Brain abscess caused by aerobic Gram-negative bacilli: clinical features and therapeutic outcomes

European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults

SCOPE

These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in children and adults.

METHODS

Key questions were developed, and a systematic review was carried out of all studies published since 1 January 1996, using the search terms 'brain abscess' OR 'cerebral abscess' as Mesh terms or text in electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September 2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects model and heterogeneity was examined by I2 tests as well as funnel and Galbraith plots. Risk of bias was assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low).

QUESTIONS ADDRESSED BY THE GUIDELINES AND RECOMMENDATIONS

Magnetic resonance imaging is recommended for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial treatment is 6-8 weeks (conditional and low). No recommendation is offered for early transition to oral antimicrobials because of a lack of data, and oral consolidation treatment after ≥6 weeks of intravenous antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very low). Research needs are addressed.

Diagnosis, Management, and Outcomes of Brain Abscess due to Gram-Negative Versus Gram-Positive Bacteria: Brain abscess due to Gram-positive vs. Gram-negative bacteria

OBJECTIVES

Differences in management and outcomes of brain abscesses due to Gram-positive (GPB) versus Gram-negative bacteria (GNB) are not well defined.

METHODS

Retrospectively reviewed adult patients with brain abscesses due to monomicrobial infection from 2009 through 2020.

RESULTS

177 had a monomicrobial brain abscess; 143 (80.8%) caused by GPB and 34 (19.2%) by GNB. Patients with GNB had more history of head/neck surgery than those with GPB (58.8% vs. 36.4%; P= 0.02). Pathogens in the GNB group included Pseudomonas aeruginosa (29.4%), Klebsiella species (spp.; 20.6%), and Enterobacter spp. (20.6%); in the GPB group were Staphylococcus aureus (32.2%) and Streptococcus spp. (31.5%). Most patients had combined medical/surgical management (64.7% GNB vs. 63.6% GPB). Median duration of antibiotic therapy was 42 days, and there were no significant differences in infection relapse or 3-month survival rates. Patients with GNB were more likely to have therapeutic failure than did those with GPB (44.1% vs. 22.4%; P= 0.01).

CONCLUSION

Compared with brain abscesses caused by GPB, those due to GNB were more likely to have prior head and neck surgery. No statistically difference in outcomes was observed between groups; however, patients with GNB had a higher therapeutic failure rate than did those with GPB.

Klebsiella oxytoca Complex: Update on Taxonomy, Antimicrobial Resistance, and Virulence

Klebsiella oxytoca is actually a complex of nine species-Klebsiella grimontii, Klebsiella huaxiensis, Klebsiella michiganensis, K. oxytoca, Klebsiella pasteurii, Klebsiella spallanzanii, and three unnamed novel species. Phenotypic tests can assign isolates to the complex, but precise species identification requires genome-based analysis. The K. oxytoca complex is a human commensal but also an opportunistic pathogen causing various infections, such as antibiotic-associated hemorrhagic colitis (AAHC), urinary tract infection, and bacteremia, and has caused outbreaks. Production of the cytotoxins tilivalline and tilimycin lead to AAHC, while many virulence factors seen in Klebsiella pneumoniae, such as capsular polysaccharides and fimbriae, have been found in the complex; however, their association with pathogenicity remains unclear. Among the 5,724 K. oxytoca clinical isolates in the SENTRY surveillance system, the rates of nonsusceptibility to carbapenems, ceftriaxone, ciprofloxacin, colistin, and tigecycline were 1.8%, 12.5%, 7.1%, 0.8%, and 0.1%, respectively. Resistance to carbapenems is increasing alarmingly. In addition to the intrinsic bla_OXY, many genes encoding β-lactamases with varying spectra of hydrolysis, including extended-spectrum β-lactamases, such as a few CTX-M variants and several TEM and SHV variants, have been found. bla_KPC-2 is the most common carbapenemase gene found in the complex and is mainly seen on IncN or IncF plasmids. Due to the ability to acquire antimicrobial resistance and the carriage of multiple virulence genes, the K. oxytoca complex has the potential to become a major threat to human health.

Subdural empyema caused by Morganella morganii

Background

Morganella morganii is a species of Gram-negative enteric rod found in normal human gut flora. Pathologically, this most often presents as urinary tract infections, wound infections, and bacteremia. It is highly uncommon for M. morganii to be implicated in a central nervous system infection, with only 12 reported cases of parenchymal abscesses or meningitis.

Case Description

A previously healthy 13-month-old female presented with fever of unknown origin and had a witnessed seizure during evaluation. A large left subdural fluid collection was identified, and the patient underwent emergent burr hole drainage and subdural drain placement. Cultures demonstrated M. morganii empyema, and she subsequently completed a course of directed antibiotics. Six months following surgery, she has no further clinical or radiographic evidence of infection, seizures, or neurological sequelae.

Conclusion

We describe the first reported case of isolated subdural empyema caused by M. morganii. The child was successfully treated with the evacuation of the empyema and direct antibiotics with no lasting neurological injury.

Heterophynone and methyl ester of Colic acid, two new compounds with antimicrobial activity from Cola heterophylla (Sterculiaceae)

The ethyl acetate fraction, the stem bark and the residual methanolic extracts from the leaves of Cola heterophylla (Sterculiaceae) led to the isolation of two new compounds: Heterophynone (1) and methyl ester of Colic acid (6), along with four known triterpenes: betulinic acid (2), oleanolic acid (3), ursolic acid (4) and chletric acid (5). Structures of compounds were established by different spectroscopic methods that included 1D and 2D NMR experiment. The antimicrobial activity of isolated compounds was evaluated against two yeasts, Candida Albicans NR 29456 and Candida Krusei 1415; and five Gram-positive bacterial, Salmonella enteric Serovar Muenchem, Salmonella enteric Serovar Thyphimurium, Staphylococcus aureus NR 46003, Staphylococcus aureus NR46374 and Pseudomonas aeruginosa HM 601). Among tested compounds, Heterophynone was found to be the most active with significant antimicrobial activity against Salmonella enteric Serovar Thyphimurium (MIC = 7.82 μg/mL and MBC = 62.5 μg/mL) and good activity against Candida Albicans NR 29456 (MIC = 62.5 μg/mL).

Two new flavones glycosides with antimicrobial activities from Clerodendrum formicarum Gürke (Lamiaceae)

Clerodendrum formicarum Gürke from the Lamiaceae family is a Cameroonian medicinal plant. The crude methanol, methanol residual and ethyl acetate extracts of leaves have been phytochemically studied using chromatography column to afford four compounds; two new flavones glycoside: clerodendronone 1a (3) and clerodendronone 1b (4) along with two known compounds: 5,7-dihydroxy-4'-methoxyflavone (1) and 5-hydroxy-7,4'-dimethoxyflavone (2). Compound structures have been elucidated on the basis of their spectroscopy data and with literature information. The anti-microbial activities of extracts and three isolated compounds were performed. The antibacterial activity was evaluated against four gram positive, five gram negative and three fungus. Clerodendronone 1b (4) showed good antibacterial activity against bacterial gram negative Shigella flexineri NR518 (MIC = 62.5 μg/ml) and moderate activity against Staphylococcus aureus NR46374 (MIC = 250 μ/ml). The ethyl acetate extract recorded good antibacterial activity against Staphylococcus aureus NR46003 (MIC = 125 µg/ml) and Staphylococcus aureus NR46374 (MIC = 125 μg/ml).

Gas-containing brain abscess: etiology, clinical characteristics, and outcome

Gas-containing brain abscess remains a life-threatening disease that requires immediate diagnostic and therapeutic intervention. The aim of this study is to report on a series of gas-containing brain abscess and discuss its pathological mechanism and therapeutic consideration. This study included 11 patients with gas-containing brain abscess at Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan during a 27-year period. The predisposing factors to infection included hematogenous spread in five patients, contiguous infection in one patient, and abnormal fistulous communication due to head injury in four patients. In one patient, the predisposing factor might be contiguous infection from frontal sinusitis or abnormal fistulous communication due to previous sinus surgery. Klebsiella pneumoniae was the most common causative pathogen that was isolated from the gas-containing abscess not related to skull base defect. Among these 11 patients, six underwent excision and five accepted aspiration for the surgical treatment of abscess. In the five patients who underwent aspiration, two required repeated craniotomy to excise the recurrent abscess and repair the abnormal fistulous communication through the skull base. When encountered with a gas-containing abscess in patients with an impaired host defense mechanism, K. pneumoniae infection should be suspected, and further attention should be paid to discovering if other metastatic septic abscesses exist. For patients with a history of basilar skull fracture or surgery involving the skull base, craniotomy is indicated to excise the abscess and repair the potential fistulous communication through the cranium. Aspiration may be a reasonable alternative to treat deep-seated lesions, lesions in an eloquent area, patients with severe concomitant medical disease, or patients without a history of basilar skull fracture or surgery involving the skull base. Prompt diagnosis, appropriate antibiotic use, and meticulous surgical treatment are the only way to obtain a favorable outcome.

Epidemiology of central nervous system infection

In cases of central nervous system infection, it is crucial for the neuroradiologist to provide an accurate differential diagnosis of the possible pathogens involved so that treating physicians can be aided in the choice of empiric therapy. This approach requires the radiologist to be aware of local epidemiology and have knowledge of infectious agents that are endemic to their area of practice. This article reviews and discusses the changing epidemiology of pathogens most often observed in meningitis, brain abscess, epidural abscess, postoperative infections, and human immunodeficiency virus infection.

Consensus document on controversial issues for the treatment of infections of the central nervous system: bacterial brain abscesses

BACKGROUND

Bacterial brain abscesses remain a serious central nervous system problem despite advances in neurosurgical, neuroimaging, and microbiological techniques and the availability of new antibiotics. The successful treatment of brain abscesses requires surgery, appropriate antibiotic therapy, and eradication of the primary source; nevertheless many controversial issues on the management of this serious infection remain unresolved.

CONTROVERSIAL ISSUES

The aim of this GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) working group - a panel of multidisciplinary experts - was to define recommendations for some controversial issues using an evidence-based and analytical approach. The controversial issues were: (1) Which patients with bacterial brain abscesses can be managed safely using medical treatment alone? (1a) What is the efficacy in terms of outcome, tolerability, cost/efficacy, and quality of life of the different antibiotic regimens used to treat bacterial cerebral abscesses? (1b) Which antibiotics have the best pharmacokinetics and/or tissue penetration of brain and/or brain abscess? 2) What is the best surgical approach in terms of outcome in managing bacterial brain abscesses? Results are presented and discussed in detail.

METHODS

A systematic literature search using the MEDLINE database for the period 1988 to 2008 of randomized controlled trials and/or non-randomized studies was performed. A matrix was created to extract evidence from original studies using the CONSORT method to evaluate randomized clinical trials and the Newcastle-Ottawa Quality Assessment Scale for case-control studies, longitudinal cohorts, and retrospective studies. The GRADE method for grading quality of evidence and strength of recommendation was applied.

Piperacillin/tazobactam in treatment of brain abscess

Central nervous system (CNS) infection is a common complication following renal transplantation. Successful management of a brain abscess usually requires a combination of antibiotics and surgical drainage for both diagnostic and therapeutic purposes. We report the successful treatment of a patient with multiple brain abscesses with piperacillin/tazobactam without surgical intervention.

Nanorobot for Brain Aneurysm

In this paper we present how nanoelectronics should advance medicine, providing details on the teleoperated techniques and equipment design methodology necessary for the effective development of nanorobots. The platform architecture describes how to use a nanorobot for intracranial prognosis, and shows how it should be integrated for medical instrumentation. Furthermore, the current study establishes proteomics, nanobioelectronics, and electromagnetics as the basis to advance medical nanorobotics. To illustrate the proposed approach, the nanorobots must search for protein overexpression signals in order to recognize initial stages of aneurysm. An advanced nanomechatromics simulator, using a three-dimensional task-based environment, is implemented to provide an effective tool for device prototyping and medical instrumentation analysis. Thus, based on clinical data and nanobioelectronics, the proposed model offers details about how a nanorobot should help with the early detection of cerebral aneurysm.

Gas-forming brain abscess caused by Klebsiella pneumoniae

Gas forming brain abscess is a rare disease caused by Klebsiella pneumoniae occurring in patients with impaired host defense mechanism such as diabetes mellitus or liver cirrhosis. A 59-year-old man with 2-year history of diabetes mellitus and 20-year history of liver cirrhosis presented to the hospital with headache. On the day after admission, severe headache was developed and he deteriorated rapidly. Brain CT showed a non-enhanced mass including multiple air density as well as surrounding edema seen in the right occipital lobe, and isodensity air-fluid level seen in the right lateral ventricle. Despite emergent ventricular drainage and intraventricular and intravenous administration of antibiotics, his condition progressively worsened to sepsis and to death after 5 days. Bacterial culture of blood and ventricular fluids disclosed a Gram (-) rod, Klebsiella pneumoniae. In this report we review the pathogenic mechanism and its management.

Nanorobot Hardware Architecture for Medical Defense

This work presents a new approach with details on the integrated platform and hardware architecture for nanorobots application in epidemic control, which should enable real time in vivo prognosis of biohazard infection. The recent developments in the field of nanoelectronics, with transducers progressively shrinking down to smaller sizes through nanotechnology and carbon nanotubes, are expected to result in innovative biomedical instrumentation possibilities, with new therapies and efficient diagnosis methodologies. The use of integrated systems, smart biosensors, and programmable nanodevices are advancing nanoelectronics, enabling the progressive research and development of molecular machines. It should provide high precision pervasive biomedical monitoring with real time data transmission. The use of nanobioelectronics as embedded systems is the natural pathway towards manufacturing methodology to achieve nanorobot applications out of laboratories sooner as possible. To demonstrate the practical application of medical nanorobotics, a 3D simulation based on clinical data addresses how to integrate communication with nanorobots using RFID, mobile phones, and satellites, applied to long distance ubiquitous surveillance and health monitoring for troops in conflict zones. Therefore, the current model can also be used to prevent and save a population against the case of some targeted epidemic disease.

Isolation of Vibrio cholerae from the brain of a feedlot heifer with meningoencephalitis

A 700-pound, 9-month-old Angus heifer from a feedlot presented with acute neurologic signs, characterized by circling, posterior weakness, and nonresponsiveness, followed by death. Histologically, the frontal lobe and the thalamus contained multiple foci of liquefaction that contained numerous degenerative neutrophils and foamy macrophages. Some of these foci were centered on blood vessels that contained fibrin thrombi and exhibited varying degrees of fibrinoid necrosis of the vessel wall. There was adjacent axonal degeneration and neuronal necrosis characterized by pronounced cytoplasmic eosinophilia, peripheralization of the nuclei, and loss of Nissl substance. Aerobic culture of the brain yielded moderate growth of Vibrio species, which was determined to be Vibrio cholerae by polymerase chain reaction analysis of a 438-base pair fragment of the 16 S ribosomal RNA gene. V. cholerae are motile, gram-negative, curved rod-shaped bacteria. Some strains of V. cholerae are important food- and water-borne bacterial pathogens that produce an often fatal diarrhea in humans. This is the first known case report of V. cholerae meningoencephalitis and cerebral abscessation in a bovine.

Morganella morganii pericarditis 3 years after allogenic bone marrow transplantation for mantle cell lymphoma

We report herein a case of Morganella morganii-associated acute purulent pericarditis that developed 3 years after allogenic bone marrow transplantation. The patient was successfully treated with surgical drainage and cefotaxime for 6 weeks. Splenectomy and immunosuppression for chronic GVH-D are likely to have favored the development of this rare infectious complication after BMT. M. morganii should be added to the list of bacteria causing purulent pericarditis, especially in immunocompromised hosts.

Central nervous system infection caused by Morganella morganii

Central nervous system (CNS) infection with Morganella morganii is very rare. We describe a 38-year-old female patient with frontal brain abscess caused by M morganii who was unsuccessfully treated. We also review all reported cases of Morganella CNS infections with an emphasis on treatment modalities and outcomes. Aggressive surgical management and appropriate antimicrobial therapy can lead to cure, but the mortality rate for these infections remains high.

Induction of proinflammatory mediators requires activation of the TRAF, NIK, IKK and NF-kappaB signal transduction pathway in astrocytes infected with Escherichia coli

Escherichia coli is associated with inflammation in the brain. To investigate whether astrocytes are involved in E. coil-induced inflammation, we assessed the levels of expression of proinflammatory mediators produced by E. coli-infected astrocytes. E. coli infection in primary human astrocytes and cell lines increased expression of the CXC chemokine IL-8/GRO-alpha, the CC chemokine MCP-1, TNF-alpha, and iNOS. E. coli infection activated p65/p50 heterodimeric NF-kappaB and concurrently decreased the signals of IkappaBalpha. Blocking the NF-kappaB signals by IkappaBalpha-superrepressor-containing retrovirus or antisense p50 oligonucleotide transfection resulted in down-regulation of expression of the proinflammatory mediators. Furthermore, superrepressors of IkappaBalpha, IkappaB kinase (IKK) or NF-kappaB inducing kinase (NIK) inhibited the up-regulated expression of the downstream target genes of NF-kappaB such as IL-8 and MCP-1, and superrepressors of TNF receptor-associated factor (TRAF)2 and TRAF5 also inhibited expression of the E. coli-induced target genes of NF-kappaB. These results indicate that proinflammatory mediators such as the CXC chemokine IL-8/GRO-alpha, the CC chemokine MCP-1, TNF-alpha, and iNOS can be expressed in E. coli-infected astrocytes via an NF-kappaB pathway, suggesting that these mediators may contribute to inflammation in the brain, including infiltration of inflammatory cells.