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Page B, Adiunegiya S. Antimicrobial Resistance in Papua New Guinea: A Narrative Scoping Review. Antibiotics (Basel) 2023; 12:1679. [PMID: 38136713 PMCID: PMC10741211 DOI: 10.3390/antibiotics12121679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Antimicrobial-resistant bacterial infections are a known threat to the public health of low-income countries and are undercharacterized in Papua New Guinea. A scoping literature review of scientific peer-reviewed publications on antimicrobial resistance in Papua New Guinea was conducted, and their results were summarized. Many of the available data on resistant bacteria in Papua New Guinea have come from Port Moresby and Goroka and have been focused on Staphylococcus aureus, as well as important pediatric pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. Progressive resistance to the commonly used antibiotics penicillin and chloramphenicol among most clinically important bacterial pathogens has prompted healthcare workers to adopt expensive broad-spectrum antibiotics. There is already evidence of resistance to newly adopted antibiotics among several Gram-negative organisms. Drivers of antimicrobial resistance in Papua New Guinea include a high burden of infectious diseases, inappropriate antibiotic prescription practices, poor regulation of antibiotics, incomplete adherence, substandard drug quality, and overcrowding of healthcare facilities. There is a lack of information on antimicrobial resistance among priority pathogens and from several important regions of Papua New Guinea.
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Affiliation(s)
- Brady Page
- Department of Infectious Diseases and Global Public Health, University of California, San Diego (UCSD), La Jolla, CA 92103, USA
- Scripps Research Institute, La Jolla, CA 92037, USA
| | - Simeon Adiunegiya
- School of Public Health, University of Washington, Seattle, WA 98195, USA
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2
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Obaro S, Hassan-Hanga F, Medugu N, Olaosebikan R, Olanipekun G, Jibir B, Gambo S, Ajose T, Duru C, Ebruke B, Davies HD. Comparison of bacterial culture with BioFire® FilmArray® multiplex PCR screening of archived cerebrospinal fluid specimens from children with suspected bacterial meningitis in Nigeria. BMC Infect Dis 2023; 23:641. [PMID: 37784010 PMCID: PMC10544496 DOI: 10.1186/s12879-023-08645-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Diagnosis of bacterial meningitis remains a challenge in most developing countries due to low yield from bacterial culture, widespread use of non-prescription antibiotics, and weak microbiology laboratories. The objective of this study was to compare the yield from standard bacterial culture with the multiplex nested PCR platform, the BioFire® FilmArray® Meningitis/Encephalitis Panel (BioFire ME Panel), for cases with suspected acute bacterial meningitis. METHODS Following Gram stain and bacterial culture on cerebrospinal fluid (CSF) collected from children aged less than 5 years with a clinical suspicion of acute bacterial meningitis (ABM) as defined by the WHO guidelines, residual CSF specimens were frozen and later tested by BioFire ME Panel. RESULTS A total of 400 samples were analyzed. Thirty-two [32/400 (8%)] of the specimens were culture positive, consisting of; three Salmonella spp. (2 Typhi and 1 non-typhi), three alpha hemolytic Streptococcus, one Staphylococcus aureus, six Neisseria meningitidis, seven Hemophilus influenzae, 11 Streptococcus pneumoniae and 368 were culture negative. Of the 368 culture-negative specimens, the BioFire ME Panel detected at least one bacterial pathogen in 90 (24.5%) samples, consisting of S. pneumoniae, N. meningitidis and H. influenzae, predominantly. All culture positive specimens for H. influenzae, N. meningitidis and S. pneumoniae also tested positive with the BioFire ME Panel. In addition, 12 specimens had mixed bacterial pathogens identified. For the first time in this setting, we have data on the viral agents associated with meningitis. Single viral agents were detected in 11 (2.8%) samples while co-detections with bacterial agents or other viruses occurred in 23 (5.8%) of the samples. CONCLUSIONS The BioFire® ME Panel was more sensitive and rapid than culture for detecting bacterial pathogens in CSF. The BioFire® ME Panel also provided for the first time, the diagnosis of viral etiologic agents that are associated with meningoencephalitis in this setting. Institution of PCR diagnostics is recommended as a routine test for suspected cases of ABM to enhance early diagnosis and optimal treatment.
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Affiliation(s)
- S Obaro
- Division of Pediatric Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, US
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria
| | - F Hassan-Hanga
- Department of Pediatrics, Aminu Kano Teaching Hospital, Bayero University/ Bayero University, Kano, Nigeria
| | - N Medugu
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria.
- Department of Medical Microbiology and Immunology, Nile University of Nigeria, Abuja, Nigeria.
| | - R Olaosebikan
- Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, US
| | - G Olanipekun
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria
| | - B Jibir
- Hasiya Bayero Pediatric Hospital, Kano, Nigeria
| | - S Gambo
- Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Theresa Ajose
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria
| | - Carissa Duru
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria
| | - B Ebruke
- International Foundation Against Infectious Diseases in Nigeria (IFAIN), Abuja, Nigeria
| | - H D Davies
- Division of Pediatric Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, US
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Mellor KC, Lo S, Yoannes M, Michael A, Orami T, Greenhill AR, Breiman RF, Hawkins P, McGee L, Bentley SD, Ford RL, Lehmann D. Distinct Streptococcus pneumoniae cause invasive disease in Papua New Guinea. Microb Genom 2022; 8. [PMID: 35816442 PMCID: PMC9455700 DOI: 10.1099/mgen.0.000835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Streptococcus pneumoniae is a key contributor to childhood morbidity and mortality in Papua New Guinea (PNG). For the first time, whole genome sequencing of 174 isolates has enabled detailed characterisation of diverse S. pneumoniae causing invasive disease in young children in PNG, 1989-2014. This study captures the baseline S. pneumoniae population prior to the introduction of 13-valent pneumococcal conjugate vaccine (PCV13) into the national childhood immunisation programme in 2014. Relationships amongst lineages, serotypes and antimicrobial resistance traits were characterised, and the population was viewed in the context of a global collection of isolates. The analyses highlighted adiverse S. pneumoniae population associated with invasive disease in PNG, with 45 unique Global Pneumococcal Sequence Clusters (GPSCs) observed amongst the 174 isolates reflecting multiple lineages observed in PNG that have not been identified in other geographic locations. The majority of isolates were from children with meningitis, of which 52% (n=72) expressed non-PCV13 serotypes. Over a third of isolates were predicted to be resistant to at least one antimicrobial. PCV13 serotype isolates had 10.1 times the odds of being multidrug-resistant (MDR) compared to non-vaccine serotype isolates, and no isolates with GPSCs unique to PNG were MDR. Serotype 2 was the most commonly identified serotype; we identified a highly clonal cluster of serotype 2 isolates unique to PNG, and a distinct second cluster indicative of long-distance transmission. Ongoing surveillance, including whole-genome sequencing, is needed to ascertain the impact of the national PCV13 programme upon the S. pneumoniae population, including serotype replacement and antimicrobial resistance traits.
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Affiliation(s)
- Kate C Mellor
- Parasites and Microbes, Wellcome Sanger Institute, Hinxton, UK
| | - Stephanie Lo
- Parasites and Microbes, Wellcome Sanger Institute, Hinxton, UK
| | - Mition Yoannes
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Audrey Michael
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Tilda Orami
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew R Greenhill
- Institute of Innovation, Science and Sustainability, Federation University Australia, Churchill, Australia
| | - Robert F Breiman
- Rollins School of Public Health Emory University, Atlanta, GA, USA
| | - Paulina Hawkins
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lesley McGee
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Rebecca L Ford
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Deborah Lehmann
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Crawley WA 6009, Australia
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Vyas S, Suthar R, Agarwal V, Bhardwaj N, Salaria M, Aggarwal R, Singh P, Wickström R, Singhi P, Singhi S. MRI Spectrum of Haemophilus influenzae Meningoencephalitis in Children. Ann Indian Acad Neurol 2021; 23:616-620. [PMID: 33623260 PMCID: PMC7887487 DOI: 10.4103/aian.aian_500_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 12/01/2022] Open
Abstract
Background and Purpose: Haemophilus influenzae type b (Hib) infection occurs mostly in children and is transmitted from person to person through the respiratory pathway. Hib strain is associated with meningitis or encephalitis. It is not an uncommon infection, particularly, in the developing world. This prospective cohort study was done with the aim of describing imaging findings in patients with Hib meningoencephalitis. Materials and Methods: In a prospective cohort study, consecutive children admitted in the pediatric emergency unit with acute febrile encephalopathy were enrolled. The clinical details, CSF analysis, and microbiological and serological investigations were recorded on a case record proforma. Children with confirmed Hib meningoencephalitis were included in this study. Clinicoradiological features were assessed. Results: A total of 16 patients with acute febrile encephalopathy, in whom CSF latex agglutination, CSF culture, or CSF multiplex PCR were positive for H. influenzae were included in this study. All these children were investigated with magnetic resonance imaging (MRI) brain. Important imaging findings were meningitis, predominantly around frontoparietal lobes (43%), cerebritis (28%), ventriculitis (14%), and subdural collections (21.5%). One patient had features consistent with acute disseminated encephalomyelitis (ADEM) while four patients had normal MRI scan. Conclusions: H. influenzae is still a common cause of meningitis in infants and children in the developing world. We have tried to study the most common MRI features associated with Hib infection to help radiologists alert the treating clinicians to further investigate these patients for appropriate prognostication.
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Affiliation(s)
- Sameer Vyas
- Department of Radiodiagnosis and Imaging, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Renu Suthar
- Department of Pediatrics, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vivek Agarwal
- Department of Radiodiagnosis and Imaging, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Bhardwaj
- Department of Medicine, Government Medical College and Hospital (GMCH), Chandigarh, India
| | - Manila Salaria
- Department of Immunopathology, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritu Aggarwal
- Department of Immunopathology, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Paramjeet Singh
- Department of Radiodiagnosis and Imaging, Post graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ronny Wickström
- Senior Consultant and Associate Professor Child Neurology, Neuropediatric Unit, Astrid Lindgren's Children's Hospital, Karolinska, Stockholm, Sweden
| | - Pratibha Singhi
- Department of Pediatrics, Medanta, The Medicity, Gurugram, NCR, Haryana, India.,Former: Department of Pediatrics PGIMER, Chandigarh, India
| | - Sunit Singhi
- Department of Pediatrics, Medanta, The Medicity, Gurugram, NCR, Haryana, India.,Former: Department of Pediatrics PGIMER, Chandigarh, India
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Abstract
Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig's sign and Brudzinski's sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.
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Affiliation(s)
- Alexander Tracy
- General Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - Thomas Waterfield
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Liang L, Kotadia N, English L, Kissoon N, Ansermino JM, Kabakyenga J, Lavoie PM, Wiens MO. Predictors of Mortality in Neonates and Infants Hospitalized With Sepsis or Serious Infections in Developing Countries: A Systematic Review. Front Pediatr 2018; 6:277. [PMID: 30356806 PMCID: PMC6190846 DOI: 10.3389/fped.2018.00277] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 09/12/2018] [Indexed: 01/27/2023] Open
Abstract
Background: Neonates and infants comprise the majority of the 6 million annual deaths under 5 years of age around the world. Most of these deaths occur in low/middle income countries (LMICs) and are preventable. However, the clinical identification of neonates and infants at imminent risk of death is challenging in developing countries. Objective: To systematically review the literature on clinical risk factors for mortality in infants under 12 months of age hospitalized for sepsis or serious infections in LMICs. Methods: MEDLINE and EMBASE were systematically searched using MeSH terms through April 2017. Abstracts were independently screened by two reviewers. Subsequently, full-text articles were selected by two independent reviewers based on PICOS criteria for inclusion in the final analysis. Study data were qualitatively synthesized without quantitative pooling of data due to heterogeneity in study populations and methodology. Results: A total of 1,139 abstracts were screened, and 169 full-text articles were selected for text review. Of these, 45 articles were included in the analysis, with 21 articles featuring neonatal populations (under 28 days of age) exclusively. Most studies were from Sub-Saharan Africa and South Asia. Risk factors for mortality varied significantly according to study populations. For neonatal deaths, prematurity, low birth-weight and young age at presentation were most frequently associated with mortality. For infant deaths, malnutrition, lack of breastfeeding and low oxygen saturation were associated with mortality in the highest number of studies. Conclusions: Risk factors for mortality differ between the neonatal and young infant age groups and were also dependant on the study population. These data can serve as a starting point for the development of individualized predictive models for in-hospital and post-discharge mortality and for the development of interventions to improve outcomes among these high-risk groups.
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Affiliation(s)
- Li(Danny) Liang
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Naima Kotadia
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lacey English
- School of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - J. Mark Ansermino
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, British Columbia Children's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Jerome Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Matthew O. Wiens
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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7
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Blyth CC, Ford R, Sapura J, Kumani T, Masiria G, Kave J, Yuasi L, Greenhill A, Hwaihwanje I, Lang A, Lehmann D, Pomat W. Childhood pneumonia and meningitis in the Eastern Highlands Province, Papua New Guinea in the era of conjugate vaccines: study methods and challenges. Pneumonia (Nathan) 2017; 9:5. [PMID: 28702307 PMCID: PMC5471671 DOI: 10.1186/s41479-017-0029-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 01/23/2017] [Indexed: 12/18/2022] Open
Abstract
Background Pneumonia and meningitis are common causes of severe childhood illness in Papua New Guinea (PNG). The etiology of both clinical conditions in PNG has not been recently assessed. Changes in lifestyle, provision and access to healthcare, antimicrobial utilization and resistance, and the national childhood vaccination schedule necessitate reassessment. Methods A prospective case-control study was undertaken, enrolling children <5 years of age to determine the contemporary etiology of clinically defined moderate or severe pneumonia or suspected meningitis. Cases were identified following presentation for inpatient or outpatient care in Goroka town, the major population centre in the Eastern Highlands Province. Following enrolment, routine diagnostic specimens including blood, nasopharyngeal swabs, urine and (if required) cerebrospinal fluid, were obtained. Cases residing within one hour’s drive of Goroka were followed up, and recruitment of healthy contemporaneous controls was undertaken in the cases’ communities. Results 998 cases and 978 controls were enrolled over 3 years. This included 784 cases (78.6%) with moderate pneumonia, 187 (18.7%) with severe pneumonia and 75 (7.5%) with suspected meningitis, of whom 48 (4.8%) had concurrent pneumonia. The median age of cases was 7.8 months (Interquartile range [IQR] 3.9–14.3), significantly lower than community controls, which was 20.8 months (IQR 8.2–36.4). Half the cases were admitted to hospital (500/998; 50.1%). Recruitment of cases and controls and successful collection of diagnostic specimens improved throughout the study, with blood volume increasing and rates of blood culture contamination decreasing. The overall case fatality rate was 18/998 (1.8%). Of cases eligible for follow-up, outcome data was available from 76.7%. Low but increasing coverage of Haemophilus influenzae type B conjugate vaccines on the national schedule was observed during the study period: three dose DTPw-HepB-Hib coverage in children >3 months increased from 14.9 to 43.0% and 29.0 to 47.7% in cases and controls (both p < 0.001). Despite inclusion in the national immunization program in 2014, 2015 PCV13 three-dose coverage in cases and controls >3 months was only 4.0 and 6.5%. Conclusions Recruitment of large numbers of pediatric pneumonia and meningitis cases and community controls in a third-world setting presents unique challenges. Successful enrolment of 998 cases and 978 controls with comprehensive clinical data, biological specimens and follow up was achieved. Increased vaccine coverage remains an ongoing health priority. Electronic supplementary material The online version of this article (doi:10.1186/s41479-017-0029-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher C Blyth
- School of Paediatrics and Child Health, The University of Western Australia, Princess Margaret Hospital for Children, Roberts Road, Subiaco, 6008 WA Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box 855, West Perth, 6872 WA Australia.,Department of Infectious Diseases and PathWest Department of Microbiology, Princess Margaret Hospital for Children, Roberts Road, Subiaco, 6008 WA Australia
| | - Rebecca Ford
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Joycelyn Sapura
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Tonny Kumani
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Geraldine Masiria
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - John Kave
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Lapule Yuasi
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Andrew Greenhill
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea.,School of Applied and Biomedical Sciences, Federation University Australia, Gippsland Campus, Northways Road, Churchill, 3842 VIC Australia
| | - Ilomo Hwaihwanje
- Eastern Highlands Provincial Hospital, PO Box 392, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Amanda Lang
- Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - Deborah Lehmann
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box 855, West Perth, 6872 WA Australia.,Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
| | - William Pomat
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box 855, West Perth, 6872 WA Australia.,Papua New Guinea Institute of Medical Research, PO Box 60, Goroka, 441 Eastern Highlands Province Papua New Guinea
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8
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Greenhill AR, Phuanukoonnon S, Michael A, Yoannes M, Orami T, Smith H, Murphy D, Blyth C, Reeder J, Siba P, Pomat W, Lehmann D. Streptococcus pneumoniae and Haemophilus influenzae in paediatric meningitis patients at Goroka General Hospital, Papua New Guinea: serotype distribution and antimicrobial susceptibility in the pre-vaccine era. BMC Infect Dis 2015; 15:485. [PMID: 26521138 PMCID: PMC4628371 DOI: 10.1186/s12879-015-1197-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacterial meningitis remains an important infection globally, with the greatest burden in children in low-income settings, including Papua New Guinea (PNG). We present serotype, antimicrobial susceptibility and outcome data from paediatric meningitis patients prior to introduction of Haemophilus influenzae type b (Hib) and pneumococcal conjugate vaccines (PCVs) in PNG, providing a baseline for evaluation of immunisation programs. METHODS Cerebrospinal fluid (CSF) was collected from children admitted to Goroka General Hospital with suspected meningitis between 1996 and 2005. Culture and sensitivity was conducted, and pneumococci and H. influenzae were serotyped. Laboratory findings were linked to clinical outcomes. RESULTS We enrolled 1884 children. A recognised pathogen was identified in 375 children (19.9%). Streptococcus pneumoniae (n = 180) and Hib (n = 153) accounted for 88.8% of pathogens isolated. 24 different pneumococcal serogroups were identified; non-PCV types 2, 24 and 46 accounted for 31.6% of pneumococcal meningitis. 10- and 13-valent PCVs would cover 44.1% and 45.4% of pneumococcal meningitis respectively. Pneumococcal isolates were commonly resistant to penicillin (21.5%) and 23% of Hib isolates were simultaneously resistant to ampicillin, co-trimoxazole and chloramphenicol. The case fatality rate in patients with a recognised bacterial pathogen was 13.4% compared to 8.5% in culture-negative patients. CONCLUSIONS If implemented in routine expanded programme of immunisation (EPI) with high coverage, current PCVs could prevent almost half of pneumococcal meningitis cases. Given the diversity of circulating serotypes in PNG serotype replacement is of concern. Ongoing surveillance is imperative to monitor the impact of vaccines. In the longer term vaccines providing broader protection against pneumococcal meningitis will be needed.
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Affiliation(s)
- Andrew R Greenhill
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Telethon Kids Institute, The University of Western Australia, Perth, Australia. .,School of Applied and Biomedical Sciences, Federation University, Churchill, Australia.
| | - Suparat Phuanukoonnon
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.
| | | | - Mition Yoannes
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Tilda Orami
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Helen Smith
- Queensland Department of Health, Forensic and Scientific Services, Coopers Plains, Australia.
| | - Denise Murphy
- Queensland Department of Health, Forensic and Scientific Services, Coopers Plains, Australia
| | - Christopher Blyth
- Telethon Kids Institute, The University of Western Australia, Perth, Australia. .,School of Paediatrics and Child Health, The University of Western Australia, Perth, Australia. .,Princess Margaret Hospital for Children, Perth, Australia. .,PathWest Laboratory Medicine, Perth, Western Australia, Australia.
| | - John Reeder
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea. .,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - William Pomat
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Deborah Lehmann
- Telethon Kids Institute, The University of Western Australia, Perth, Australia.
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9
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Alpers MP. Reflections on pneumonia in the tropics. Pneumonia (Nathan) 2014; 4:1-7. [PMID: 31641567 PMCID: PMC5922322 DOI: 10.15172/pneu.2014.4/416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/22/2014] [Indexed: 11/25/2022] Open
Abstract
This review of pneumonia in the tropics is based on experience with respiratory infectons in Papua New Guinea since the 1970s. It discusses ideas, principles, historical aspects of pneumonia research and the need to work with people in the community. In order to understand pneumonia in a tropical setng and evaluate new interventons it is essental to study the ecosystem of the causatve infectons, within the host and the community and between interactng microorganisms. Vaccines are much-needed preventve tools, and for pneumonia in a highly endemic setng the preventon of severe and fatal disease takes priority over the preventon of infecton. In this setng mild infecton plays an important role in preventng severe disease. For achieving long-term sustainable outcomes, sometmes ‘less is more’. A multpronged approach is required to control and prevent pneumonia, and in devising new ways of doing so. This includes appropriate and accessible clinical care, a clean, smoke-free environment, good nutriton and a range of vaccines. Also required are persistent advocacy from the global scientfc community and strong engagement with and by the communites that bear the burden of disease. Beter health care must be pursued in conjuncton with raising literacy rates and reducing poverty.
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Affiliation(s)
- Michael P Alpers
- Faculty of Health Sciences, Curtn University, Perth, Australia Room 108, Health Research Campus, Shenton Park, GPO Box U1987
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10
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Aipit J, Laman M, Hwaiwhanje I, Bona C, Pomat N, Siba P, Davis TME, Manning L. Accuracy of initial clinical diagnosis of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea. Trans R Soc Trop Med Hyg 2014; 108:444-8. [PMID: 24794922 DOI: 10.1093/trstmh/tru067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The diagnosis of acute bacterial meningitis (ABM) is challenging in resource-limited settings where cerebral malaria and viral encephalitis are also common. METHODS To assess the accuracy of an initial clinical diagnosis of ABM in a malaria-endemic area of Papua New Guinea (PNG), a retrospective chart review of hospitalized children aged 2 months to 10 years was conducted. RESULTS Of the 481 eligible children, 240 had an initial clinical diagnosis of ABM that was confirmed independently by trained research staff under standardized conditions, with laboratory support in only 84 (17.5%; 84/481). When compared with the final laboratory-confirmed diagnosis, an initial diagnosis of ABM had a sensitivity, specificity, positive predictive value and negative predictive value of 76% (95% CI 66-85%), 56% (95% CI 51-61%), 27% (95% CI 21-33) and 92% (95% CI 87-95%), respectively. There was discordance between initial and final diagnosis of ABM in 196 children; 176 initially considered to have ABM had an alternative diagnosis, while 20 without an initial diagnosis of ABM were confirmed to have ABM. CONCLUSION These data show that initial misdiagnosis of ABM is common in a malaria-endemic area of PNG. A diagnostic algorithm using standardized assessment for meningeal irritation, coma and malaria parasitological testing needs further evaluation in this setting.
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Affiliation(s)
- Jimmy Aipit
- Modilon General Hospital, Paediatrics Unit, Madang, Papua New Guinea
| | - Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Ilomo Hwaiwhanje
- Modilon General Hospital, Paediatrics Unit, Madang, Papua New Guinea
| | - Cathy Bona
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Naomi Pomat
- Modilon General Hospital, Paediatrics Unit, Madang, Papua New Guinea
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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Laman M, Pomat W, Siba P, Betuela I. Ethical challenges in integrating patient-care with clinical research in a resource-limited setting: perspectives from Papua New Guinea. BMC Med Ethics 2013; 14:29. [PMID: 23885908 PMCID: PMC3750755 DOI: 10.1186/1472-6939-14-29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 07/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In resource-limited settings where healthcare services are limited and poverty is common, it is difficult to ethically conduct clinical research without providing patient-care. Therefore, integration of patient-care with clinical research appears as an attractive way of conducting research while providing patient-care. In this article, we discuss the ethical implications of such approach with perspectives from Papua New Guinea. DISCUSSION Considering the difficulties of providing basic healthcare services in developing countries, it may be argued that integration of clinical research with patient-care is an effective, rational and ethical way of conducting research. However, blending patient-care with clinical research may increase the risk of subordinating patient-care in favour of scientific gains; therapeutic misconception and inappropriate inducement; and the risk of causing health system failures due to limited capacity in developing countries to sustain the level of healthcare services sponsored by the research. Nevertheless, these ethical and administrative implications can be minimised if patient-care takes precedence over research; the input of local ethics committees and institutions are considered; and funding agencies acknowledge their ethical obligation when sponsoring research in resource-limited settings. SUMMARY Although integration of patient-care with clinical research in developing countries appears as an attractive way of conducting research when resources are limited, careful planning and consideration on the ethical implications of such approach must be considered.
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Affiliation(s)
- Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea.
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Pomat WS, van den Biggelaar AHJ, Phuanukoonnon S, Francis J, Jacoby P, Siba PM, Alpers MP, Reeder JC, Holt PG, Richmond PC, Lehmann D. Safety and immunogenicity of neonatal pneumococcal conjugate vaccination in Papua New Guinean children: a randomised controlled trial. PLoS One 2013; 8:e56698. [PMID: 23451070 PMCID: PMC3579820 DOI: 10.1371/journal.pone.0056698] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 01/14/2013] [Indexed: 11/19/2022] Open
Abstract
Background Approximately 826,000 children, mostly young infants, die annually from invasive pneumococcal disease. A 6-10-14-week schedule of pneumococcal conjugate vaccine (PCV) is efficacious but neonatal PCV may provide earlier protection and better coverage. We conducted an open randomized controlled trial in Papua New Guinea to compare safety, immunogenicity and priming for memory of 7-valent PCV (PCV7) given in a 0-1-2-month (neonatal) schedule with that of the routine 1-2-3-month (infant) schedule. Methods We randomized 318 infants at birth to receive PCV7 in the neonatal or infant schedule or no PCV7. All infants received 23-valent pneumococcal polysaccharide vaccine (PPV) at age 9 months. Serotype-specific serum IgG for PCV7 (VT) serotypes and non-VT serotypes 2, 5 and 7F were measured at birth and 2, 3, 4, 9, 10 and 18 months of age. Primary outcomes were geometric mean concentrations (GMCs) and proportions with concentration ≥0.35 µg/ml of VT serotype-specific pneumococcal IgG at age 2 months and one month post-PPV. Results We enrolled 101, 105 and 106 infants, respectively, into neonatal, infant and control groups. Despite high background levels of maternally derived antibody, both PCV7 groups had higher GMCs than controls at age 2 months for serotypes 4 (p<0.001) and 9V (p<0.05) and at age 3 months for all VTs except 6B. GMCs for serotypes 4, 9V, 18C and 19F were significantly higher (p<0.001) at age 2 months in the neonatal (one month post-dose2 PCV7) than in the infant group (one month post-dose1 PCV7). PPV induced significantly higher VT antibody responses in PCV7-primed than unprimed infants, with neonatal and infant groups equivalent. High VT and non-VT antibody concentrations generally persisted to age 18 months. Conclusions PCV7 is well-tolerated and immunogenic in PNG neonates and young infants and induces immunologic memory to PPV booster at age 9 months with antibody levels maintained to age 18 months. Trial Registration ClinicalTrials.gov NCT00219401NCT00219401
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Affiliation(s)
- William S. Pomat
- Papua New Guinean Institute of Medical Research, Goroka, Papua New Guinea
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Anita H. J. van den Biggelaar
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | | | - Jacinta Francis
- Papua New Guinean Institute of Medical Research, Goroka, Papua New Guinea
| | - Peter Jacoby
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Peter M. Siba
- Papua New Guinean Institute of Medical Research, Goroka, Papua New Guinea
| | - Michael P. Alpers
- Centre for International Health, Curtin University, Perth, Western Australia, Australia
| | - John C. Reeder
- Papua New Guinean Institute of Medical Research, Goroka, Papua New Guinea
- Burnet Institute, Melbourne, Victoria, Australia
| | - Patrick G. Holt
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Peter C. Richmond
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Deborah Lehmann
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
- * E-mail:
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van den Biggelaar AHJ, Pomat WS. Immunization of newborns with bacterial conjugate vaccines. Vaccine 2012; 31:2525-30. [PMID: 22728221 DOI: 10.1016/j.vaccine.2012.06.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 05/20/2012] [Accepted: 06/06/2012] [Indexed: 11/29/2022]
Abstract
Bacterial conjugate vaccines are based on the principle of coupling immunogenic bacterial capsular polysaccharides to a carrier protein to facilitate the induction of memory T-cell responses. Following the success of Haemophilus influenzae type b conjugate vaccines in the 1980s, conjugate vaccines for Streptococcus pneumoniae and Neisseria meningitidis infections were developed and proven to be effective in protecting children against invasive disease. In this review, the use of conjugate vaccines in human newborns is discussed. Neonatal Haemophilus influenzae type b and pneumococcal conjugate vaccination schedules have been trialed and proven to be safe, with the majority of studies demonstrating no evidence for the induction of immune tolerance. Whether their neonatal administration also results in an earlier induction of clinical protection in the first 2-3 critical months of life is still to be demonstrated.
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Affiliation(s)
- Anita H J van den Biggelaar
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, PO Box 855, West Perth, WA 6872, Australia.
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Deen J, von Seidlein L, Andersen F, Elle N, White NJ, Lubell Y. Community-acquired bacterial bloodstream infections in developing countries in south and southeast Asia: a systematic review. THE LANCET. INFECTIOUS DISEASES 2012; 12:480-7. [DOI: 10.1016/s1473-3099(12)70028-2] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Laman M, Manning L, Greenhill AR, Mare T, Michael A, Shem S, Vince J, Lagani W, Hwaiwhanje I, Siba PM, Mueller I, Davis TME. Predictors of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea. Am J Trop Med Hyg 2012; 86:240-5. [PMID: 22302856 DOI: 10.4269/ajtmh.2012.11-0312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Predictors of acute bacterial meningitis (ABM) were assessed in 554 children in Papua New Guinea 0.2-10 years of age who were hospitalized with culture-proven meningitis, probable meningitis, or non-meningitic illness investigated by lumbar puncture. Forty-seven (8.5%) had proven meningitis and 36 (6.5%) had probable meningitis. Neck stiffness, Kernig's and Brudzinski's signs and, in children < 18 months of age, a bulging fontanel had positive likelihood ratios (LRs) ≥ 4.3 for proven/probable ABM. Multiple seizures and deep coma were less predictive (LR = 1.5-2.1). Single seizures and malaria parasitemia had low LRs (≤ 0.5). In logistic regression including clinical variables, Kernig's sign and deep coma were positively associated with ABM, and a single seizure was negatively associated (P ≤ 0.01). In models including microscopy, neck stiffness and deep coma were positively associated with ABM and parasitemia was negatively associated with ABM (P ≤ 0.04). In young children, a bulging fontanel added to the model (P < 0.001). Simple clinical features predict ABM in children in Papua New Guinea but malaria microscopy augments diagnostic precision.
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Affiliation(s)
- Moses Laman
- Papua New Guinea Institute of Medical Research, Madang and Goroka, Papua New Guinea.
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Karthikeyan P, Ramalingam KP. Meningitis: is a major cause of disability amongst Papua New Guinea children? Disabil Rehabil 2012; 34:1585-8. [PMID: 22256779 DOI: 10.3109/09638288.2011.651190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE This article is intended to focus on the need for the use of rehabilitation services, for children with meningitis in Papua New Guinea, which is one of largest developing country in The Pacific with diverse culture and landscape. Meningitis is the fifth leading disease that results in disability in the country. The first line of treatment is usually antibiotics, administration of vaccination is also recommended. Currently community based rehabilitation workers and Physiotherapist offer the rehabilitation services. There is a need for the other rehabilitation professionals and appropriate education to the CBR workers, caregivers for providing effective Rehabilitation. METHOD Articles related to meningitis were recruited through various electronic database such as Ovid SP, MEDLINE, CINHAL, Google Scholar and HINARI and EBSCOhost for full text. The search includes journal articles, editorials, research reports, systematic reviews and books. RESULTS The neurological sequelae resulting from meningitis are increasing. There is a need for Hib vaccination to reduce the rate of mortality. Physiotherapists are new professionals that emerged since 2006 and are assisting in reducing the motor and neurological disability. CONCLUSIONS A multidisciplinary approach is required to manage the child with meningitis. Adequate knowledge, resources and assistance about the condition among the health professionals, carers and teachers would enable the children to achieve the quality of life.
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Affiliation(s)
- Priya Karthikeyan
- Department of Physiotherapy, Divine Word University, Madang, Papua New Guinea.
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Vekemans J, Marsh K, Greenwood B, Leach A, Kabore W, Soulanoudjingar S, Asante KP, Ansong D, Evans J, Sacarlal J, Bejon P, Kamthunzi P, Salim N, Njuguna P, Hamel MJ, Otieno W, Gesase S, Schellenberg D. Assessment of severe malaria in a multicenter, phase III, RTS, S/AS01 malaria candidate vaccine trial: case definition, standardization of data collection and patient care. Malar J 2011; 10:221. [PMID: 21816031 PMCID: PMC3221632 DOI: 10.1186/1475-2875-10-221] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 08/04/2011] [Indexed: 11/10/2022] Open
Abstract
Background An effective malaria vaccine, deployed in conjunction with other malaria interventions, is likely to substantially reduce the malaria burden. Efficacy against severe malaria will be a key driver for decisions on implementation. An initial study of an RTS, S vaccine candidate showed promising efficacy against severe malaria in children in Mozambique. Further evidence of its protective efficacy will be gained in a pivotal, multi-centre, phase III study. This paper describes the case definitions of severe malaria used in this study and the programme for standardized assessment of severe malaria according to the case definition. Methods Case definitions of severe malaria were developed from a literature review and a consensus meeting of expert consultants and the RTS, S Clinical Trial Partnership Committee, in collaboration with the World Health Organization and the Malaria Clinical Trials Alliance. The same groups, with input from an Independent Data Monitoring Committee, developed and implemented a programme for standardized data collection. The case definitions developed reflect the typical presentations of severe malaria in African hospitals. Markers of disease severity were chosen on the basis of their association with poor outcome, occurrence in a significant proportion of cases and on an ability to standardize their measurement across research centres. For the primary case definition, one or more clinical and/or laboratory markers of disease severity have to be present, four major co-morbidities (pneumonia, meningitis, bacteraemia or gastroenteritis with severe dehydration) are excluded, and a Plasmodium falciparum parasite density threshold is introduced, in order to maximize the specificity of the case definition. Secondary case definitions allow inclusion of co-morbidities and/or allow for the presence of parasitaemia at any density. The programmatic implementation of standardized case assessment included a clinical algorithm for evaluating seriously sick children, improvements to care delivery and a robust training and evaluation programme for clinicians. Conclusions The case definition developed for the pivotal phase III RTS, S vaccine study is consistent with WHO recommendations, is locally applicable and appropriately balances sensitivity and specificity in the diagnosis of severe malaria. Processes set up to standardize severe malaria data collection will allow robust assessment of the efficacy of the RTS, S vaccine against severe malaria, strengthen local capacity and benefit patient care for subjects in the trial. Trial registration Clinicaltrials.gov NCT00866619
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Increasing chloramphenicol resistance in Streptococcus pneumoniae isolates from Papua New Guinean children with acute bacterial meningitis. Antimicrob Agents Chemother 2011; 55:4454-6. [PMID: 21709079 DOI: 10.1128/aac.00526-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In Papua New Guinean (PNG) children with acute bacterial meningitis (ABM), all Haemophilus influenzae isolates were resistant to chloramphenicol. Although Streptococcus pneumoniae isolates had a median chloramphenicol MIC of 3 μg/ml, it was ≥4 μg/ml in 42.8%, and the likelihood of an area under the 24-hour concentration-time curve/MIC ratio of >100 h at a MIC of ≥4 μg/ml was approximately 50%. All isolates were ceftriaxone sensitive. These data support ceftriaxone rather than conventional chloramphenicol for all PNG children with suspected ABM.
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Molyneux E, Nizami SQ, Saha S, Huu KT, Azam M, Bhutta ZA, Zaki R, Weber MW, Qazi SA. 5 versus 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Lancet 2011; 377:1837-45. [PMID: 21620467 DOI: 10.1016/s0140-6736(11)60580-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bacterial meningitis is an important cause of morbidity and mortality in developing countries, but the duration of treatment is not well established. We aimed to compare the efficacy of 5 and 10 days of parenteral ceftriaxone for the treatment of bacterial meningitis in children. METHODS We did a multicountry, double-blind, placebo-controlled, randomised equivalence study of 5 versus 10 days of treatment with ceftriaxone in children aged 2 months to 12 years with purulent meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae type B, or Neisseria meningitidis. Our study was done in ten paediatric referral hospitals in Bangladesh, Egypt, Malawi, Pakistan, and Vietnam. We randomly assigned children who were stable after 5 days of treatment, through site-balanced computer-generated allocation lists, to receive a further 5 days of ceftriaxone or placebo. Patients, their guardians, and staff were masked to study-group allocation. Our primary outcomes were bacteriological failure or relapse. Our analysis was per protocol. This study is registered with the International Standard Randomised Controlled Trial Number Register, number ISRCTN38717320. FINDINGS We included 1004 of 1027 children randomly assigned to study groups in our analyses; 496 received treatment with ceftriaxone for 5 days, and 508 for 10 days. In the 5-day treatment group, two children (one infected with HIV) had a relapse; there were no relapses in the 10-day treatment group and there were no bacteriological failures in either study group. Side-effects of antibiotic treatment were minor and similar in both groups. INTERPRETATION In children beyond the neonatal age-group with purulent meningitis caused by S pneumoniae, H influenzae type b, or N meningitidis who are stable by day 5 of ceftriaxone treatment, the antibiotic can be safely discontinued. FUNDING United States Agency for International Development.
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Affiliation(s)
- Elizabeth Molyneux
- University of Malawi Medical School Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics 2010; 126:952-60. [PMID: 20974781 DOI: 10.1542/peds.2010-0277] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
CONTEXT Clinical diagnosis of pediatric meningitis is fundamental; therefore, familiarity with evidence underscoring clinical features suggestive of meningitis is important. OBJECTIVE To seek evidence supporting accuracy of clinical features of pediatric bacterial meningitis. METHODS A review of Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed was conducted for all articles of relevance. Articles contained prospective data of clinical features in children with laboratory-confirmed bacterial meningitis and in comparison groups of those without it. Two authors independently assessed quality and extracted data to calculate accuracy data of clinical features. RESULTS Of 14 145 references initially identified, 10 met our inclusion criteria. On history, a report of bulging fontanel (likelihood ratio [LR]: 8.00 [95% confidence interval (CI): 2.4-26]), neck stiffness (7.70 [3.2-19]), seizures (outside febrile-convulsion age range) (4.40 [3.0-6.4]), or reduced feeds (2.00 [1.2-3.4]) raised concern about the presence of meningitis. On examination, jaundice (LR: 5.90 [95% CI: 1.8-19]), being toxic or moribund (5.80 [3.0-11]), meningeal signs (4.50 [2.4-8.3]), neck stiffness (4.00 [2.6-6.3]), bulging fontanel (3.50 [2.0-6.0]), Kernig sign (3.50 [2.1-5.7]), tone up (3.20 [2.2-4.5]), fever of >40°C (2.90 [1.6-5.5]), and Brudzinski sign (2.50 [1.8-3.6]) independently raised the likelihood of meningitis. The absence of meningeal signs (LR: 0.41 [95% CI: 0.30-0.57]) and an abnormal cry (0.30 [0.16-0.57]) independently lowered the likelihood of meningitis. The absence of fever did not rule out meningitis (LR: 0.70 [95% CI: 0.53-0.92]). CONCLUSIONS Evidence for several useful clinical features that influence the likelihood of pediatric meningitis exists. No isolated clinical feature is diagnostic, and the most accurate diagnostic combination is unclear.
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Affiliation(s)
- Sarah Curtis
- Division of Pediatric Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
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van den Biggelaar AHJ, Richmond PC, Pomat WS, Phuanukoonnon S, Nadal-Sims MA, Devitt CJ, Siba PM, Lehmann D, Holt PG. Neonatal pneumococcal conjugate vaccine immunization primes T cells for preferential Th2 cytokine expression: a randomized controlled trial in Papua New Guinea. Vaccine 2009; 27:1340-7. [PMID: 19150378 PMCID: PMC2697326 DOI: 10.1016/j.vaccine.2008.12.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 12/18/2008] [Accepted: 12/23/2008] [Indexed: 11/30/2022]
Abstract
The effects of neonatal immunization with 7-valent pneumococcal conjugate vaccine (7vPCV) on development of T-cell memory and general immune maturation were studied in a cohort of Papua New Guinean newborns. Neonatal 7vPCV priming (followed by a dose at 1 and 2 months of age) was associated with enhanced Th2, but not Th1, cytokine responses to CRM197 compared to 7vPCV at 1 and 2 months of age only. T cell responses to non-7vPCV vaccine antigens were similar in all groups, but TLR-mediated IL-6 and IL-10 responses were enhanced in 7vPCV vaccinated compared to controls. Neonatal 7vPCV vaccination primes T cell responses with a polarization towards Th2 with no bystander effects on other T cell responses.
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Affiliation(s)
- Anita H J van den Biggelaar
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, PO Box 855, West Perth, WA 6872, Australia.
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Scarborough M, Thwaites GE. The diagnosis and management of acute bacterial meningitis in resource-poor settings. Lancet Neurol 2008; 7:637-48. [PMID: 18565457 DOI: 10.1016/s1474-4422(08)70139-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute bacterial meningitis is more common in resource-poor than resource-rich settings. Survival is dependent on rapid diagnosis and early treatment, both of which are difficult to achieve when laboratory support and antibiotics are scarce. Diagnostic algorithms that use basic clinic and laboratory features to distinguish bacterial meningitis from other diseases can be useful. Analysis of the CSF is essential, and simple techniques can enhance the yield of diagnostic microbiology. Penicillin-resistant and chloramphenicol-resistant bacteria are a considerable threat in resource-poor settings that go undetected if CSF and blood can not be cultured. Generic formulations of ceftriaxone are becoming more affordable and available, and are effective against meningitis caused by penicillin-resistant or chloramphenicol-resistant bacteria. However, infection with Streptococcus pneumoniae with reduced susceptibility to ceftriaxone is reported increasingly, and alternatives are either too expensive (eg, vancomycin) or can not be widely recommended (eg, rifampicin, which is the key drug to treat tuberculosis) in resource-poor settings. Additionally, improved access to affordable antibiotics will not overcome the problems of poor access to hospitals and the fatal consequences of delayed treatment. The future rests with the provision of effective conjugate vaccines against S pneumoniae, Haemophilus influenzae, and Neisseria meningitides to children in the poorest regions of the world.
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Affiliation(s)
- Matthew Scarborough
- Nuffield Department of Clinical Laboratory Science, John Radcliffe Hospital, Oxford, UK
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Abucejo-Ladesma E, Simoes EAF, Lupisan SP, Sombrero LT, Quiambao BP, Gozum LS, Herva E, Ruutu P. Serious community-acquired paediatric infections in rural Asia (Bohol Island, Philippines): bacterial meningitis in children less than 5 years of age. ACTA ACUST UNITED AC 2007; 39:983-9. [PMID: 17852943 DOI: 10.1080/00365540701466157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This paper describes the clinical profile and aetiology of bacterial meningitis in infants and children less than 5 y old admitted to a rural general hospital in the Philippines. A total of 989 infants and children 0-59 months old with suspected meningitis using a standardized guideline based on clinical signs and symptoms were prospectively enrolled from April 1994 to May 2000. Blood and CSF were drawn on admission for culture, antigen testing and cell count. All had blood cultures and 623 (63%) had CSF samples. Bacterial aetiology was found in 54 (5%). The most common bacterial pathogens were H. influenzae type b (Hib) (20, 37%) and S. pneumoniae (Pnc) (10, 18%). All of the Hib infections and 8 (80%) Pnc infections were in infants less than 1 y old. 12 (22%) of the subjects with bacterial meningitis died. All strains of S. pneumoniae and H. influenzae were sensitive to chloramphenicol, cotrimoxazole and ampicillin. In conclusion, S. pneumoniae and H. influenzae type b are the most common aetiological agents of bacterial meningitis in a rural area in the Philippines, and occur especially in infants less than 1 y old. Aetiological agents were susceptible to the currently recommended antimicrobial agents.
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Berkley JA, Versteeg AC, Mwangi I, Lowe BS, Newton CRJC. Indicators of acute bacterial meningitis in children at a rural Kenyan district hospital. Pediatrics 2004; 114:e713-9. [PMID: 15574603 DOI: 10.1542/peds.2004-0007] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Acute bacterial meningitis remains an important cause of death and neurologic sequelae in African children. The clinical features of meningitis are often nonspecific and in this setting may overlap with those of malaria. Early diagnosis and appropriate antibiotic treatment are perhaps the most important steps in management, but published data suggest that fewer than half of the cases of childhood meningitis are identified at first assessment in hospitals in this region. The objective of this study was to identify clinical indicators of acute bacterial meningitis by examining components of the World Health Organization Integrated Management of Childhood Illness (IMCI) referral criteria for meningitis (lethargy, unconsciousness, inability to feed, stiff neck, or seizures) and other symptoms and signs. METHODS Kilifi District Hospital, serving approximately 200,000 people in a rural, malaria-endemic area of the Kenyan coast, was studied. A Kenya Medical Research Institute research center is located at the hospital. All pediatric admissions aged > or =60 days between June 2001 and July 2002 were eligible. RESULTS A total of 91 (2.0%) of 4582 admissions had meningitis, including 77 (4.0%) of 1929 of those who met the IMCI referral criteria for meningitis at admission (sensitivity: 85%; specificity: 59%). Independent indicators of the presence of meningitis were a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range. One or more of these indicators was present in 895 (19%) of admissions, 72 (8.0%) of whom had meningitis (sensitivity: 79%; specificity: 80%). Independent indicators of the absence of meningitis were the absence of a history of fever, a history of diarrhea, and a positive malaria slide. The area under the receiver operating characteristic curve for a set of simple screening rules based on the positive indicators identified was 0.88 (95% confidence interval: 0.85-0.92). CONCLUSIONS The presence of > or =1 of a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range is a clear indication for lumbar puncture and/or presumptive treatment. However, careful observation and reassessment may be the only practical way to identify one fifth of meningitis cases in this setting.
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Affiliation(s)
- James A Berkley
- Centre for Geographic Medicine Research (Coast), Kilifi, Kenya.
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Fuller DG, Duke T, Shann F, Curtis N. Antibiotic treatment for bacterial meningitis in children in developing countries. ACTA ACUST UNITED AC 2004; 23:233-53. [PMID: 14738571 DOI: 10.1179/027249303225007752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Bacterial meningitis causes 125,000 deaths each year in infants and young children and 96% of these occur in less developed countries where up to 50% of children with this disease die and 25-50% of survivors have neurological sequelae. Although 3rd-generation cephalosporins are optimal empirical therapy for bacterial meningitis, they are unaffordable in many developing countries. The majority of children worldwide are currently treated with cheaper alternatives. This paper reviews the challenges facing clinicians treating bacterial meningitis in developing countries, highlighting the problem of changing patterns of antibiotic resistance. In particular, it details the evidence for the use of chloramphenicol and 3rd-generation cephalosporins.
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Affiliation(s)
- David G Fuller
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia.
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Weber MW. Management of meningitis in resource-poor settings. ANNALS OF TROPICAL PAEDIATRICS 2003; 23:255-7. [PMID: 14738572 DOI: 10.1179/027249303225007815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Martin W Weber
- Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland.
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Abstract
Bacterial meningitis is still a major cause of death and disability in children worldwide. With the advent of conjugate vaccines against the three major pathogens, the burden of disease is increasingly concentrated in developing countries that cannot afford the vaccines. Antibiotic resistance is an increasing problem; in developed countries, high-level resistance to beta-lactams among Streptococcus pneumoniae necessitates the addition of vancomycin to third-generation cephalosporins. In many developing countries, the problems are more fundamental. Increasing resistance of S. pneumoniae to penicillin and chloramphenicol and of Haemophilus influenzae to chloramphenicol means that many children with bacterial meningitis receive ineffective treatments, as third-generation cephalosporins are often unavailable or unaffordable. Case fatality rates are as high as 50% and neurological sequelae occur in one-third of survivors. The use of corticosteroids in meningitis is controversial; the evidence that they protect against neurological complications of childhood meningitis (particularly severe hearing loss) is strongest when: meningitis is caused by H. influenzae type b; dexamethasone is given before the first dose of antibiotics; a bactericidal antibiotic such as a third-generation cephalosporin is used; and in the early stages of the infection. There are few controlled clinical trials on which to base recommendations about other adjuvant therapy for meningitis. Avoidance of secondary brain injury from hypoxia, hypotension, hypo-osmolarity and cerebral oedema, hypoglycaemia or convulsions is essential for a good outcome. The problem of bacterial meningitis will only be solved if protein-conjugate vaccines (or other effective vaccine strategies) against S. pneumonia, H. influenzae and epidemic strains of Neisseria meningitidis are available to all the world's children. Making third-generation cephalosporins affordable in the developing world is also a necessary intervention, but better antibiotics will not overcome the problems of poor access to hospitals and late presentation with established brain injury, and will inevitably bring further pressure for antimicrobial resistance.
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Affiliation(s)
- Trevor Duke
- Centre for International Child Health, University Department of Paediatrics, Royal Children's Hospital, Flemington Road, Parkville, Victoria, 3052, Australia.
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Weber MW, Herman J, Jaffar S, Usen S, Oparaugo A, Omosigho C, Adegbola RA, Greenwood BM, Mulholland EK. Clinical predictors of bacterial meningitis in infants and young children in The Gambia. Trop Med Int Health 2002; 7:722-31. [PMID: 12225501 DOI: 10.1046/j.1365-3156.2002.00926.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Bacterial meningitis is an important cause of childhood morbidity and mortality world-wide. In the developing world, where the burden of acute meningitis and its long-term sequelae are especially high, staff with limited training at primary health care facilities must be able to recognize the symptoms and signs of meningitis, so that suspected cases can be referred urgently to hospitals. METHODS Children who presented with possible invasive bacterial infection to health facilities in The Gambia, West Africa, between 1993 and 1995 were investigated in a standardized manner and clinical findings were documented. Bacterial meningitis was defined as the growth of bacteria from the cerebrospinal fluid. Clinical findings were compared between cases of meningitis and other children. RESULTS Of 2097 children between 2 months and 3 years of age investigated, 51 had a confirmed diagnosis of bacterial meningitis. In multivariate analysis using a model adjusting for age but not including respiratory signs, the variables associated independently with meningitis were appearance of being very sick (odds ratio for meningitis vs. no meningitis or no lumbar puncture performed (OR) 4.1, 95% CI 1.5-11.1), being lethargic or unconscious (OR 5.2, 95% CI 2.1-13), a stiff neck (OR 29.3, 95% CI 12.2-70.3), a bulging fontanel (OR 3.2, 95% CI 1.2-8.5) and reduced feeding as a prompted complaint (OR 2.9, 95% CI 1.3-6.7). A combination model of a history of convulsions, or being lethargic or unconscious, or having a stiff neck, as used in the WHO-Integrated Management of Childhood Illness (IMCI) guidelines, had a sensitivity of 98% and a specificity of 72% to predict meningitis. CONCLUSIONS A combination of a limited number of signs is sufficient to predict meningitis with high sensitivity, without a large number of children who do not have meningitis being unnecessarily referred.
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Affiliation(s)
- Martin W Weber
- Medical Research Council Laboratories, Fajara, The Gambia.
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Duke T, Mokela D, Frank D, Michael A, Paulo T, Mgone J, Kurubi J. Management of meningitis in children with oral fluid restriction or intravenous fluid at maintenance volumes: a randomised trial. ANNALS OF TROPICAL PAEDIATRICS 2002; 22:145-57. [PMID: 12070950 DOI: 10.1179/027249302125000878] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A multi-centre randomised open trial was done to determine whether moderate oral fluid restriction or intravenous fluid at full maintenance volumes would result in a better outcome for children with bacterial meningitis in Papua New Guinea, and what clinical signs could guide fluid management. Children with clinical signs and cerebrospinal fluid suggestive of bacterial meningitis received either breast milk by nasogastric tube at 60% of normal maintenance volumes (n = 172) or intravenous half-normal saline and 5% dextrose at 100% of normal maintenance volumes (n = 174) for the 1st 48 hrs of treatment. An adverse outcome was death or severe neurological sequelae, and a good outcome was defined as intact survival or survival with at worst mild-to-moderate neurological sequelae. The probability of an adverse outcome was 24.7% in the intravenous group and 33.1% in the oral-restricted group, but the difference was not statistically significant (RR 0.75, 0.53-1.04, p = 0.08). Sunken eyes or reduced skin turgor at presentation were risk factors for an adverse outcome (OR 5.70, 95% CI 2.87-11.29) and were most strongly associated with adverse outcome in the fluid-restricted group. Eyelid oedema during treatment was also a risk factor for an adverse outcome (OR 2.54, 95% CI 1.36-4.75) and eyelid oedema was much more common in the intravenous group (26%) than in the restricted group (5%). For many children with bacterial meningitis in less developed countries, moderate fluid restriction is unnecessary and will be harmful; a normal state of hydration should be achieved but over-hydration should be avoided. Giving 100% of normal maintenance fluids, especially with intravenous hypotonic fluid, will lead to oedema in up to one quarter of children with bacterial meningitis. If additional intravenous fluids are required for children with meningitis, an isotonic solution should be used.
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Duke T, Poka H, Dale F, Michael A, Mgone J, Wal T. Chloramphenicol versus benzylpenicillin and gentamicin for the treatment of severe pneumonia in children in Papua New Guinea: a randomised trial. Lancet 2002; 359:474-80. [PMID: 11853793 DOI: 10.1016/s0140-6736(02)07677-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pneumonia is the most frequent cause of child mortality in less-developed countries. We aimed to establish whether the combination of benzylpenicillin and gentamicin or chloramphenicol would be better as first-line treatment in children with severe pneumonia in Papua New Guinea. METHODS We did an open randomised trial in which we enrolled children aged 1 month to 5 years of age who fulfilled the WHO criteria for very severe pneumonia and who presented to hospitals in two provinces. Children were randomly assigned to receive chloramphenicol (25 mg/kg 6 hourly) or benzylpenicillin (50 mg/kg 6 hourly) plus gentamicin (7.5 mg/kg daily) by intramuscular injection. The primary outcome measure was a good or an adverse outcome. FINDINGS 1116 children were enrolled; 559 children were treated with chloramphenicol and 557 with benzylpenicillin and gentamicin. At presentation the median haemoglobin oxygen saturation was 71% (IQR 57-77) for those allocated chloramphenicol and 69% (55-77) for those allocated penicillin and gentamicin. 147 (26%) children treated with chloramphenicol and 123 (22%) treated with penicillin and gentamicin had adverse outcomes (p=0.11). 36 children treated with chloramphenicol and 29 treated with penicillin and gentamicin died. More children treated with chloramphenicol than penicillin and gentamicin represented with severe pneumonia within 1 month of hospital discharge (p=0.03). INTERPRETATION For children with severe pneumonia in less-developed countries the probability of a good outcome is similar if treated with chloramphenicol or with the combination of benzylpenicillin and gentamicin.
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Affiliation(s)
- Trevor Duke
- Department of Paediatrics, Goroka Base Hospital, PO Box 392, Goroka, Papua New Guinea.
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