Risk factor of complications requiring neurosurgical intervention in infants with bacterial meningitis

Neonatal Escherichia coli Meningitis, Complications, and Neurological Outcome

Neonatal bacterial meningitis represents a major cause of mortality and morbidity in newborns worldwide. It leads to immediate and long-term neurological complications. In this article, we reported a case of a term newborn with an unremarkable pregnancy and delivery, who was admitted to our neonatal ward on the fifth day of life for fever. Cerebrospinal fluid culture was positive for Escherichia coli. The infant had neurological deterioration and continued fever despite adequate antibiotic therapy. Brain MRI showed multiple subdural abscesses with ventriculitis. Antibiotic therapy was maintained for 90 days with total resolution of the abscesses. The child has a normal physical examination and appropriate psychomotor development at 9 months of age.

Neurological sequelae remain frequent after bacterial meningitis in children

AIM

To examine the incidence, clinical presentation and risk factors for neurological sequelae following childhood community-acquired bacterial meningitis (CABM).

METHODS

We included all children aged 1 month to 15 years old with CABM in North Denmark Region, 1998-2016. Using medical records, we registered baseline demographics, signs and symptoms at admission, laboratory investigations, and outcome assessed by the Glasgow Outcome Scale (GOS). A GOS score of 1-4 was considered an unfavourable outcome. We used modified Poisson regression to examine predefined risk factors for neurological sequelae among survivors.

RESULTS

We identified 88 cases of CABM in 86 patients (45 female) with a median age of 1.4 years (interquartile range 0.7-4.6). Neisseria meningitidis was the most common pathogen (48/88). Neurological sequelae occurred in 23 (27%) as hearing deficits in 13 (15%), cognitive impairment in 10 (12%) and motor or sensory nerve deficits in 8 (9%). Unfavourable outcome was observed in 16 (18%) patients and three (3%) patients died. Abnormalities on cranial imaging remained the only independent risk factor for developing neurological sequelae in adjusted analysis.

CONCLUSION

Neurological sequelae following CABM in children remain frequent and abnormal cranial imaging may be an independent risk factor.

Infantile supratentorial subdural empyema managed by percutaneous aspiration: an outcome study in a Nigerian city

Subdural empyema (SDE), a common neurosurgical emergency in the developing countries, accounts for 15%-20% of localised paediatric intracranial infections. In regions where modern diagnostic tools are scarce and inaccessible, detection of SDE may be delayed with subsequent poor outcome. Percutaneous subdural aspiration in patients with open anterior fontanel may be the only surgical option in resource-poor regions of the world. This review focuses on the management outcome, including neurological outcome of these children. Clinical charts of children with SDE and treated by percutaneous subdural tap between February 2006 and August 2014 were reviewed. Demographic, clinical, radiological, bacteriological parameters and outcome data were analysed. Forty-five children with a mean age of 10.6 ± 6.2 months (range: 2-17 months) and followed up for a median duration of 16.4 months were included. The most frequent clinical features were enlarged head circumference, fever, focal neurologic deficits and altered level of consciousness. Diagnosis of SDE was confirmed using trans-fontanel ultrasound scan in 32 (71.1%) children, computerised tomography in 12 (26.7%) children and magnetic resonance imaging in one (2.2%) child. SDE was unilateral in 73.3% and bilateral in 26.7%. In 23 (51.1%) children with a positive culture, Staphylococcus aureus (n = 10), anaerobes (n = 7), Escherishia coli and Haemophilus influenza (n = 6 each) were the most common organisms. Forty-three children (95.6%) survived, 36 of which had good Glasgow outcome score. Seven children still had moderate deficits at 3 months. Treatment of SDE in young children with patent fontanel using percutaneous subdural tap has good therapeutic and neurological outcome.

Treatment-refractory Escherichia coli subdural empyema caused by infection of a chronic subdural hematoma in an infant

INTRODUCTION

Subdural empyema (SDE) is a neurosurgical emergency that is typically treated with surgical drainage, either by burr hole or by craniotomy. Escherichia coli is an uncommon cause of SDE and is associated with infection of a pre-existing subdural hematoma.

CASE REPORT

We report the case of an otherwise healthy, immunocompetent 4-month-old infant girl with an E. coli-infected subdural hematoma. The infection persisted despite aggressive neurosurgical treatment that included drainage of the subdural space through burr holes and, subsequently, a wide craniotomy was performed. Ultimately, after 30 days, the SDE resolved with good neurological outcome. A review of prior literature indicates that infected subdural hematomas (including those caused by E. coli) are typically less aggressive and respond to burr hole drainage.

CONCLUSION

We illustrate the fulminant progression of the SDE in the face of neurosurgical treatment. Our experience suggests lowering the threshold for wide craniotomy in these incompletely understood cases.

Neurological complications after neonatal bacteremia: the clinical characteristics, risk factors, and outcomes

Background

Neonates with bacteremia are at risk of neurologic complications. Relevant information warrants further elucidation.

Study Design

This was a retrospective cohort study of neonates with bacteremia-related neurologic complications (BNCs) in a tertiary-level neonatal intensive care unit (NICU). A systemic chart review was performed conducted to identify clinical characteristics and outcomes. A cohort of related conditions was constructed as the control group. Logistic regression analysis was used to identify independent risk factors for BNC.

Results

Of 1037 bacteremia episodes, 36 (3.5%) had BNCs. Twenty-four cases of BNCs were related to meningitis, five were presumed meningitis, and seven occurred after septic shock. The most common causative pathogens were Group B streptococcus (41.7%) and E. coli (16.7%). The major BNCs consisted of seizures (28), hydrocephalus (20), encephalomalacia (11), cerebral infarction (7), subdural empyema (6), ventriculitis (8), and abscess (4). Eight (22.8%) neonates died and six (16.7%) were discharged in critical condition when the family withdrew life-sustaining treatment. Among the 22 survivors, eight had neurologic sequelae upon discharge. After multivariate logistic regression analysis, neonates with meningitis caused by Group B streptococcus (adjusted odds ratio [OR]: 8.90, 95% confidence interval [CI]: 2.20–36.08; p = 0.002) and combined meningitis and septic shock (OR, 5.94; 95% CI: 1.53–23.15; p = 0.010) were independently associated with BNCs.

Conclusions

Neonates with bacteremia-related neurologic complications are associated with adverse outcomes or sequelae. Better strategies aimed at early detection and reducing the emergence of neurologic complications and aggressive treatment of Group B streptococcus sepsis are needed in neonates with meningitis and septic shock.

Less is more: combination antibiotic therapy for the treatment of gram-negative bacteremia in pediatric patients

IMPORTANCE

Definitive combination antibiotic therapy with a β-lactam and an aminoglycoside for the treatment of gram-negative bacteremia is commonly prescribed in pediatric patients; however, its efficacy and toxicity relative to β-lactam monotherapy are unknown.

OBJECTIVE

To determine whether definitive combination antibiotic therapy affects mortality and nephrotoxicity in pediatric patients with gram-negative bacteremia.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study including pediatric patients (aged ≤18 years) with gram-negative bacteremia hospitalized at the Johns Hopkins Children's Center between 2002 and 2011.

MAIN OUTCOMES AND MEASURES

Outcomes included 30-day mortality and nephrotoxicity classified according to the pediatric RIFLE (risk for renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal disease) criteria. To account for nonrandom assignment of combination therapy, propensity score weighting was combined with multivariable logistic regression to estimate the effect of combination therapy on mortality and nephrotoxicity.

RESULTS

Of the 879 eligible pediatric patients with bacteremia, 537 (61.1%) received combination therapy. After propensity score adjustment, baseline demographic and clinical characteristics between the groups were well balanced. There was no association between combination therapy and 30-day mortality (odds ratio, 0.98; 95% CI, 0.93-1.02; P = .27). There were 170 patients (19.3%) with evidence of acute kidney injury, including 135 (25.1%) and 35 (10.2%) in the combination therapy and monotherapy arms, respectively. Patients receiving combination therapy had approximately twice the odds of nephrotoxicity compared with those receiving monotherapy (odds ratio, 2.15; 95% CI, 2.09-2.21).

CONCLUSIONS AND RELEVANCE

The use of β-lactam monotherapy for gram-negative bacteremia in pediatric patients reduces subsequent nephrotoxicity without compromising survival.

Neonatal bacterial meningitis

Neonatal meningitis contributes substantially to neurological disability worldwide. Its incidence remains low but is significantly higher in neonates with documented sepsis, preterm infants, and when meningitis is nosocomial. Neonates are at higher risk of meningitis because of immaturity in humoral and cellular immunity, and the absence of specific clinical signs makes diagnosis of meningitis more difficult in neonates than in older children. Neonatal meningitis remains, therefore, a public health challenge for pediatricians. Mortality and long-term complications in survivors are observed in 10-15% and 20-50%, respectively, depending on term at diagnosis, type of identified organisms, and delay before treatment. Neurological deficits range from moderate-to-severe disabilities to more subtle problems including visual deficits, middle-ear disease, and cognitive and behavioral impairments. Intracerebral complications should be documented using magnetic resonance imaging. Treatment should be initiated once the diagnosis is suspected using a parenteral combination of bactericidal antibiotics adapted to pathogen sensitivity.

Contrast-enhanced MR imaging in neuroimaging

MR imaging without and with gadolinium-based contrast agents (GBCAs) is an important imaging tool for defining normal anatomy and characteristics of lesions. GBCAs have been used in contrast-enhanced MR imaging in defining and characterizing lesions of the central nervous system for more than 20 years. The combination of unenhanced and GBCA-enhanced MR imaging is the clinical gold standard for the noninvasive detection and delineation of most intracranial and spinal lesions. MR imaging has a high predictive value that rules out neoplasm and most inflammatory and demyelinating processes of the central nervous system.

Combination therapy for treatment of infections with gram-negative bacteria

Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa, those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.

[Antibiotics and timing in infectious disease in the emergency department]

Infectious diseases, besides being a major cause of mortality in developing countries, are one of the main reasons for consultation in emergency medicine. In the last few years, there have been numerous published studies on the importance of starting antibiotic treatment at an early stage in the Emergency Department. However, this issue is of great controversy, owing to some contradictory studies as well as the implications this may have on the pressure of the patient care. This review is presents a summary of the scientific evidence published in this regard, and makes some recommendations based on this published evidence to improve the initial management of patients with an infection; a question of great importance as it can reduce mortality in some specific situations.

Therapeutic management of bacterial meningitis in children: a systematic review and comparison of published guidelines from a European perspective

Bacterial meningitis is an infectious disease emergency that can cause substantial morbidity and mortality. We compared the most recent international guidelines and recommendations on bacterial meningitis management in infants and children in developed countries, in terms of initial management approach, empirical antimicrobial therapy, timing, dosages, and duration of antimicrobial therapy, and possible adjunctive treatment with dexamethasone. Secondly, epidemiological data on bacterial resistance in several european countries were analyzed and discussed in relation to the therapies currently recommended for bacterial meningitis. The comparative analysis of the selected guidelines highlighted significant differences in the therapeutic management of bacterial meningitis. Differences among guidelines have important consequences for daily practice. An agreed protocol for early, evidence-based, and effective therapeutic management of bacterial meningitis is essential for the best outcome. further studies and expert consensus are required to establish the best management of bacterial meningitis in the european setting based on the most recent epidemiological data on resistance rates.

The treatment and outcome of postmeningitic subdural empyema in infants

OBJECT

The management of subdural empyema (SDE) has been debated in the literature for decades. Craniotomy and bur hole drainage have been shown to achieve a favorable outcome. However, there is a lack of comparative data for these modes of management of SDE subsequent to meningitis in infants.

METHODS

The authors conducted a retrospective review of 33 infants identified with SDE due to meningitis at the Department of Neurosurgery, Chang Gung Memorial Hospital between 2000 and 2006. Preoperative clinical presentation, duration of symptoms, radiological investigations, CSF data, and postoperative outcome were analyzed and compared between these 2 surgical groups.

RESULTS

At diagnosis, there were no differences between the groups in age, weight, degree of consciousness, CSF analysis, or duration of fever. The outcome data showed no difference in the number of days until afebrile, number of days of postsurgical antibiotic treatment, neurological outcome, recurrence rate, or complication rate. There was only 1 death in the series.

CONCLUSIONS

Subdural empyema due to meningitis in infants is unique with respect to the pathophysiology, presentation, and treatment of SDE. Early detection and removal of SDE provide a favorable outcome in both surgical intervention groups. Bur hole drainage is less invasive, and it is possible to expect a clinical outcome as good as with craniotomy in postmeningitic SDE.

Cerebral abscess associated with meningococcal meningitis

Purulent fluid collections, including brain abscess and subdural empyema, are exceedingly rare in association with meningococcal meningitis. We present a 5-month-old infant with meningococcal meningitis and sepsis complicated by an intracerebral abscess.

Postmeningitis subdural fluid collection in infants: changing pattern and indications for surgery

OBJECT

Postmeningitis subdural fluid collection (PMSFC) is a classic complication of bacterial meningitis in infants. When the diagnosis was based solely on subdural puncture (SDP), its incidence was estimated to be as high as one half of the cases of meningitis, with Haemophilus influenzae as the most common causative bacterium. Knowledge concerning the diagnostic and bacteriological characteristics of PMSFC has expanded greatly since the introduction of computerized imaging and the use of the anti-H. influenzae vaccine; however, in no recent study have the authors reappraised this clinical entity with regard to diagnosis, bacteriology, and indications for surgery.

METHODS

The authors reviewed their cases of PMSFC in infants in which a diagnosis was made based on computerized tomography findings and confirmed with SDP. They treated PMSFC using placement of a subdural drain whenever the collection was either clinically eloquent or exerted a mass effect on the brain. In the 26 years preceding the study, the authors had treated 29 patients younger than 16 months of age for PMSFC. Eight patients required SDP only, 20 underwent surgical drainage, and five required craniotomy. In six cases, the fluid was grossly purulent; in the others, it was clear, xanthochromatic, or hemorrhagic. Cultures were positive for Streptococcus pneumoniae in only two cases. Although H. influenzae was the most common bacterium at the beginning of the series, Neisseria meningitidis has become more prevalent since vaccination against the former became widespread. Based on their data the authors estimate that 5% of N. meningitidis infections in infants are complicated by a significant PMSFC.

CONCLUSIONS

At present, PMSFCs are most often caused by N. meningitidis. Temporary surgical drain placement is advised for all cases in which a significant mass effect is apparent on imaging.

Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures

STUDY OBJECTIVES

To test whether routine quantitative cultures of endotracheal aspirates obtained before the onset of ventilator-associated pneumonia (VAP) could help to predict the causative microorganisms and to select early appropriate antimicrobial therapy before obtaining BAL culture results.

DESIGN

Prospective observational study.

SETTING

French medical ICU.

PATIENTS

A total of 299 patients received mechanical ventilation for at least 48 h.

INTERVENTIONS

Endotracheal aspiration (EA) was performed twice weekly in all mechanically ventilated patients. A diagnosis of VAP was made by BAL culture. Only the EA performed just before the suspicion of VAP (EA-pre) were evaluated. This strategy (ie, the EA-pre-based strategy) was compared with an antibiotic therapy that would have been prescribed if the recommendations of both the American Thoracic Society (ATS) and Trouillet et al (Am J Respir Crit Care Med 1998; 157:531-539) had been applied.

MEASUREMENTS AND RESULTS

VAP was diagnosed (by BAL culture) in 41 of the 75 patients in whom BAL was performed. Among the 41 BAL specimens that were positive for VAP, EA-pre had identified the same microorganisms (with the same antibiotic resistance patterns) in 34 cases (83%). In one case, EA-pre was not available at the time BAL was performed (a case of early-onset VAP), but the empiric antibiotic therapy was adequate. While EA-pre did not give the same results as the BAL culture, the antibiotic therapy based on the results of the EA-pre was adequate in four other cases. Finally, antibiotic therapy was delayed in only two cases. Antibiotic treatment was therefore adequate in 38 of the 40 assessable cases (95%). If the Trouillet-based strategy had been used, the antibiotic treatment would have been adequate in 34 of the 41 cases (83%; p = 0.15 [vs EA-pre strategy]). Based on the ATS classification, the antibiotic treatment would have been adequately prescribed in only 28 of the 41 cases (68%; p = 0.005 [vs EA-pre strategy]).

CONCLUSIONS

Routine EA performed twice a week makes it possible to prescribe adequate antibiotic therapy (while waiting for BAL culture results) in 95% of the patients in whom a VAP is ultimately diagnosed by BAL culture.

Cerebral white matter injury in the newborn following Escherichia coli meningitis

MR findings from six newborns with Escherichia coli (E. coli) meningitis are reported. Five of the six infants were infected with the K1 strain. All the infants displayed significant white matter injury on MR imaging. E. coli remains a serious cause of meningitis and MR imaging in this case series provides additional important information highlighting the vulnerability of the cerebral white matter in this condition in the newborn infant.

Bacterial meningitis in infants: the epidemiology, clinical features, and prognostic factors

This 16-year (1986-2001) retrospective study enrolled 80 infantile patients (aged, 30-365 days old) with culture-proven bacterial meningitis. The most prevalent pathogens were Salmonellaspecies, Streptococcus (S.) agalactiae, Escherichia (E.) coli, and Haemophilus (H.) influenzae, accounting for about 59% of the episodes. Meningitis caused by Salmonella species, E. coli and H. influenzae occurs more often in the older infants, while that caused by S. agalactiae occurs more often in young infants. Our study revealed a decrease in the proportion of Salmonella meningitis from 27% in the first 8 years to 9% in the second 8 years with E. coli replacing Salmonella species as the leading pathogen of this disease during the second period. Overall mortality rate for both periods of time was 11%. However, if we take those with undesirable poor outcomes into account, 43% of patients could be considered treatment failures. The study also reveals a high prevalence of neurological complications when this disease is caused by H. influenzae, S. pneumoniae, and Salmonella species. Stepwise logistic regression analysis revealed that only initial changing levels of consciousness (P = 0.006) were independently associated with treatment failure. The most frequent neurological complications associated with this disease included subdural empyema, hydrocephalus, cerebral infarctions, and seizures. Because therapeutic regimens may require attention to the eradication of bacterial pathogen but also the neurological complications, early diagnosis and choice of appropriate antibiotics are essential to increasing the possibility of survival.

Supportive management in bacterial meningitis

The central nervous system and systemic complications of bacterial meningitis cause significant morbidity and mortality. This article offers insight into the clinical features, pathogenesis, and management of these complications. In many instances, the improved outcome of intervention is based on clinical suspicion and early recognition. The management of complications is evolving and is presently based mainly on supportive care.

Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients

STUDY OBJECTIVE

To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission.

DESIGN

Prospective cohort study.

SETTING

Barnes-Jewish Hospital, a university-affiliated urban teaching hospital.

PATIENTS

Two thousand consecutive patients requiring admission to the medical or surgical ICU.

INTERVENTIONS

Prospective patient surveillance and data collection.

MEASUREMENTS AND RESULTS

One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission.

CONCLUSIONS

Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.

Basic fibroblast growth factor in experimental and clinical bacterial meningitis

Basic fibroblast growth factor (bFGF), a neurotrophic factor in the CNS, is expressed at high levels in response to seizures or strokes. We examined the expression of bFGF during experimental bacterial meningitis and the levels of bFGF in the cerebrospinal fluid (CSF) of children with bacterial meningitis. For the experimental study, a mouse model of meningitis was established by intracranial injection of Streptococcus pneumoniae. Twenty-four hours after induced meningitis, the brains were sectioned and stained immunohistochemically for bFGF. Neutrophils and macrophages infiltrating the leptomeninges and the ventricles exhibited strong bFGF immunoreactivity. The neurons in the areas adjacent to the inflamed ventricles also showed enhanced bFGF expression. For the clinical study, we used an enzyme immunoassay to measure bFGF in CSF in 18 children with bacterial meningitis, 12 with aseptic meningitis, and 18 controls. The CSF levels of bFGF were twice as high in children with bacterial meningitis (medians 6.75-7.21 pg/mL) compared with those who had aseptic meningitis (2.9 pg/mL) or in control subjects (2.65 pg/mL, p < 0.0001, respectively). In patients with bacterial meningitis who survived, CSF bFGF decreased significantly after 24-50 h of antibiotic therapy (p < 0.0005). Patients who developed major sequelae or died had much higher levels of CSF bFGF than those without (134.9 pg/mL versus 7.38 pg/mL, p < 0.05). These findings of enhanced immunoreactivity of bFGF in experimental bacterial meningitis and an association of CSF levels of bFGF with disease severity in childhood bacterial meningitis suggest a biologic role for this neurotrophic factor in the pathophysiology of bacterial meningitis.