No change in antibiotic susceptibility patterns in the neonatal ICU over two decades

Global Case Fatality of Bacterial Meningitis During an 80-Year Period: A Systematic Review and Meta-Analysis

Importance

The impact of vaccination, antibiotics, and anti-inflammatory treatment on pathogen distribution and outcome of bacterial meningitis over the past century is uncertain.

Objective

To describe worldwide pathogen distribution and case fatality ratios of community-acquired bacterial meningitis.

Data Sources

Google Scholar and MEDLINE were searched in January 2022 using the search terms bacterial meningitis and mortality.

Study Selection

Included studies reported at least 10 patients with bacterial meningitis and survival status. Studies that selected participants by a specific risk factor, had a mean observation period before 1940, or had more than 10% of patients with health care-associated meningitis, tuberculous meningitis, or missing outcome were excluded.

Data Extraction and Synthesis

Data were extracted by 1 author and verified by a second author. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Random-effects models stratified by age (ie, neonates, children, adults), Human Development Index (ie, low-income or high-income countries), and decade and meta-regression using the study period's year as an estimator variable were used.

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

This review included 371 studies performed in 108 countries from January 1, 1935, to December 31, 2019, describing 157 656 episodes. Of the 33 295 episodes for which the patients' sex was reported, 13 452 (40%) occurred in females. Causative pathogens were reported in 104 598 episodes with Neisseria meningitidis in 26 344 (25%) episodes, Streptococcus pneumoniae in 26 035 (25%) episodes, Haemophilus influenzae in 22 722 (22%), other bacteria in 19 161 (18%) episodes, and unidentified pathogen in 10 336 (10%) episodes. The overall case fatality ratio was 18% (95% CI, 16%-19%), decreasing from 32% (95% CI, 24%-40%) before 1961 to 15% (95% CI, 12%-19%) after 2010. It was highest in meningitis caused by Listeria monocytogenes at 27% (95% CI, 24%-31%) and pneumococci at 24% (95% CI, 22%-26%), compared with meningitis caused by meningococci at 9% (95% CI, 8%-10%) or H influenzae at 11% (95% CI, 10%-13%). Meta-regression showed decreasing case fatality ratios overall and stratified by S pneumoniae, Escherichia coli, or Streptococcus agalactiae (P < .001).

Conclusions and Relevance

In this meta-analysis with meta-regression, declining case fatality ratios of community-acquired bacterial meningitis throughout the last century were observed, but a high burden of disease remained.

The Validity of Positive Coagulase-Negative Staphylococcus Cultures for the Diagnosis of Sepsis in the Neonatal Unit

OBJECTIVE

Coagulase-negative Staphylococcus (CoNS) is the most frequent pathogen causing late-onset sepsis (LOS) in neonatal intensive care units (NICUs). Technical difficulties hinder blood culture (BC) collection and obtaining only one culture before initiating antibiotic therapy is a common practice. We sought to assess specific clinical information and CoNS cultures for the diagnosis of true bacteremia in the NICU.

STUDY DESIGN

This historical cohort study was conducted in NICUs at the Hadassah-Hebrew University Medical Center of Jerusalem in Israel. Clinical and laboratory data in every CoNS bacteremia were collected and compared between bacteremia groups as follows: true positive, two positive BCs; contaminant, one positive BC out of two; undefined, one BC obtained and found positive.

RESULTS

For 3.5 years, CoNS was isolated in 139 episodes. True positive was identified in 44 of 139 (31.7%), contaminant in 42 of 139 (30.2%), and the event was undefined in 53 of 139 (38.1%). Vancomycin treatment was more frequent in the true positive and undefined groups than the contaminant group (100, 90.6, and 73.8% respectively, p = 0.001); treatment was also prolonged in these two groups (p < 0.001). No clinical variables were associated with true bacteremia on multivariable analysis.

CONCLUSION

Diagnosis should definitely be based on at least two positive BCs, despite objective difficulties in obtaining BCs in neonates.

KEY POINTS

· CoNS is a frequent pathogen causing LOS in neonates.. · Due to technical difficulties, often only one culture is collected prior to antibiotic therapy.. · No clinical/laboratory variables were associated with the diagnosis of true CoNS bacteremia..

Incidence and aetiology of infant Gram-negative bacteraemia and meningitis: systematic review and meta-analysis

BACKGROUND

One in six infant deaths worldwide are caused by invasive bacterial infections, of which a substantial but unquantified proportion are caused by Gram-negative bacteria.

METHODS

We conducted a systematic review of studies published from 31 May 2010 to 1 June 2020 indexed in MEDLINE, Embase and Global Health databases. We performed meta-analyses of the incidence of Gram-negative bacteraemia and of individual Gram-negative species as proportions of all infant bacteraemia, stratified by onset (early vs late) and country income (low/middle vs high).

RESULTS

152 studies from 54 countries were included, 60 in high-income countries (HIC) and 92 in low-income/middle-income countries (LMIC). Gram-negatives represented a higher proportion (53%, 95% CI 49% to 57%) of all infant bacteraemia in LMIC compared with HIC (28%, 95% CI 25% to 32%). Incidence of infant Gram-negative bacteraemia was 2.01 (95% CI 1.15 to 3.51) per 1000 live births; it was five times higher in LMIC (4.35, 95% CI 2.94 to 6.43) compared with HIC (0.73, 95% CI 0.39 to 7.5). In HIC, Escherichia coli was the leading Gram-negative pathogen, representing 19.2% (95% CI 15.6% to 23.4%) of early and 7.3% (95% CI 5.3% to 10.1%) of all late-onset bacteraemia; Klebsiella spp were the next most common cause (5.3%) of late-onset bacteraemia. In LMIC, Klebsiella spp caused 16.4% (95% CI 11.5% to 22.7%) of early and 15.0% (95% CI 10.1% to 21.8%) of late-onset bacteraemia, followed by E. coli (early-onset 7.50%, 95% CI 4.98% to 11.1%; late-onset 6.53%, 95% CI 4.50% to 9.39%) and Pseudomonas spp (early-onset 3.93%, 95% CI 2.04% to 7.44%; late-onset 2.81%, 95% CI 1.99% to 3.95%).

CONCLUSION

E. coli, Klebsiella and Pseudomonas spp cause 20%-28% of early-onset infant bacteraemia and 14% cases of infant meningitis worldwide. Implementation of preventive measures could reduce the high incidence of Gram-negative bacteraemia in LMIC.

PROSPERO REGISTRATION NUMBER

CRD42020191618.

Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis

Objective

Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors.

Methods

We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs.

Results

The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time.

Conclusion

Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions.

Systematic Review Registration

[www.crd.york.ac.uk/prospero], identifier [CRD42020164321].

Temporal trend in early sepsis in a very low birth weight infants' cohort: an opportunity for a rational antimicrobial use

OBJECTIVE

This study aimed to evaluate annual trends of early neonatal sepsis and antimicrobial use in very low birth weight infants for 12 years, as well as to identify microbiological agents, antimicrobial sensitivity profiles, and association with early neonatal death.

METHOD

This was a retrospective cohort study including 1254 very low birth weight infants admitted from 2006 to 2017. Four groups were evaluated: culture-confirmed sepsis; presumed neonatal sepsis; ruled out neonatal sepsis group; and infants not exposed to antibiotics.

RESULTS

The medians of gestational age and birth weight were 29 weeks (27-31) and 1090g (850-1310), respectively. The rates of culture-confirmed sepsis, presumed neonatal sepsis, ruled out neonatal sepsis, and not exposed to antibiotics were 1.3, 9.0, 15.4, and 74.3%, respectively. From the initial group of newborns whose antimicrobial treatment was administered for sepsis' suspicion, it was possible to discontinue antibiotic in 44%. The culture-confirmed sepsis rates remained stable (p=0.906). Significant tendencies of decreasing presumed sepsis rates (p<0.001) and increased ruled out neonatal sepsis/not exposed to antibiotics rates (p<0.001) were observed. Streptococcus agalactiae and enteric Gram-negative rods were the predominant agents and most of them were sensitive to crystalline penicillin/ampicillin (88.2%) and to ampicillin and/or amikacin. Early death occurred in 10.8%, specifically in the culture-confirmed sepsis and presumed neonatal sepsis groups.

CONCLUSION

The confirmed sepsis rate was low and remained stable. There was a significant downward trend in the presumed neonatal sepsis rate and a significant upward trend in the ruled out neonatal sepsis group. The rate of not exposed to antibiotics infants was high, also presenting a significant downward trend. The identified bacteria were those commonly found and showed usual antimicrobial susceptibility patterns. Death predominantly occurred in groups that received antibiotic treatment.

Neonatal early onset sepsis in Middle Eastern countries: a systematic review

BACKGROUND

Early onset neonatal sepsis (EOS) accounts for a significant portion of neonatal mortality, which accounts for 46% of global under five child mortality.

OBJECTIVE

This systematic review studies the bacterial aetiology of EOS in the Middle East, susceptibility patterns to recommended empirical antibiotic therapy and whether this differs between high-income and middle-income countries in the region.

METHODS

Articles were collected from Medline, Web of Science, the Cochrane Library and Index Medicus for the Eastern Mediterranean Region. The articles included in our systematic review met the following criteria: published after January 2000, data relevant to the Middle East, data specific for early onset sepsis, no language restriction. Data on aetiology and susceptibility were extracted from prospective and retrospective studies. Risk of bias was assessed using the Newcastle-Ottawa Scale. This study focused on EOS but does include data regarding neonatal late-onset sepsis antibiotic susceptibility. The data regarding coagulase-negative Staphylococcus species were excluded from final analysis, as possible contaminants. The protocol for this systematic review was registered on PROSPERO: CRD42017060662.

RESULTS

33 articles from 10 countries were included in the analysis. There were 2215 cases of culture-positive EOS, excluding coagulase-negative Staphylococcus. In middle-income countries, Klebsiella species (26%), Staphylococcus aureus (17%) and Escherichia coli (16%) were the most common pathogens, in contrast to group B Streptococcus (26%), E. coli (24%) and Klebsiella (9%) in high-income countries. Overall susceptibility to ampicillin/gentamicin and third-generation cephalosporin were 40% and 37%, respectively, in middle-income countries versus 93% and 91%, respectively, in high-income countries.

CONCLUSIONS

EOS in middle-income countries was more likely to be due to Gram-negative pathogens and less likely to be susceptible to empirical antibiotic therapy. This has important public health implications regarding neonatal mortality in the Middle East region.

Global etiology of bacterial meningitis: A systematic review and meta-analysis

Bacterial meningitis is a global public health concern, with several responsible etiologic agents that vary by age group and geographical area. The aim of this systematic review and meta-analysis was to assess the etiology of bacterial meningitis in different age groups across global regions. PubMed and EMBASE were systematically searched for English language studies on bacterial meningitis, limited to articles published in the last five years. The methodological quality of the studies was assessed using a customized scoring system. Meta-analyses were conducted to determine the frequency (percentages) of seven bacterial types known to cause meningitis: Escherichia coli, Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae, group B Streptococcus agalactiae, Staphylococcus aureus, and Listeria monocytogenes, with results being stratified by six geographical regions as determined by the World Health Organization, and seven age groups. Of the 3227 studies retrieved, 56 were eligible for the final analysis. In all age groups, S. pneumoniae and N. meningitidis were the predominant pathogens in all regions, accounting for 25.1-41.2% and 9.1-36.2% of bacterial meningitis cases, respectively. S. pneumoniae infection was the most common cause of bacterial meningitis in the 'all children' group, ranging from 22.5% (Europe) to 41.1% (Africa), and in all adults ranging from 9.6% (Western Pacific) to 75.2% (Africa). E. coli and S. pneumoniae were the most common pathogens that caused bacterial meningitis in neonates in Africa (17.7% and 20.4%, respectively). N. meningitidis was the most common in children aged ±1-5 years in Europe (47.0%). Due to paucity of data, meta-analyses could not be performed in all age groups for all regions. A clear difference in the weighted frequency of bacterial meningitis cases caused by the different etiological agents was observed between age groups and between geographic regions. These findings may facilitate bacterial meningitis prevention and treatment strategies.

Platelet Mass Predicts Intracranial Hemorrhage in Neonates With Gram-negative Sepsis

Neonatal sepsis due to gram-negative bacteria is associated with severe hemorrhagic conditions, such as intracranial hemorrhage (ICH). The aim of the study was to investigate the significance of platelet (PLT) count and platelet mass (PM) in predicting promptly neonatal ICH. Demographics, species, PLT, PM, ICH, and outcome for neonates with gram-negative sepsis for the period 2005 to 2012 were retrospectively recorded. Eighty-four infants were enrolled with median gestational age 30 weeks, median birthweight 1481.5 g, and median age at sepsis diagnosis 23 days. The most frequently isolated bacteria were Enterobacter spp. (38.1%). ICH occurred in 16 neonates (19%), whereas the mortality rate was 25% (21 neonates). The median PLT count and PM at days 1, 2, and 3 after diagnosis of gram-negative sepsis was significantly associated with the presence of ICH. Regression analysis revealed the cutoff predictive value of 355 fL/nL for the PM at day 3 (area under the curve: 75, sensitivity 90%, P=0.002). PM levels could play an important role in predicting the occurrence of ICH in high-risk neonates.