Meningitis due to ceftriaxone-resistant Streptococcus pneumoniae

Penicillin- and Cephalosporin-Resistant Pneumococcal Meningitis: Treatment in the Real World and in Guidelines

To report on the therapy used for penicillin- and cephalosporin-resistant pneumococcal meningitis, we conducted an observational cohort study of patients admitted to our hospital with pneumococcal meningitis between 1977 and 2018. According to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommendations, we defined pneumococci as susceptible and resistant to penicillin with MIC values of ≤0.06 mg/L and > 0.06 mg/L, respectively; the corresponding values for cefotaxime (CTX) were ≤0.5 mg/L and >0.5 mg/L. We treated 363 episodes of pneumococcal meningitis during the study period. Of these, 24 had no viable strain, leaving 339 episodes with a known MIC for inclusion. Penicillin-susceptible strains accounted for 246 episodes (73%), penicillin-resistant strains for 93 (27%), CTX susceptible for 58, and CTX resistant for 35. Nine patients failed or relapsed and 69 died (20%), of whom 22% were among susceptible cases and 17% were among resistant cases. During the dexamethasone period, mortality was equal (12%) in both susceptible and resistant cases. High-dose CTX (300 mg/Kg/day) helped to treat failed or relapsed cases and protected against failure when used as empirical therapy (P = 0.02), even in CTX-resistant cases. High-dose CTX is a good empirical therapy option for pneumococcal meningitis in the presence of a high prevalence of penicillin and cephalosporin resistance, effectively treating pneumococcal strains with MICs up to 2 mg/L for either penicillin or CTX.

Penicillin- and third-generation cephalosporin-resistant strains of Streptococcus pneumoniae meningitis: Case report and literature review

BACKGROUND

Treatment of patients with penicillin-resistant S. pneumoniae (PRSP) is complicated because of the relatively poor blood-brain barrier penetration of effective antimicrobials. Our case: A previously healthy 70-year-old woman, a traveler from China to Japan, was admitted to our hospital with fever and loss of consciousness. She has no history of pneumococcal vaccination. She was diagnosed with bacterial meningitis due to penicillin-and third-generation cephalosporin-resistant strains of S. pneumoniae. The patient was successfully treated with a combination therapy of vancomycin (VCM) and levofloxacin (LVFX) and recovered without any neurological sequelae. As the treatment of penicillin-and third-generation cephalosporin-resistant strains of S. pneumoniae meningitis remains unclear, we conducted a review of the reported cases of meningitis caused by penicillin- and cephalosporin-resistant S. pneumoniae.

METHOD

We performed a search using the keywords "penicillin-resistant Streptococcus pneumoniae," "meningitis," and "pneumococcal meningitis". We searched the electronic databases PubMed, Embase, and Ichushi from their inception to March 2020. Subsequently, two authors independently reviewed the resulting database records, retrieved full texts for eligibility assessment, and extracted data from these cases.

RESULT

We identified 18 papers describing thirty-five cases of penicillin- and cephalosporin-resistant S. pneumoniae meningitis including our case. The patient's characteristics were; median age: 50 years, men:50%, 85% of cases received combination regimens of antibiotics: Ceftroriaxone (CTRX) plus VCM (20 cases), CTRX plus VCM plus rifampicin (RFP) (two cases), CTRX plus linezolid (one case), fluoroquinolones (two cases), carbapenems (six cases), Thirty-five percent received steroids. Twenty-four percent of patients died. Twenty-six percent of patients complicated neurological sequalae.

CONCLUSION

Combination therapy including VCM plus LVFX could be a treatment option.

Rare but not forgotten: A case of meningitis due to ceftriaxone-resistant Streptococcus pneumoniae

Despite the dramatic decrease in invasive pneumococcal disease since the widespread use of the first pneumococcal vaccine, invasive and resistant disease still occurs. We present a case of ceftriaxone-resistant pneumococcal meningitis suggesting that continued vigilance is warranted for empiric treatment of meningitis when Streptococcus pneumoniae is a concern.

Clinical observation of meningitis caused by penicillin-susceptible and -non-susceptibleStreptococcus pneumoniaein Taiwanese children

AIM

To compare differences between clinical features and outcome in bacterial meningitis caused by penicillin-susceptible Streptococcus pneumoniae (PSSP) with that caused by penicillin-non-susceptible Streptococcus pneumoniae (PNSP).

METHODS

All patients <18 yrs hospitalised with pneumococcal meningitis between January 1984 and December 2002 at Chang Gung Children's Hospital, Taipei were reviewed retrospectively.

RESULTS

There were 28 PNSP (63.6%) and 16 PSSP cases of meningitis eligible for the study. The incidence of PNSP meningitis increased significantly over the 8-yr period (p = 0.007). Age <4 yrs (78.6% vs 50%), a lower initial white blood count (mean 11.7 vs 19.9 x10(9)/L), admission to the intensive care unit (70.4% vs 50%) and mortality (28.6% vs 6.3%) were more common in the PNSP group. However, the only significant finding was a lower proportion of polymorphic neutrophils in the CSF of the PNSP meningitis group (p = 0.04).

CONCLUSIONS

There was an increase in PNSP isolates from patients with meningitis over the 8-yr study period. No major differences were observed in clinical or laboratory features or outcome between the PSSP and PNSP groups.

Pneumococcal meningitis in Taiwanese children: emphasis on clinical outcomes and prognostic factors

Pneumococcal meningitis causes high morbidity or mortality in childhood despite the progress in medicine. Children with pneumococcal meningitis were identified and retrospectively reviewed. Forty-nine children were eligible, with mortality in 24.5% of all and neurological sequelae in 40.5% of survivors. In the analysis of clinical profiles, ventilator support (p = 0.001), septic shock (p < 0.001), multiple organ failure (p < 0.001) and lower cerebrospinal fluid (CSF) leukocyte count (p = 0.001) were more frequently found in non-survivors. Besides, CSF protein (p = 0.006) was higher in survivors with neurological sequelae. Initial dexamethasone usage and disease severity did not affect the occurrence of neurological sequelae. Multivariate logistic regression analysis revealed that CSF leukocyte count <or=200 mm(-3) (p = 0.013) and protein level >or=330 g l(-1) (p = 0.022) were significantly risk factors associated with poor outcomes, and physicians should be cautious if such conditions occur.

Health care resource utilization associated with treatment of penicillin-susceptible and -nonsusceptible isolates of Streptococcus pneumoniae

Despite failure to correlate in vitro susceptibility with clinical outcomes for respiratory tract infections and bacteremia, resistance affects management of patients with pneumococcal infections. The economic impact of resistance among pneumococci has not been evaluated. We conducted a single-center, retrospective, observational, cohort study of hospitalized patients infected with Streptococcus pneumoniae isolated from blood or a respiratory source between January 1, 1995, and December 31, 1998. Data were collected for 36 days surrounding the day that the first positive culture was collected. Patients were grouped according to isolate penicillin-susceptibility profile [susceptible minimum inhibitory concentration (MIC) < or = 0.06 microg/ml, nonsusceptible MIC > or = 0.125 microg/ml), and data were analyzed with respect to health care resource utilization patterns. Of 231 patients identified, 142 and 89 had susceptible and nonsusceptible isolates, respectively. Groups were similar with respect to demographics and comorbidities, except that patients infected with a nonsusceptible isolate were more likely to have the isolate obtained from a respiratory source and to have a history of recent antibiotic therapy. No difference was noted with respect to clinical outcome; however, patients infected with a nonsusceptible isolate had a longer median stay (14 vs 10 days, p<0.05). They also had significantly higher total median costs (1600 dollars, 95% confidence interval 257-2943 dollars) due to room and nursing services. Infections caused by penicillin-nonsusceptible pneumococci were not associated with a worse outcome in hospitalized patients but were associated with increased cost of care.

Prevention of Pneumococcal Meningitis

With the success of the conjugated Haemophilus influenzae type b vaccines, Streptococcus pneumoniae has become one of the most important causes of bacterial meningitis worldwide, causing significant morbidity and mortality. Additionally, the increasing amount of resistance that this organism is developing to multiple classes of antimicrobial agents has made the treatment of pneumococcal infections, especially meningitis, much more difficult. Immunization has been shown to be one of most effective methods for preventing pneumococcal meningitis, resulting not only in a decrease in disease burden, but also a decrease in antimicrobial resistance. Currently, a 23-valent pneumococcal polysaccharide vaccine and a heptavalent protein conjugate vaccine are licensed for use. However, the 23-valent polysaccharide vaccine is poorly immunogenic in infants and young children. The continued development, licensing, and use of pneumococcal conjugate vaccines have the best potential to both prevent disease and decrease the prevalence of pneumococcal 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.

Current pharmacotherapy of pneumococcal meningitis

Streptococcus pneumoniae is the leading cause of bacterial meningitis for people of all age groups after infancy. Prior to the emergence of penicillin-resistant pneumococci as the cause of meningitis, penicillin was the traditional therapy for this life-threatening infection. Treatment guidelines for both suspected and confirmed cases of pneumococcal meningitis (PM) have had to evolve in response to the phenomenon of increasing antibiotic resistance. In addition, research efforts have attempted to clarify the role of dexamethasone and the importance of prompt antibiotic therapy in the management of patients with PM. This article provides a review of general therapeutic principles, current treatment guidelines and alternative therapeutic choices for patients with PM.

Pneumococcal meningitis in children: relationship of antibiotic resistance to clinical characteristics and outcomes

BACKGROUND

The relationship of antibiotic susceptibility to clinical outcome in children with pneumococcal meningitis is uncertain. Previous studies have been limited by inclusion of relatively few patients infected with nonsusceptible pneumococci and inconsistent use of empiric vancomycin.

METHODS

Medical records of 86 children with culture-confirmed pneumococcal meningitis at a single institution from October, 1991, to October, 1999, were retrospectively reviewed, and differences in presentation and outcome based on antibiotic susceptibility of pneumococcal isolates were assessed.

RESULTS

Of 86 isolates 34 were nonsusceptible to penicillin (12 resistant). Of 60 isolates for which cefotaxime susceptibility data were available, 17 were nonsusceptible (12 resistant). Antibiotic susceptibility was not significantly associated with death, intensive care unit admission, mechanical ventilation, focal neurologic deficits, seizures, secondary fever, abnormal neuroimaging studies or hospital days. Children with penicillin-resistant isolates had significantly higher median blood leukocyte counts (24,100/microliter vs. 15,700/microliter, P = 0.03) and lower median CSF protein concentrations (85 mg/dl vs. 219 mg/dl, P = 0.04), were more likely to have a CSF glucose concentration of > or = 50 mg/dl (7 of 11 vs. 15 of 68, P = 0.009) and had lower rates of sensorineural hearing loss (1 of 8 vs. 25 of 40, P = 0.02) than children with isolates that were not resistant to penicillin. Children with cefotaxime-nonsusceptible isolates had an increased median duration of primary fever compared with those with nonsusceptible strains (6 days vs. 3.5 days, P = 0.02).

CONCLUSIONS

In children with pneumococcal meningitis, penicillin resistance was associated with a reduced risk of hearing loss, while cefotaxime resistance was associated with a longer duration of fever. Other outcome measures were not significantly influenced by the antibiotic susceptibility of pneumococcal isolates.

Clinical outcomes of meningitis caused by Streptococcus pneumoniae in the era of antibiotic resistance

Limited data are available on clinical outcomes of meningitis due to cefotaxime-nonsusceptible Streptococcus pneumoniae. We analyzed data from 109 cases of pneumococcal meningitis in Atlanta, Baltimore, and San Antonio, which were identified through population-based active surveillance from November 1994 to April 1996. Pneumococcal isolates from 9% of the cases were resistant to cefotaxime, and isolates from 11% had intermediate susceptibility. Children were more likely to have cephalosporin-nonsusceptible pneumococcal meningitis, but mortality was significantly higher among adults aged 18-64 years. Vancomycin was given upon admission to 29% of patients, and within 48 h of admission to 52%. Nonsusceptibility to cefotaxime was not associated with the following outcomes: increased mortality, prolonged length of hospital or intensive care unit (ICU) stay, requirement of intubation or oxygen, ICU care, discharge to another medical or long-term-care facility, or neurological deficit. Empirical use of vancomycin, current prevalence of drug-resistant S. pneumoniae, and degree of nonsusceptibility to cefotaxime may have influenced these findings.

Drug-resistant Streptococcus pneumoniae: rational antibiotic choices

Increasingly, Streptococcus pneumoniae with reduced susceptibility to penicillin is becoming a healthcare concern, not only because of the high prevalence of infections caused by this pathogen but also because of the rate at which resistance has progressed. The incidence of penicillin resistance in strains of S. pneumoniae approaches 40% in some areas of the United States, and the incidence of high-level resistance has increased by 60-fold during the past 10 years. With the exception of meningitis and otitis media, there is no conclusive evidence that the acquisition of resistance by S. pneumoniae to beta-lactam antibiotics incurs greater morbidity and mortality in infections caused by this pathogen. However, if the current trends of resistance patterns continue, one can expect the morbidity and mortality to increase. The mechanism of beta-lactam resistance of S. pneumoniae involves genetic mutations which alter penicillin-binding protein structure, resulting in a decreased affinity for all beta-lactam antibiotics. In the treatment of infections caused by S. pneumoniae, it should not be assumed that nonsusceptibility to beta-lactam antibiotics correlates with clinical ineffectiveness of these agents. On the contrary, the recommended therapy for nonmeningeal pneumococcal infections (e.g., pneumonia, sepsis, acute otitis media) includes a beta-lactam antibiotic: penicillin G, amoxicillin, amoxicillin/clavulanate, cefuroxime, cefotaxime, or ceftriaxone. Recommended therapy for meningitis is cefotaxime or ceftriaxone, with the addition of vancomycin until susceptibility is known. These agents are recommended because of their ability to achieve serum/tissue concentrations greater than the minimum inhibitory concentrations (MICs) of these agents against penicillin-susceptible, penicillin-intermediate, and most penicillin-resistant strains (e.g., penicillin G, cefotaxime, ceftriaxone, amoxicillin, amoxicillin/clavulanate, and cefuroxime), or their ability to provide adequate concentrations in cerebrospinal fluid (e.g., cefotaxime, ceftriaxone).

Description of two new isolates of Streptococcus pneumoniae in spain that are highly resistant to cefotaxime

Two strains of Streptococcus pneumoniae isolated from sputum and bronchoalveolar samples with high-level resistance to cefotaxime (MIC = 8 to 16 microg/ml) are described. One of them, belonging to serogroup 19, was also highly resistant to penicillin (MIC = 16 microg/ml), while the other, of serogroup 14, was intermediate in its resistance to penicillin (MIC = 0.25 microg/ml). To our knowledge, these are the first two strains to be isolated in Spain with such high levels of resistance to cefotaxime.

Management of infections due to antibiotic-resistant Streptococcus pneumoniae

Antibiotic-resistant strains of Streptococcus pneumoniae are becoming more prevalent throughout the world; this has resulted in modifications of treatment approaches. Management of bacterial meningitis has the greatest consensus. Strategies for treating other systemic infections such as pneumonia, bacteremia, and musculoskeletal infections are evolving, in part related to the availability of new antibiotics which are active in vitro against isolates resistant to penicillin and the extended-spectrum cephalosporins. However, there are currently very limited data related to the clinical efficacy of these new agents. The studies upon which current recommendations are based are reviewed. Otitis media represents the single most common infection due to S. pneumoniae. Recommendations for treatment of acute otitis media due to drug-resistant strains and the rationale for these recommendations are discussed.

Breakthrough bacteremia and meningitis during treatment with cephalosporins parenterally for pneumococcal pneumonia

An extended-spectrum cephalosporin has been considered appropriate therapy for non-meningeal infections caused by drug-resistant Streptococcus pneumoniae. We report a toddler who had breakthrough bacteremia and meningitis develop because of drug-resistant pneumococcus while receiving treatment with cefotaxime and cefuroxime for pneumonia.

Cerebrospinal fluid bactericidal activity against cephalosporin-resistant Streptococcus pneumoniae in children with meningitis treated with high-dosage cefotaxime

We determined cefotaxime and desacetyl-cefotaxime concentrations in children with bacterial meningitis receiving high-dose cefotaxime (300 mg/kg of body weight/day) and concomitant dexamethasone therapy. The median peak cerebrospinal fluid cefotaxime and desacetyl-cefotaxime concentrations were 4.7 and 8.1 microg/ml, respectively. In vitro bactericidal activity (>99.9% killing in 6 h) was found in 17 (94%), 13 (72%), and 8 (44%) of 18 cerebrospinal fluid specimens against cefotaxime-susceptible, -intermediate (MIC, 1 microg/ml), and -resistant (MIC, 4 microg/ml) strains, respectively. High-dose cefotaxime, while safe, is not reliably sufficient therapy for cephalosporin-nonsusceptible pneumococcal meningitis, and combination therapy is recommended.

Case report: penicillin-resistant pneumococcal meningitis: navigating a therapeutic minefield

Pneumococcal meningitis is a common infection in adults for which penicillin has long been the drug of choice. Optimal treatment has recently become controversial, however, owing to an alarming increase in the number of penicillin-resistant isolates. The authors report a representative case of meningitis caused by such an organism, and provide a discussion of the history, mechanisms of resistance, laboratory evaluation, and treatment of these infections. Guidelines for prevention are also reviewed, including a renewed call for utilization of the 23-valent pneumococcal vaccine.

High doses of cefotaxime in treatment of adult meningitis due to Streptococcus pneumoniae with decreased susceptibilities to broad-spectrum cephalosporins

We treated nine patients (10 episodes) with meningitis caused by Streptococcus pneumoniae isolates with decreased susceptibilities to broad-spectrum cephalosporins with high doses of cefotaxime (300 mg/kg of body weight per day; maximum dose, 24 g/day). Early adjunctive therapy with dexamethasone was also administered. Cefotaxime MICs were 0.5 (three episodes), 1 (five episodes), and 2 (two episodes) micrograms/ml, and MBCs ranged from 1 to 4 micrograms/ml. Therapy was well tolerated, and all patients experienced prompt clinical improvement. One patient died 8 days after the end of therapy, the central nervous system infection had already been cured, and the remaining patients recovered without relapses.

Evaluation of accuracy and reproducibility of E test for susceptibility testing of Streptococcus pneumoniae to penicillin, cefotaxime, and ceftriaxone

We evaluated the reproducibility with which technologists perform and interpret the E test (AB Biodisk, North America, Inc., Piscataway, N.J.) for determining the susceptibility of Streptococcus pneumoniae to penicillin, cefotaxime, and ceftriaxone. Four technologists prepared E test assays to test 124 isolates of S. pneumoniae. Each technologist then interpreted the results of the E test blinded to the interpretation of the other technologists. In addition, E test results were compared with the reference method of broth microdilution. Intraobserver and interobserver agreement were assessed by use of the kappa statistic. Interpretation of the E test and broth microdilution results showed substantial to excellent agreement, with kappa values ranging from 0.878 to 0.987. Compared with broth microdilution, no very major errors and only four major errors were made with the E test. Most minor errors with penicillin and ceftriaxone occurred for isolates with intermediate or high-level resistance, whereas for cefotaxime the minor errors were more evenly distributed between susceptible and intermediate resistance and between intermediate and high-level resistance. These results indicate that there is good agreement between technologists for the interpretation of the E test when testing the susceptibility of S. pneumoniae to penicillin, cefotaxime, and ceftriaxone and that the results of the E test agree with those of broth microdilution.

In vitro killing of penicillin-susceptible, -intermediate, and -resistant strains of Streptococcus pneumoniae by cefotaxime, ceftriaxone, and ceftizoxime: a comparison of bactericidal and inhibitory activity with achievable CSF levels

This study assessed total microbial killing of 30 penicillin-susceptible, -intermediate, and -resistant strains of Streptococcus pneumoniae by cefotaxime, ceftriaxone, and ceftizoxime and compared these values with MICs for each strain against each agent as determined by three different methods/media. The results confirm the appropriateness of recent NCCLS recommendations for MIC interpretive criteria for third generation cephalosporins in which < or = 0.25 microgram/ml = susceptible and > or = 2.0 micrograms/ml = resistant when these agents are used to treat pneumococcal meningitis and data from total microbial killing studies suggests that most isolates with MICs of 0.5 and 1.0 mcg/ml would respond to high dose therapy with all three agents. The study also confirmed the recently described two- to four-fold decrease in activity of ceftizoxime against S. pneumoniae as compared with either cefotaxime or ceftriaxone; but noted that current NCCLS MIC interpretive criteria for the therapy of meningitis remain valid for all three agents. Finally, the study found that MICs determined by the E test or by microdilution broth methods using supplemented Todd Hewitt broth predict susceptibility as well as the NCCLS reference method. The actual selection among these agents for the therapy of pneumococcal meningitis should also consider other parameters including protein binding, age groups of clinical use, maximum potency against all clinically relevant pathogens, and cost.