Adults with spontaneous aerobic Gram-negative bacillary meningitis admitted to the intensive care unit

Clinical Characteristics, Treatment, and Outcomes of Veterans with Cerebrospinal Fluid Culture Positive for Gram-Negative Rod Bacteria: A Retrospective Analysis over 18 Years in 125 Veterans Health Administration Hospitals

Optimal management for patients with bacterial ventriculitis/meningitis due to Gram-negative rods (GNRs) has yet to be well investigated. We assessed the clinical characteristics, treatment, and outcomes of patients with a positive cerebrospinal fluid (CSF) culture for GNRs. We conducted a retrospective cohort study of all patients with a positive CSF culture within the Veterans Health Administration (VHA) system during 2003-2020. Clinical and microbiological characteristics between the true meningitis and contamination groups were compared. Of the 5919 patients with positive CSF cultures among 125 nationwide VHA acute-care hospitals, 297 (5.0%) were positive for GNRs. Among 262 patients analyzed, 156 (59.5%) were assessed as patients with true meningitis, and 106 (40.5%) were assessed as patients with contaminated CSF cultures. Patients with true meningitis had a significantly higher CSF protein (median 168 vs 57 mg/dL, p < 0.001), CSF white blood cell count (median 525 vs 3/µL, p = 0.008) and percentage of neutrophils in CSF (median 88 vs 4%, p < 0.001). Enterobacterales were more common in the true meningitis group, while unidentified GNR or polymicrobial CSF cultures were more common in the contamination group. The all-cause 90-day mortality was 25.0% (39/156) in patients with true meningitis and 10.4% (11/106) in those with contaminated CSF cultures. None of the 11 patients with contaminated CSF cultures who died were considered due to missed meningitis. More than 40% of patients with a positive CSF culture with GNR did not receive treatment without negative consequences. Careful clinical judgment is required to decide whether to treat such patients.

Spontaneous nosocomial Proteus mirabilis meningitis in a Human Immunodeficiency Virus (HIV)-infected adult patient: a case report

BACKGROUND

Gram-negative bacillary meningitis remains a rare occurrence, even in patients with human immunodeficiency virus. Current literature only describes anecdotal cases of spontaneous nosocomial Proteus mirabilis meningitis. This report describes the clinical manifestations and management of a patient with healthcare-associated spontaneous Gram-negative bacillary meningitis in a patient with advanced human immunodeficiency virus disease.

CASE PRESENTATION

A 23-year-old Congolese female was hospitalized in a human immunodeficiency virus specialized center for ongoing weight loss, chronic abdominal pain, and vomiting 9 months after initiation of treatment for tuberculosis meningitis. Hospitalization was complicated by healthcare-associated Gram-negative bacillary meningitis on day 18. Blood and cerebrospinal fluid cultures confirmed Proteus mirabilis. Antibiotic susceptibility testing showed extended spectrum beta-lactamase resistant to common antibiotics, and sensitive to meropenem. Despite initiation of high-dose meropenem by intravenous infusion (2 g every 8 hours), the patient did not improve, and died after 4 days of meropenem treatment. Gram-negative bacillary meningitis remains rare and is associated with an unfavorable prognosis.

CONCLUSIONS

This case report highlights the importance of microbiological identification of pathogens in resource-limited settings. As Gram-negative bacillary meningitis does not present with pleocytosis in patients with advanced human immunodeficiency virus, a negative lumbar puncture cannot exclude this diagnosis. Access to clinical bacteriology in resource-limited settings is essential to enable correct antibiotic treatment and avoid overuse of antibiotics to which there is already resistance. It further plays an essential role in public health by identifying antibiotic susceptibilities. Infection prevention and control measures must be reinforced in order to protect patients from such avoidable healthcare-associated infections.

The clinical characteristics of spontaneous Gram-negative bacterial meningitis in adults: A hospital-based study

The epidemiologic trend of acute bacterial meningitis can change more dramatically than any other bacterial disease, and a decrease in spontaneous adult bacterial meningitis (ABM) has been noted in serial studies of the epidemiologic trend of ABM in Taiwan. The purpose of this study was to analyze the clinical characteristics, laboratory data and therapeutic outcomes of 149 patients with spontaneous Gram-negative (G(-)) ABM collected during a study period of 31 years (1986-2016). The 149 patients included 107 men and 42 women, aged 18-86 years. The common underlying conditions were diabetes mellitus, liver cirrhosis and alcoholism, and the leading clinical presentations were fever, altered consciousness and septic shock. Compared the clinical characteristics of the patients identified in the study period of 2001-2106 to the patients identified in the study period of 1986-2000, the former group of patients had a significantly higher incidence of systemic malignance. In the recent 16 years (2001-2016), Klebsiella pneumoniae, Pseudomonas spp. and Escherichia coli were the leading three implicated bacterial pathogens of spontaneous G(-) ABM, accounting for 61.3% (38/62), 11.3% (7/62) and 11.3% (7/62%) of all cases, respectively. The overall mortality rate from spontaneous G(-) ABM was high (47.0%, 70/149) and the presence of septic shock and lower cerebrospinal fluid glucose level were significant prognostic factors. Because of the decreasing incidence of spontaneous ABM in Taiwan, close examination of this specific infectious syndrome is important in order to monitor the epidemiologic trend and improve the therapeutic strategy.

Occult community acquired Klebsiella pneumoniae purulent meningitis in an adult: A case report

RATIONALE

Klebsiella pneumonia (K. pneumonia), primarily a hospital-acquired pathogen, can cause a variety of deep-seated infections with significant morbidities. However, in the current scenario of global rise in antibiotic abuse, unexpected infection could be caused by K. pneumoniae.

PATIENT CONCERNS

A 56-year-old male who presented with intermittent headache and low fever was admitted, he had transsphenoidal surgery for pituitary adenoma 3 years ago. Routine laboratory tests revealed an elevated WBC count of 10.12 × 10/L and C-reactive protein (CRP) 12.9 mg/L. computed tomography (CT) revealed the sellar region with suspicious hemorrhage.

DIAGNOSES

The patient was initially diagnosed with acute residual tumor hemorrhage. But the consequent diagnose of Klebsiella pneumoniae purulent meningitis was made based on the cerebrospinal fluid lab test and cerebrospinal fluid (CSF) and blood culture, and CT scan.

INTERVENTIONS

Lumbar puncture examination was made and the antibiotics were adjusted to meropenem and vancomycin according to the antibiotic sensitivity test. But because of the patient's unstable vital signs, his family refuse further lateral ventricular drainage.

OUTCOMES

The infection was out of control and the patient died of spontaneous breath and heartbeat arrest.

LESSONS

Through this case, we could learn that any clue of suspicious intracranial infection should be carefully considered in the current scenario of global rise in antibiotic abuse. The manifestation of intermittent headache and mild fever could be potential signs of fatal infection, and prompt appropriate measures should be taken timely.

Escherichia coli spontaneous community-acquired meningitis in adults: A case report and literature review

Gram-negative bacillary meningitis occurring post-trauma and following neurosurgical procedures has been described widely. However, reports of spontaneous cases are sparse, particularly community-acquired cases. Spontaneous community-acquired Escherichia coli meningitis is a rare (although increasingly seen) and specific entity that is poorly reported in the literature. A review of the literature identified only 43 cases of community-acquired E. coli meningitis reported between 1946 and 2016. This article describes two new cases of spontaneous community-acquired E. coli meningitis encountered in Marseille, France, and presents the results of a literature review on spontaneous community-acquired E. coli meningitis.

Gram-negative bacillary meningitis in Egypt

BACKGROUND

Gram-negative bacillary meningitis (GNBM) is a rare disease with a high rate of mortality.

OBJECTIVES

The aim of this study was to describe the clinical presentation and outcome of primary and secondary GNBM and to evaluate the efficacy of ceftriaxone (a third-generation cephalosporin) in the treatment of this disease.

MATERIALS AND METHODS

A retrospective study was conducted including 95 patients with GNBM admitted to the Abbassia and Imbaba fever hospitals' meningitis wards in Egypt during the period from 1993 to the end of the year 2009. Their cerebrospinal fluid samples were subjected to conventional bacteriological methods for isolation of the causative Gram-negative bacilli. Forty-nine patients had primary GNBM (no predisposing cause of meningitis was detected) and 46 patients had secondary GNBM (with a predisposing cause of meningitis).

RESULTS

Primary GNBM was characterized by an abrupt onset and was significantly associated with typical signs of meningeal irritation. The most common infecting organisms were Salmonella typhi in 16 (33%) patients and Escherichia coli in 15 (31%) patients. Of the patients with primary GNBM, 26 (53%) were cured, 11 (22%) developed neurological sequalae, and 12 (24%) patients died. Secondary GNBM was characterized by an insidious onset and significantly associated with unarousable coma. The most common infecting organisms were Proteus mirabilis in 17 (37%) patients and Pseudomonas aeruginosa in 16 (35%) patients. The most common predisposing factor of meningitis was otitis media and occurred in 26 (57%) patients. Of the patients with secondary GNBM, 15 (33%) were cured, 15 (33%) developed neurological sequalae, and 16 (35%) died. Primary GNBM was significantly associated with a higher cure rate than secondary GNBM. The duration of symptoms in patients with secondary GNBM was significantly higher than in those with primary GNBM. Ceftriaxone was the initial drug for treatment of these patients until the antibiotic sensitivity tests were reported. The overall resistance rate to the drug was 4%.

CONCLUSION AND RECOMMENDATIONS

GNBM still has a high mortality rate and should be managed as a medical emergency. GNBM should be suspected in patients with otitis media, neurosurgical, and head trauma or who underwent spinal anesthesia and have disturbance in their level of consciousness, even if there are no signs of meningeal irritation. Ceftriaxone is still an effective drug and had a low rate of resistance in our study.

Spontaneous Escherichia coli bacterial meningitis mimicking heatstroke in an adult

Bacterial meningitis can be difficult to recognize: the meningeal triad symptoms are not always present and the alteration in mental status can mimic heatstroke. Escherichia coli meningitis is a serious disease whose early diagnosis, appropriate antibiotic treatment, and hemodynamic management are essential.

Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital

BACKGROUND

Pseudomonas aeruginosa is a rare cause of meningitis and ventriculitis but is generally associated with significant morbidity and mortality.

AIM

We sought to determine the epidemiology, risk factors and outcome of meningitis and ventriculitis due to P. aeruginosa at our institution in order to inform preventive strategies and treatment guidelines.

METHODS

Retrospective study of all patients with a positive cerebrospinal fluid (CSF) culture admitted to a tertiary care hospital over 18 years. Clinical details, demographic, microbiological and antibiotic data were obtained from laboratory and medical records.

RESULTS

Twenty-four episodes occurred in 21 patients over 18 years. Pyrexia (75%), fluctuating mental status (50%) and headache (41%) were the most frequent presenting symptoms. Nineteen of the 21 patients had previously undergone a neurosurgical procedure and seven had extra-ventricular devices in situ. Twelve (57%) patients had P. aeruginosa isolated from another site prior to their episode. Most (89%) CSF samples demonstrated a neutrophilia; the CSF protein, when measured, was raised in all cases. Gram-negative bacilli were visible on CSF microscopy in only three isolates. There were relatively low rates of resistance to most antimicrobials tested and combination treatment of intravenous with intrathecal antibiotics was often used. No patients died within 28 days.

CONCLUSION

Pseudomonas aeruginosa meningitis and ventriculitis are predominantly nosocomial and related to prior neurosurgery. It can be difficult to diagnose as CSF Gram-film and meningism are insensitive markers. Appropriate empirical treatment, neurosurgical prophylaxis and surveillance can aid in managing this infection.

Community-acquired adult Escherichia coli meningitis leading to diagnosis of unrecognized retropharyngeal abscess and cervical spondylodiscitis: a case report

Background

Escherichia coli is a rare cause of community-acquired meningitis in adults unless predisposing factors are present (e.g., previous penetrating cranio-cerebral injury or neurosurgery, immunosuppression, chronic alcoholism, history of cancer, diabetes mellitus, advanced age).

Case presentation

We describe the case of a 53-year-old woman, resident in Germany, suffering from community-acquired bacterial meningitis caused by CTX-M-9 type extended spectrum β-lactamase producing Escherichia coli. Because typical predisposing factors were not apparent, pathogen identification resulted in expanded diagnostics to exclude a distant or contiguous primary focus. By magnetic resonance tomography, a previously unrecognized large retropharyngeal abscess with cervical spondylodiscitis was detected. In retrospect, the patient had complained about neck pain for a few weeks prior to meningitis onset, but the symptoms were interpreted as being related to a herniated disk. Meningitis and osteomyelitis resolved completely under surgical treatment and meropenem therapy.

Conclusion

In case of adult Escherichia coli meningitis, underlying diseases should always be carefully excluded, especially if predisposing factors are not apparent.

Escherichia Coli Meningitis Features in 325 Children From 2001 to 2013 in France

BACKGROUND

We aimed to describe features of Escherichia coli meningitis in a large population of children and the molecular characteristics of the involved strains to determine factors associated with severe disease or death.

METHODS

Between 2001 and 2013, a prospective national survey collected data for 325 children hospitalized with E. coli meningitis. The national reference center genetically characterized 141 isolates.

RESULTS

Among the 325 cases, 65.2% were term, 22.4% late preterm, and 12.5% very/extremely preterm infants. Escherichia coli meningitis was 7-fold more frequent in preterm than term infants. Median age at diagnosis was 14 days; 71.1% of infants were neonates, with 2 peaks of infection at age 0-3 days (mostly preterm neonates) and 11-15 days (mostly term neonates); 8.9% were >89 days old. In total, 51.1% patients were considered to have severe disease, and 9.2% died. B2.1 phylogenetic subgroup (56%) and O1 serogroup (27.7%) were the most frequently identified. On multivariate analysis, death was associated with preterm birth (odds ratio [OR], 3.3 [95% confidence interval {CI}, 1.3-8.4], P = .015 for late preterm infants; OR, 7.3 [95% CI, 2.7-20.9], P < .001 for very/extremely preterm infants) and cerebrospinal fluid (CSF) to blood glucose ratio <0.10 (OR, 15.3 [95% CI, 1.8-128.3], P = .012). Death was associated with uncommon O serogroup strains (P = .014) and severe disease with O7 serogroup (P = .034) and PapGII adhesin (OR, 2.3 [95% CI, 1.2-4.5], P = .015).

CONCLUSIONS

In this large study of 325 cases of E. coli meningitis, risk factors of severe disease or death were preterm birth, severe hypoglycorrhachia, CSF/blood glucose ratio <0.10, and molecular characteristics of strains, which should help optimize therapeutic management.

Spontaneous adult Gram-negative bacillary meningitis in Soweto, South Africa

BACKGROUND

Gram-negative bacillary (GNB) meningitis is a rare cause of meningitis in adults and can occur as a spontaneous infection or as a complication of a neurosurgical procedure or trauma. We aimed to describe the characteristics and outcomes of adults with spontaneous GNB meningitis.

METHODS

A retrospective cohort analysis was performed of 26 patients with GNB meningitis seen at a single hospital in Soweto, South Africa.

RESULTS

A predisposing condition was found in 24 (92%) patients. The 19 (73%) HIV-infected patients had a median CD4 count of 24/mm(3). Chronic renal disease, diabetes mellitus, myeloma, and alcoholism were other underlying conditions. The HIV-infected had a median cerebrospinal fluid (CSF) neutrophil count of 2/mm(3) compared to the HIV-non-infected of 560/mm(3). Common organisms were Escherichia coli, Klebsiella pneumoniae, and non-typhoidal Salmonella in HIV-positive patients and K. pneumoniae in the HIV-negative group. Ten (38%) isolates were resistant to third-generation cephalosporins. Mortality was 65%.

CONCLUSIONS

A disproportionate burden of GNB meningitis fell on the HIV-infected, among whom absent or low CSF white cells was common. Management was complicated by high rates of resistance to third-generation cephalosporins.

Strategies to increase the activity of microglia as efficient protectors of the brain against infections

In healthy individuals, infections of the central nervous system (CNS) are comparatively rare. Based on the ability of microglial cells to phagocytose and kill pathogens and on clinical findings in immunocompromised patients with CNS infections, we hypothesize that an intact microglial function is crucial to protect the brain from infections. Phagocytosis of pathogens by microglial cells can be stimulated by agonists of receptors of the innate immune system. Enhancing this pathway to increase the resistance of the brain to infections entails the risk of inducing collateral damage to the nervous tissue. The diversity of microglial cells opens avenue to selectively stimulate sub-populations responsible for the defence against pathogens without stimulating sub-populations which are responsible for collateral damage to the nervous tissue. Palmitoylethanolamide (PEA), an endogenous lipid, increased phagocytosis of bacteria by microglial cells in vitro without a measurable proinflammatory effect. It was tested clinically apparently without severe side effects. Glatiramer acetate increased phagocytosis of latex beads by microglia and monocytes, and dimethyl fumarate enhanced elimination of human immunodeficiency virus from infected macrophages without inducing a release of proinflammatory compounds. Therefore, the discovery of compounds which stimulate the elimination of pathogens without collateral damage of neuronal structures appears an achievable goal. PEA and, with limitations, glatiramer acetate and dimethyl fumarate appear promising candidates.

Meningitis associated with strongyloidiasis in an area endemic for strongyloidiasis and human T-lymphotropic virus-1: a single-center experience in Japan between 1990 and 2010

Meningitis caused by enteric flora is a known complication of strongyloidiasis, and human T-lymphotropic virus-1 (HTLV-1) predisposes individuals to severe strongyloidiasis. We reviewed the clinical features of bacterial meningitis associated with strongyloidiasis seen at a single center in subtropical Japan, in an area endemic for both strongyloidiasis and HTLV-1. We found 33 episodes in 21 patients between 1990 and 2010. The results were remarkable for the high incidence of meningitis due to Gram-positive cocci (27.3 %), especially Streptococcus bovis, and culture-negative cases (42.4 %). Given the high incidence of Gram-positive meningitis, a modified approach to corticosteroid use would be advisable in areas where strongyloidiasis is endemic, due to the potentially adverse consequences of glucocorticoid therapy.

Spontaneous gram-negative bacillary meningitis in adult patients: characteristics and outcome

BACKGROUND

Spontaneous meningitis caused by gram-negative bacilli in adult patients is uncommon and poorly characterized. Our objective is to describe and compare the characteristics and the outcome of adult patients with spontaneous gram-negative bacilli meningitis (GNBM) and spontaneous meningitis due to other pathogens.

METHODS

Prospective single hospital-based observational cohort study conducted between 1982 and 2006 in a university tertiary hospital in Barcelona (Spain). The Main Outcome Measure: In-hospital mortality.

RESULTS

Gram-negative bacilli meningitis was diagnosed in 40 (7%) of 544 episodes of spontaneous acute bacterial meningitis. The most common pathogens were Escherichia coli and Pseudomonas species. On admission, characteristics associated with spontaneous gram-negative bacilli meningitis by multivariate modeling were advanced age, history of cancer, nosocomial acquisition of infection, urinary tract infection as distant focus of infection, absence of rash, hypotension, and a high cerebrospinal fluid white-cell count. Nine (23%) episodes were acquired in the hospital and they were most commonly caused by Pseudomonas. The in-hospital mortality rate was 53%. The mortality rate was higher among patients with Gram-negative bacillary meningitis than among those with other bacterial meningitis and their risk of death was twenty times higher than among patients infected with Neisseria meningitidis (odds ratio 20.47; 95% confidence interval 4.03-103.93; p<0.001).

CONCLUSIONS

Gram-negative bacilli cause 9% of spontaneous bacterial meningitis of known etiology in adults. Characteristics associated with GNBM include advanced age, history of cancer, nosocomial acquisition, and urinary tract infection as distant focus of infection. The mortality rate is higher among patients with gram-negative bacillary meningitis than among those with other bacterial meningitides.

E. coli Meningitis Presenting in a Patient with Disseminated Strongyloides stercoralis

Introduction. Spontaneous Escherichia coli meningitis is an infrequent condition in adults and is associated with some predisposing factors, including severe Strongyloides stercoralis (SS) infections. Case Presentation. A 43-year-old Hispanic man, with history of travelling to the jungle regions of Peru and Brazil two decades ago, and who received prednisone due to Bell's palsy for three weeks before admission, presented to the Emergency Department with diarrhea, fever, and hematochezia. A week after admission he developed drowsiness, meningeal signs, abdominal distension, and constipation. A cerebrospinal fluid culture showed extended spectrum β -lactamase producing E. coli. A colonoscopy was performed and showed pancolitis. Three days after the procedure the patient became unstable and developed peritoneal signs. He underwent a laparotomy, which ended up in a total colectomy and partial proctectomy due to toxic megacolon. Three days later the patient died in the intensive care unit due to septic shock. Autopsy was performed and microscopic examination revealed the presence of multiple Strongyloides larvae throughout the body. Conclusion. Strongyloides stercoralis infection should be excluded in adults with spontaneous E. coli meningitis, especially, if gastrointestinal symptoms and history of travelling to an endemic area are present. Even with a proper diagnosis and management, disseminated strongyloidiasis has a poor prognosis.

First initial community-acquired meningitis due to extended-spectrum beta-lactamase producing Escherichia coli complicated with multiple aortic mycotic aneurysms

We report the first case of extended-spectrum beta-lactamase producing E. coli community-acquired meningitis complicated with multiple aortic mycotic aneurysms. Because of the acute aneurysm expansion with possible impending rupture on 2 abdominal CT scan, the patient underwent prompt vascular surgery and broad spectrum antibiotic therapy but he died of a hemorrhagic shock. Extended-spectrum beta-lactamase producing E. coli was identified from both blood and cerebrospinal fluid culture before vascular treatment. The present case report does not however change the guidelines of Gram negative bacteria meningitis in adults.

[A serious and unexpected infectious complication after transrectal prostate biopsy]

Serious infectious complications may appear after a surgical procedure despite antimicrobial prophylaxis. We report a case of Escherichia Coli meningitis after a prostate puncture biopsy. Many factors may have contributed to this rare complication such as fluoroquinolone resistance, and/or the bacterium's ability to cross the brain blood barrier. The patient was not found susceptible to severe infections.

Changing epidemiology of adult bacterial meningitis in southern taiwan: a hospital-based study

BACKGROUND

Many factors may influence the epidemiologic trend of adult bacterial meningitis (ABM). The objective of this study was to analyze recent epidemiologic trends of ABM in order to provide a better therapeutic strategy.

MATERIALS AND METHODS

The clinical features, laboratory data, and therapeutic outcomes of 181 ABM cases collected in the last 6.5 years (July 1999-December 2005) were analyzed. The results were compared with those of our previous study (202 cases, January 1986-June 1999).

RESULTS

The 181 cases consisted of 130 men (age range: 18-82 years) and 51 women (age range: 18-78 years). Monomicrobial infection and mixed infection were found in 165 cases and 16 cases, respectively. A preceding postneurosurgical state was noted in 56.9% (103/181) of cases. Despite a decrease in incidence, Klebsiella pneumoniae (25.5%, 42/165) was still the most common pathogen. A marked increase of Acinetobacter meningitis (11.5%, 19/165) was noted, which replaced Pseudomonas meningitis as the second most common Gram-negative pathogen in ABM. A marked increase in staphylococcal infection, accounting for 23% (38/165) of all cases, was also noted, of which 76% (29/38) were methicillin-resistant strains. The therapeutic result showed a mortality rate of 30.3% (55/181). Significant prognostic factors included septic shock and age at infection.

CONCLUSIONS

This study revealed a change in the epidemiologic trend of ABM, with an increase in the number of patients with a postneurosurgical state and a rising incidence of Acinetobacter and staphylococcal infections. Clinicians should pay greater attention to these changes, which may affect their management of ABM.

Community-acquired Klebsiella pneumoniae meningitis in an alcoholic patient with an infected pancreatic pseudocyst; a case report and review of literature

We report a case of a 49-year-old male with a history of chronic alcoholism and evidence of a pancreatic pseudocyst on CT scanning. He presented with a 3-days history of fever, loss of appetite and upper abdominal pain. Blood cultures grew Klebsiella pneumoniae and he improved clinically with a seven-day course of intravenous co-amoxiclav and metronidazole. Two weeks later he was readmitted to hospital with impaired consciousness and septic shock, and died three days later in intensive care. Post mortem examination revealed bacterial meningitis and an infected pancreatic pseudocyst. Klebsiella pneumoniae was isolated from the pancreas and meninges.