Comparative efficacy of ceftriaxone and cefuroxime for treatment of bacterial meningitis

Molecular characterization of cefepime and aztreonam nonsusceptibility in Haemophilus influenzae

BACKGROUND

Cefepime and aztreonam are highly efficacious against H. influenzae, and resistant strains are rare. In this study, we isolated cefepime- and aztreonam-nonsusceptible H. influenzae strains and addressed the molecular basis of their resistance to cefepime and aztreonam.

METHODS

Two hundred and 28 specimens containing H. influenzae were screened, of which 32 isolates were enrolled and applied to antimicrobial susceptibility testing and whole-genome sequencing. Genetic variations that were detected in all nonsusceptible isolates with statistical significance by Fisher's exact tests were identified as cefepime or aztreonam nonsusceptibility related. Functional complementation assays were conducted to assess the in vitro effects of proteins with sequence substitutions on drug susceptibility.

RESULTS

Three H. influenzae isolates were nonsusceptible to cefepime, one of which was also nonsusceptible to aztreonam. Genes encoding TEM, SHV and CTX-M extended-spectrum β-lactamases were not detected in the cefepime- and aztreonam-nonsusceptible isolates. Five genetic variations in four genes and 10 genetic variations in five genes were associated with cefepime and aztreonam nonsusceptibility, respectively. Phylogenetic analyses revealed that changes in FtsI were correlated strongly with the MIC of cefepime and moderately with aztreonam. FtsI Thr532Ser-Tyr557His cosubstitution linked to cefepime nonsusceptibility and Asn305Lys-Ser385Asn-Glu416Asp cosubstitution to aztreonam nonsusceptibility. Functional complementation assays revealed that these cosubstitutions increased MICs of cefepime and aztreonam in susceptible H. influenzae isolates, respectively.

CONCLUSIONS

Genetic variations relevant to resistant phenotypes of cefepime and aztreonam nonsusceptibility in H. influenzae were identified. Moreover, the effects of FtsI cosubstitutions on increasing MICs of cefepime and aztreonam in H. influenzae were demonstrated.

Strategies and new developments in the management of bacterial meningitis

The principles of antimicrobial therapy for acute bacterial meningitis include use of agents that penetrate well into cerebrospinal fluid and attain appropriate cerebrospinal fluid concentrations, are active in purulent cerebrospinal fluid, and are bactericidal against the infecting pathogen. Recommendations for treatment of bacterial meningitis have undergone significant evolution in recent years, given the emergence of pneumococcal strains that are resistant to penicillin. Clinical experience with use of newer agents is limited to case reports, but these agents may be necessary to consider in patients who are failing standard therapy.

Principles of antimicrobial therapy

We have discussed important factors involved in choosing appropriate antimicrobial regimens for the treatment of bacterial meningitis and brain abscess to illustrate common themes relevant to the treatment of these diseases. We have limited this review to these conditions for two main reasons: (1) the principles involved in optimal antimicrobial therapy for these diseases likely apply to others CNS infections, such as viral and fungal diseases; and (2) little pharmacological information is currently available for other types of CNS infections. Many of the studies addressing the relevant pharmacological and microbiological aspects of antimicrobial therapy for CNS infections have been performed in experimental animal models and, as a result, the information derived from these studies may be different when examined in appropriate human studies. Our current understanding of appropriate antimicrobial therapy for CNS infections may be summarized as follows: 1. Choose bactericidal antimicrobials that effectively cross the BBB to achieve CSF concentrations well above the MBC (≥ 10-fold) for the suspected bacterial pathogen(s). 2. Take into consideration the relevant PD parameters the bactericidal activity of the antimicrobials used to treat bacterial meningitis, such as t > MBC or AUC/MBC. 3. Tailor the antimicrobial regimen based on microbiological information, once available. However, with respect to brain abscess therapy, keep in mind that anaerobes are commonly involved, but difficult to culture, and consider including antianaerobic therapy even if the bacterial cultures do not grow anaerobes. 4. Treat bacterial meningitis caused by nonmeningococcal pathogens for 7-10 days, but monitor clinical progress to determine whether the patient should continue on a more prolonged antimicrobial course. Meningococcal meningitis may be treated with 3-4 days of effective antimicrobial therapy, again with the caveat that the patients clinical course should dictate duration of therapy. 5. Treat brain abscess, preferably after aspiration/drainage, for at least 6 weeks with intravenous antimicrobials for brain abscess on the clinical response (e.g., improved symptoms, lack of new neurological findings) and radiographic changes (e.g., reduction in cavity size).

Antibacterial agents in pediatrics

Antibiotics are among the most widely prescribed therapeutic agents in children. Several new trends in antibiotic usage for pediatric care have emerged. New mechanisms of antibacterial resistance have required a broader repertoire of antibiotic usage, including new agents directed at multidrug resistance. After promotion of judicious antibiotic use, there has been a decline in the number of pediatric prescriptions for antibiotics. Recent legislation addresses the necessity for pediatric clinical drug trials, ensuring development of further antibacterial agents for use in pediatric patients.

Bacterial meningitis in children

This review comprises aspects of the epidemiology, microbiology, pathophysiology, clinical manifestations, diagnosis, management, prognosis, and prevention of bacterial meningitis, with emphasis on the paediatric population. The beginning of this millennium has witnessed the virtual disappearance of Haemophilus invasive disease in some countries, emergence of pneumococcal strains that are resistant to multiple antibiotics, isolation of pneumococci with tolerance to vancomycin, outbreaks and clusters of meningococcal meningitis in several geographical areas, and intense research in development of effective conjugate pneumococcal and meningococcal vaccines. Bacterial meningitis has become an uncommon disease in the developed world. Unfortunately, because of limited economic resources and poor living conditions, many developing countries are still affected by the devastating consequences of this life-threatening systemic infection. Basic and clinical research is needed to discover new antimicrobial and anti-inflammatory agents to improve outcome from disease. Novel strategies are needed to distribute and implement effective vaccines worldwide to prevent bacterial meningitis.

Ceftriaxone: an update of its use in the management of community-acquired and nosocomial infections

Ceftriaxone is a parenteral third-generation cephalosporin with a long elimination half-life which permits once-daily administration. It has good activity against Streptococcus pneumoniae, methicillin-susceptible staphylococci, Haemophilus influenzae, Moraxella catarrhalis and Neisseria spp. Although active against Enterobacteriaceae, the recent spread of derepressed mutants which hyperproduce chromosomal beta-lactamases and extended-spectrum beta-lactamases has diminished the activity of all third-generation cephalosporins against these pathogens necessitating careful attention to sensitivity studies. Extensive data from randomised clinical trials confirm the efficacy of ceftriaxone in serious and difficult-to-treat community-acquired infections including meningitis, pneumonia and nonresponsive acute otitis media. Ceftriaxone also has efficacy in other community-acquired infections including uncomplicated gonorrhoea, acute pyelonephritis and various infections in children. In the nosocomial setting, extensive data also confirm the efficacy of ceftriaxone with or without an aminoglycoside in serious Gram-negative infections, pneumonia, spontaneous bacterial peritonitis and as surgical prophylaxis. Outpatient use of ceftriaxone, either as part of a step-down regimen or parenterally, is a distinguishing feature of the data gathered on the agent over the last decade. The review focuses on new applications of the drug and its use in infections in which the causative pathogens or their resistance patterns have changed over the past decade. Ceftriaxone has a good tolerability profile, the most common events being diarrhoea, nausea, vomiting, candidiasis and rash. Ceftriaxone may cause reversible biliary pseudolithiasis, notably at higher dosages of the drug (>/=2 g/day); however, the incidence of true lithiasis is <0.1%. Injection site discomfort or phlebitis can occur after intramuscular or intravenous administration.

CONCLUSIONS

As a result of its strong activity against S. pneumoniae, ceftriaxone holds an important place, either alone or as part of a combination regimen, in the treatment of invasive pneumococcal infections, including those with reduced beta-lactam susceptibility. Its once-daily administration schedule allows simplification of otherwise complex regimens in a hospital setting and has also contributed to its popularity as a parenteral agent in an ambulatory setting. These properties, together with a well characterised tolerability profile, mean that ceftriaxone is likely to retain its place as an important third-generation cephalosporin in the treatment of serious community-acquired and nosocomial infections.

Antibacterial agents in infections of the central nervous system

Experimental animal models have provided information applicable to antimicrobial therapy of infections of the central nervous system. The efficacy of an antimicrobial agent in the therapy of bacterial meningitis depends on its ability to penetrate the blood-brain barrier, its activity in purulent cerebrospinal fluid, and a demonstration of rapid bactericidal activity against the offending pathogen. The recent emergence of resistant pathogens is challenging the therapy for bacterial meningitis. Various strategies for treating resistant pathogens have been evaluated in experimental animal models. Encouraging results have led to clinical trials to evaluate the efficacy of newer agents, alone or in combination with standard regimens.

Antibacterial agents in pediatrics

From low birth weight infants to adolescents, physiologic and developmental differences underlie the marked differences in pharmacokinetics and pharmacodynamics of antibacterial agents. Certain diseases, such as cystic fibrosis, also can alter these parameters. This article describes the principles of pharmacokinetics and pharmacodynamics that are unique to children and that characterize the clinical application of selected antibacterial agents to infectious diseases in children.

Adjunctive dexamethasone therapy for pediatric bacterial meningitis

There have been numerous studies performed to assess the impact of adjunctive corticosteroid therapy on the outcome of pediatric bacterial meningitis. Much of these data are conflicting, which can result in confusion regarding therapeutic efficacy. The present article will review the pathophysiology of this disease, critique the body of medical literature on this aspect of therapy, and provide guidelines for the emergency physician on the use of dexamethasone therapy for bacterial meningitis in children.

Clinical usefulness of cerebrospinal fluid bacterial antigen studies

A retrospective chart review was performed to evaluate the effect that positive results of cerebrospinal fluid bacterial antigen tests had on the care of patients with presumed bacterial meningitis. Of 901 tests ordered, costing $26,000 per year, 29 showed positive results--and only four of these affected patient care. By using cerebrospinal fluid bacterial antigen testing only when another test does not identify an organism, or in an attempt to determine central nervous system infection late in therapy for presumed sepsis, one can greatly reduce costs with no detrimental effect on patients.

Bacterial meningitis in infants and children: a review

Emergency physicians are often required to evaluate febrile infants and children with no obvious source of infection. Most have uncomplicated viral illnesses. It is imperative, however, to identify the child with potentially life-threatening bacterial meningitis. The clinical presentation of meningitis is variable and depends on many factors. These variables are discussed as well as the indications for lumbar puncture and guidelines for laboratory evaluation. Recommendations for antibiotic selection and dosages are provided. The clinical trials regarding the use of dexamethasone are also reviewed.

Viral meningitis. Tips to rapidly diagnose treatable causes

Viral meningitis is a common illness among children and is most often caused by enteroviruses. Diagnosis is made on the basis of clinical findings and analysis of the cerebrospinal fluid. Important conditions to consider in diagnosis are partially treated bacterial meningitis, tuberculous meningitis, fungal meningitis, other infections, and central nervous system tumor. Ruling out treatable causes early is important. Treatment of enteroviral meningitis is supportive, and the prognosis is usually very good, although significant neurologic sequelae have been reported.

Outcome of paediatric bacterial meningitis 1979-1989

OBJECTIVE

To determine the outcome of all cases of paediatric bacterial meningitis over the 11-year period 1979-1989 and discuss the role of adjunctive therapy with dexamethasone.

DESIGN AND SETTING

The study was performed by retrospective case review at Flinders Medical Centre, a general teaching hospital.

RESULTS

There were 80 episodes in 79 patients. The age range was 2 days to 15 years (mean, 1.7 years). Haemophilus influenzae type b was the commonest organism (60 of 80 cases; 75%). There were five deaths (6.3%). Sensorineural hearing loss was found in six of 71 children (8.5%) and was bilateral and severe in four (5.6%). Other problems included learning difficulties (12.7%), motor problems (7%), speech delay (7%), hyperactivity (4.2%), blindness (2.8%), obstructive hydrocephalus (2.8%) and recurrent seizures (2.8%).

CONCLUSIONS

Bacterial meningitis remains a disease with significant morbidity and mortality. Adjunctive therapy with dexamethasone should be considered, and vaccination against Haemophilus influenzae type b should be routine.

Initial therapy of bacterial meningitis with cefuroxime: Experience in 167 children

The morbidity and mortality of patients with bacterial meningitis treated initially with cefuroxime were studied and compared with the results of a previous prospective study of patients treated initially with ampicillin plus chloramphenicol in the same institution from 1979 to 1983. A retrospective chart review was completed in all cases of microbiologically confirmed bacterial meningitis admitted to the Hospital for Sick Children in Toronto, Ontario between January 1, 1984 and August 1, 1988. During this period all patients were treated initially with intravenous cefuroxime. The 167 children reviewed ranged in age from six weeks to 17.1 years (median 11.6 months). The case fatality rate was 7.8% and the rate of hearing deficit 13%. There were no statistically significant differences in abnormal neurological outcome (20 versus 20%, respectively), hearing loss (12.9 versus 13%, respectively), and case fatality rate (6.4 versus 7.8%, respectively) between the cohort of 1979-83 and the present study. The rate of hearing loss following meningitis caused by Haemophilus influenzae type b increased from 7.3 to 11.7% (P=0.26).

Antibiotic therapy for severe infections in infants and children

In infants and children, the absorption, distribution, metabolism, and excretion of drugs may differ considerably in comparison with these factors in adults; consequently, differences exist in therapeutic efficacy and toxicity of various antibiotic agents. Because of known toxicity, certain drugs--such as chloramphenicol in high doses, the sulfonamides, and tetracycline--should not be used in neonates. Antibiotic therapy should be modified in neonates because of biologic immaturity of organs important for the termination of drug action. Because of poor conjugation, inactivation, or excretion, the serum concentrations of many antibiotics may be higher and more prolonged in neonates than in older infants; thus, lower doses and longer intervals between administration may be necessary. In this article, we suggest dosages of antimicrobial agents for severe infections in children, older infants, and neonates. Included in the discussion are the cephalosporins, especially the third-generation cephalosporins that have assumed an important role in empiric treatment of bacterial meningitis in pediatric patients because of their ability to penetrate the central nervous system and their effectiveness against beta-lactamase-positive and negative strains of Haemophilus influenzae type b, Streptococcus pneumoniae, Neisseria meningitidis, and many gram-negative bacteria in the Enterobacteriaceae group. In patients with congenital or acquired immunodeficiencies, antifungal, antiviral, or anti-Pneumocystis agents are often added to the antimicrobial regimen for severe infections. We review the agents available for such treatment in children, the drugs used for childhood tuberculosis, and certain new antibiotics (aztreonam, ticarcillin-clavulanate, ciprofloxacin, and imipenem-cilastatin) that have proved useful in select cases but whose precise role in pediatric practice will necessitate additional clinical experience.

Ceftriaxone in treatment of serious infections. Meningitis

In many pediatric infectious disease programs, ceftriaxone or cefotaxime is now the preferred drug for bacterial meningitis caused by H. influenzae, meningococci, and pneumococci. Ceftriaxone reaches a high bactericidal titer in the cerebrospinal fluid and persists at the site of infection longer than any other beta-lactam antibiotic. Short-course, once-daily therapy with ceftriaxone requires more study; currently, many pediatricians administer the agent twice daily for suspected or proven meningitis. Given the association of sequelae with prolongation of positive CSF cultures, ceftriaxone's rapid bactericidal activity is an advantage, which may require an adjunctive agent to block the inflammatory response due to antibiotic-induced release of endotoxin and other cell wall components. As empiric therapy, ceftriaxone is effective in infants and children three months to 18 years old. It is not yet recommended in neonates, because of concerns about bilirubin displacement. Thus, infants up to three months of age should receive ampicillin plus cefotaxime. In adults, ceftriaxone is effective therapy for presumed bacterial meningitis but must be combined with ampicillin initially, since L. monocytogenes meningitis cannot be excluded in most cases until CSF culture results are available.

Antibiotic resistance in Haemophilus influenzae: mechanisms, clinical importance and consequences for therapy

Invasive and non-invasive infections caused by Haemophilus influenzae are frequently diagnosed in children below the age of 5 years. The treatment of choice for these infections was ampicillin. However, since the early 1970s the increasing prevalence of resistance to ampicillin and other antibiotics has necessitated major changes in antibiotic therapy. This article summarizes some of the important clinical features of diseases caused by H. influenzae. The epidemiology, the problems with in vitro susceptibility testing and the mechanisms of resistance to major antibiotics are reviewed. The consequences of antibiotic resistance for the treatment of diseases caused by H. influenzae are discussed.

Efficacy and safety of cefotaxime in the management of pediatric infections

The utilization of cephalosporins in serious bacterial infections in children has become more widely accepted by pediatric infectious disease specialists over the past five years. The use of cephalosporins has become increasingly popular in empiric antibiotic regimens. The recognition that age-specific bacterial pathogens in neonates, older infants and children can be effectively treated with cephalosporins alone, or in combination with ampicillin, has led to this increasing popularity. This review will discuss the use of cephalosporins in empiric antibiotic regimens and relate the efficacy and safety of specific cephalosporins in the treatment of serious bacterial infections in children.

The role of corticosteroids in infants and children with bacterial meningitis

Bacterial meningitis continues to be a cause of substantial morbidity in infants and children. Hearing impairment is the most common sequela of this disease. Corticosteroids have been used in an attempt to reduce the incidence of meningitis-induced hearing loss. Some studies have demonstrated a decrease in the incidence of hearing impairment in patients treated with cefuroxime plus dexamethasone compared with cefuroxime alone. Similar data are lacking for other frequently used antibiotics. Based on these studies, the use of dexamethasone should be considered in infants and children greater than two months of age with suspected bacterial meningitis. Critical issues including the timing of steroid initiation in relation to antibiotic therapy and the appropriate antibiotic-corticosteroid regimen must be addressed. Studies should be performed to define the exact role of corticosteroids in the treatment of bacterial meningitis. Until additional data are available, we recommend the use of dexamethasone in pediatric patients older than two months of age with bacterial meningitis.

Antibiotic susceptibility of 629 bacterial blood and CSF isolates from Swedish infants and the therapeutic implications

Blood and CSF isolates (n = 629) from Swedish infants up to one year of age were tested in vitro against 13 antimicrobial agents in order to update the guidelines for empiric therapy of septicaemia and meningitis. Ampicillin plus gentamicin provided inadequate empiric therapy for meningitis, due to the poor CSF penetration of the aminoglycoside and the frequent occurrence of bacterial resistance to ampicillin. Ceftazidime and cefuroxime were moderately active, particularly against isolates from small infants. Cefotaxime today seemed to provide the best empiric therapy of septicaemia and meningitis in infants. Because of the occurrence of Listeria and enterococcal infections, ampicillin should initially be added and other combinations are also advisable for the occasional cases of Enterobacter, Citrobacter, Serratia, and Pseudomonas infections. For coagulase-negative staphylococci only vancomycin offered a broad activity (100% at achievable serum levels).

Antibiotic treatment of community acquired bacterial meningitis

Community acquired meningitis is predominantly caused by three agents: Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis Four physical properties of available drugs--molecular size, protein binding, lipid solubility and ionization--affect drug entry to the central nervous system (CNS). These factors, coupled with acute changes in blood-brain barriers and intrinsic bactericidal activity, have a bearing on the success of treatment with all agents. Third generation cephalosporins have largely supplanted older regimens due to their intrinsic qualities of greater bactericidal activity, optimal cerebrospinal fluid pharmacokinetics, and low toxicity. The pharmacological principles of treatment of CNS bacterial infections, pharmacology of available drugs, and current treatment recommendations are reviewed.

Long term sequelae of childhood acute bacterial meningitis in a developing country. A study from the Sudan

35 survivors of acute bacterial meningitis (ABM) from a group of 44 Sudanese children--seen during 18 months (April 1985-November 1986)--were prospectively followed to ascertain the long-term sequelae of the disease. 30 (17 with Haemophilus influenzae, 8 Neisseria meningitidis, 4 Streptococcus pneumoniae and one child with Enterobacter cloacae meningitis) could be followed during the surveillance period (3-4 years). Three (10%), including 2 with hemiplegia, died after 11-12 months. The association between motor deficit on discharge from hospital and subsequent death was significant (p = 0.04). Of the remaining 27, neuropsychologic sequelae were recorded in 9 (33%). Sensorineural hearing loss was observed in 6 (22%) patients and improved in one during surveillance. Motor deficits were found to improve with time but were replaced by the development of epilepsy about 3 years later in 11% of the survivors. The mean IQ (+/- SD) score for a subgroup of 19 post-meningitic children (92.3 +/- 13.9) was found to be significantly lower than in their nearest-age sibling controls (100.7 +/- 10.2; p = less than 0.01). Younger age at admission and longer duration of ABM symptoms before treatment were significantly associated with poorer outcome (respectively, r = 0.63, p = less than 0.01, r = 0.67, p = less than 0.01). The potential impact of vaccination against the commonest organisms causing ABM in developing countries is discussed.

Antibiotic susceptibility of invasive Haemophilus influenzae type b isolates in Denmark in 1988 and 1989

A system for surveillance of invasive Haemophilus influenzae type b infections in Denmark yielded 135 strains isolated from blood or cerebrospinal fluid from August 1988 through December 1989. The susceptibility of the strains to 7 antibiotics was investigated by an agar dilution method. Ceftriaxone was found to be the most active drug followed by cefotaxime, ceftazidime, rifampicin, ampicillin, cefuroxime, and chloramphenicol. Except for ampicillin the MICs for the individual antibiotics were similar. Seven strains (5.2%), which all produced beta-lactamase, were resistant to ampicillin. Since H. influenzae type b meningitis in otherwise healthy individuals almost exclusively occurs in children aged 2 months to 4 years, a third generation cephalosporin such as ceftriaxone or cefotaxime may be considered the drug of choice for initial therapy of meningitis in this age group.

Seizures and other neurologic sequelae of bacterial meningitis in children

BACKGROUND

Although the mortality rate among children with bacterial meningitis has decreased dramatically in recent decades, some patients are left with neurologic sequelae. It has not been clearly established which features of the acute illness predict the chronic neurologic sequelae, including late seizures or epilepsy.

METHODS

We followed 185 infants and children prospectively during and after acute bacterial meningitis. The mean duration of follow-up was 8.9 years (range, 0.1 to 15.5). During the first six years standard neurologic examinations were performed; telephone interviews were conducted thereafter.

RESULTS

One month after meningitis, 69 children (37 percent) had neurologic abnormalities. Many of these signs resolved within a year, leaving only 26 children (14 percent) with persistent deficits: 18 (10 percent) had only sensorineural hearing loss, and 8 (4 percent) had multiple neurologic deficits. Thirteen children (7 percent) had one or more late seizures not associated with fever. The presence of persistent neurologic deficits indicative of cerebral injury was the only independent predictor of late afebrile seizures (P less than 0.001).

CONCLUSIONS

After bacterial meningitis only children with permanent neurologic deficits are at high risk for epilepsy. Those with normal examinations after the acute illness have an excellent change of escaping serious neurologic sequelae, including epilepsy.

Animal models as predictors of the safety and efficacy of antibiotics

As opposed to the testing of safety, the testing of the efficacy of antibiotics in animals is not specified in any directives or guidelines and not explicitly required by regulatory authorities. There exists, however, no doubt that in the evaluation of new compounds testing of both safety and efficacy forms an essential link between in vitro tests and clinical trials. It is inconceivable that clinicians would be prepared to conduct a trial in patients without evidence of the efficacy of the antibiotic in question in an appropriate animal model of infection. Both the models for testing safety and those for testing efficacy suffer from a number of shortcomings. If investigators are aware of these deficiencies and take them into account when interpreting the results, the predictive value of the models can be significantly enhanced.

A comparison of ceftriaxone and cefuroxime for the treatment of bacterial meningitis in children

To compare ceftriaxone with cefuroxime for the treatment of meningitis, we conducted a study in which 106 children with acute bacterial meningitis were randomly assigned to receive either ceftriaxone (100 mg per kilogram of body weight per day, administered intravenously once daily; n = 53) or cefuroxime (240 mg per kilogram per day, administered intravenously in four equal doses; n = 53). The mean age of the children was 3 years (range, 42 days to 16 years), and the characteristics of the two treatment groups were comparable at admission. Excluded from the study were eight other children who died within 48 hours of admission. After 18 to 36 hours of therapy, cultures of cerebrospinal fluid remained positive for 1 of the 52 children (2 percent) receiving ceftriaxone for whom cultures were available and 6 of 52 (12 percent) receiving cefuroxime (P = 0.11). In both groups the mean duration of antibiotic therapy was 10 days. The clinical responses to therapy were similar in the two treatment groups, and all 106 children were cured. Reversible biliary pseudolithiasis was detected by serial abdominal ultrasonography only in the children treated with ceftriaxone (16 of 35 vs. 0 of 35; P less than 0.001). The treatment of three children was switched from ceftriaxone to alternative antibiotics because these children had upper abdominal pain. Other side effects were infrequent in both groups. At follow-up examination two months later, moderate-to-profound hearing loss was present in two children (4 percent) treated with ceftriaxone and in nine (17 percent) treated with cefuroxime (P = 0.05); other neurologic abnormalities were similar in the two treatment groups. We conclude that ceftriaxone is superior to cefuroxime for the treatment of acute bacterial meningitis in children and that the benefits of milder hearing impairment and more rapid sterilization of the cerebrospinal fluid with ceftriaxone outweigh the problem of reversible biliary pseudolithiasis with this drug.

Childhood acute bacterial meningitis in the Sudan: an epidemiological, clinical and laboratory study

The aims of the present study were to document the epidemiology, clinical features and complications of childhood acute bacterial meningitis (ABM) in The Sudan during both an inter-epidemic (endemic) period (1985-1986), and the 1988 serogroup A epidemic; and to examine the phenotypic and genetic similarities and differences of Neisseria meningitidis strains isolated in The Sudan and Sweden. A new enzyme immunoassay test (Pharmacia Meningitis EIA-Test) was evaluated as a potential rapid diagnostic method for the detection of Haemophilus influenzae (HI) type b, Neisseria meningitidis (MC) and Streptococcus pneumoniae (PNC). The test was found to have good sensitivity (0.86) and specificity (0.95) in the inter-epidemic period; and to be adaptable to the field work in The Sudan during the 1988 MC epidemic. During inter-epidemic (endemic) situations in The Sudan, greater than 90% of childhood ABM was caused by one of the three organisms, HI type b, MC and PNC. HI accounted for 57% of the cases. The peak incidence (76%) of HI cases was in infants (less than 12 months) similar to the situation in other African countries. The overall case fatality ratio was 18.6%. Prospective follow-up of survivors for 3-4 years revealed that an additional 43% either died or had permanent neurological complications, the most prevalent and persistent of which was sensorineural hearing loss recorded in 22% of long term survivors. Post-meningitic children were found to have significantly lower intelligence quotients (92.3 +/- 13.9) than their sibling controls (100.7 +/- 10.2, P = 0.029). Features of the large serogroup A sulphonamide resistant MC epidemic (February-August 1988) in Khartoum are described. An estimated annual incidence of 1,679/100,000 was recorded at the peak of the epidemic. The highest attack rate was in young children less than 5 years, as in many other African countries; nevertheless, a high morbidity was observed in adults (31% of the cases greater than or equal to 20 years). The clinical features, mortality (6.3%) and short term sequelae in Sudanese children were generally within the framework described for MC disease elsewhere. Detailed analysis of MC isolates from Sudan and Sweden by characterizing their electrophoretic enzyme types, DNA restriction endonuclease pattern and outer membrane proteins, revealed that serogroup A MC clone III-1 was responsible of The Sudan epidemic in 1988 and has been the dominant serogroup A organism in Sweden since 1973. The Sudanese strains isolated prior to the epidemic (1985) were clone IV-1.(ABSTRACT TRUNCATED AT 250 WORDS)