gathered additional responses but no new domains or areas of clinical need were identified. The resultant RFP generated 23 letters of intent from industry and academic institutions, of which three were chosen for funding.

CONCLUSIONS

Assessing clinical needs is a necessary first step in developing new technologies. A multi-faceted approach assures that the views of interested stakeholders are represented and can influence success.

Infections of the nervous system

Glycemic control is an important aspect of patient care in the surgical Infections of the nervous system are among the most difficult infections in terms of the morbidity and mortality posed to patients, and thereby require urgent and accurate diagnosis. Although viral meningitides are more common, it is the bacterial meningitides that have the potential to cause a rapidly deteriorating condition that the physician should be familiar with. Viral encephalitis frequently accompanies viral meningitis, and can produce focal neurologic findings and cognitive difficulties that can mimic other neurologic disorders. Brain abscesses also have the potential to mimic and present like other neurologic disorders, and cause more focal deficits. Finally, other infectious diseases of the central nervous system, such as prion disease and cavernous sinus thrombosis, are explored in this review.

Clinical characteristics, pathogens implicated and therapeutic outcomes of mixed infection in adult bacterial meningitis

We reviewed retrospectively the data for adult patients with bacterial meningitis over a period of 10.5 years in our hospital. The clinical characteristics and laboratory data of the 21 cases (52 strains) of mixed infection were analyzed. Two hundred and fifteen cases of single pathogen adult bacterial meningitis (ABM) were also included for comparison. Post-neurosurgical type of ABM was presented in 86% of the mixed infection group. Brain abscess was found in three patients. Fourteen patients survived and seven cases died. The analysis showed a statistical significance for the mixed infection group having a higher rate of nosocomially-acquired, post-neurosurgical condition, hydrocephalus, and lower level of cerebrospinal fluid white cell count, protein and lactate than the single pathogen group. Logistic regression analysis showed the independent factor of "hydrocephalus" (p = 0.002). Presence of hydrocephalus is a significant neuroimaging feature when compared with the single pathogen group. As compared with the previous study results of mixed infection in ABM, the present study showed a change of pathogens implicated of increasing Pseudomonas spp. and Acinetobacter spp. infections, and an emergence of anaerobic pathogens. All these changes deserve special attention because of the need for an appropriate choice of empirical antibiotics and choice of culture method.

Neurologic infectious disease emergencies

Nearly 70 years after the discovery of penicillin, neurologic infectious diseases (NIDs) remain an important worldwide source of morbidity and mortality. The clinician faced with a potential NID must urgently consider patient demographics, pace of illness and clinical syndrome, and laboratory data. In keeping with the topics of this issue, initial emergency diagnosis and management are emphasized, with appropriate references to relevant literature for subsequent longer-term interventions.

Infectious causes of seizures and epilepsy in the developing world

Central nervous system (CNS) infections are the main cause of seizures and acquired epilepsy in the developing world. Geographical variations determine the common causes in a particular region. Acute seizures are common in severe meningitis, viral encephalitis, malaria, and neurocysticercosis, and in most cases are associated with increased mortality and morbidity, including subsequent epilepsy. Neuronal excitability secondary to proinflammatory signals induced by CNS infections are an important common mechanism for the generation of seizures, in addition to various other specific mechanisms. Newer insights into the neurobiology of these infections and the associated epilepsy could help in developing neuroprotective interventions. Management issues include prompt treatment of acute seizures and the underlying CNS infection, correction of associated predisposing factors, and decisions regarding the appropriate choice and duration of antiepileptic therapy. Strategies for the prevention of epilepsy in CNS infections such as early anti-infective and anti-inflammatory therapy need scientific exploration. Prevention of CNS infections is the only definitive way forward to reduce the burden of epilepsy in developing countries.