The epidemiology of acute meningitis in children in England and Wales

Epidemiological characteristics and climatic variability of viral meningitis in Kazakhstan, 2014-2019

Background

The comprehensive epidemiology and impact of climate on viral meningitis (VM) in Kazakhstan are unknown. We aimed to study the incidence, in-hospital mortality and influence of climatic indicators on VM from 2014 to 2019.

Methods

Nationwide electronic healthcare records were used to explore this study. ICD-10 codes of VM, demographics, and hospital outcomes were evaluated using descriptive statistics and survival analysis.

Results

During the 2014-2019 period, 10,251 patients with VM were admitted to the hospital. 51.35% of them were children, 57.85% were males, and 85.9% were from the urban population. Enteroviral meningitis was the main cause of VM in children. The incidence rate was 13 and 18 cases per 100,000 population in 2014 and 2019, respectively. Case fatality rate was higher in 2015 (2.3%) and 2017 (2.0%). The regression model showed 1°C increment in the daily average temperature might be associated with a 1.05-fold (95% CI 1.047-1.051) increase in the daily rate of VM cases, 1hPa increment in the average air pressure and 1% increment in the daily average humidity might contribute to a decrease in the daily rate of VM cases with IRRs of 0.997 (95% CI 0.995-0.998) and 0.982 (95% CI 0.981-0.983), respectively. In-hospital mortality was 35% higher in males compared to females. Patients residing in rural locations had a 2-fold higher risk of in-hospital death, compared to city residents. Elderly patients had a 14-fold higher risk of in-hospital mortality, compared to younger patients.

Conclusion

This is the first study in Kazakhstan investigating the epidemiology and impact of climate on VM using nationwide healthcare data. There was a tendency to decrease the incidence with outbreaks every 5 years, and mortality rates were higher for Russians and other ethnicities compared to Kazakhs, for males compared to females, for elder patients compared to younger patients, and for patients living in rural areas compared to city residents. The climatic parameters and the days of delay indicated a moderate interaction with the VM cases.

Evaluation of Rat Brain Morphology Following the Induction of Acute Meningitis Treated with Ceftriaxone

The soft and delicate tissue of the brain, which is the center of our coordination, is protected by its surrounding layers. The disruption of these layers results in complicated situations and serious health problems. The brain has three protective layers of bone or skull tissue, the blood tissue layer, and finally the meningeal layer. The layer of blood tissue contains the blood vessels that are located between the skull and the meningeal membranes. If germs or foreign matter enter the fluid through the blood vessels under any circumstances and cause infection, the bones that protect the meninges will break and cause tissue damage. The present study aimed to assess the histological and immunohistochemical characteristics of the brain of rats that underwent induced acute purulent pneumococcal meningitis after antibiotic therapy with Ceftriaxone. A number of 20 white adult male Wistar rats were assigned to three groups. The first group (n=5) regarded as the control were injected with a saline solution into the subarachnoid space in an equivalent amount. The second and third groups of rats (n=5 and 10, respectively) were infected with acute purulent meningitis by the injection of 10 μl of Streptococcus pneumoniae (S. pneumonia) suspension into the subarachnoid space of the brain using a 23-G needle. The various areas of the brains of rats after meningitis induced by S. pneumoniae were examined after the treatment with Ceftriaxone. The S. pneumoniae culture was injected into the subarachnoid space in the area of the rhomboid fossa. Treatment started 18 h after the injection. On day 10, a repeated puncture was performed with the analysis of cerebrospinal fluid in order to confirm the absence of meningitis; thereafter, the animals were taken out of the experiment. No signs of meningitis were found on histological examination. Mild perivascular and pericellular focal edema were revealed with signs of overload of the lymphatic system in the brain and focal ischemic changes in neurons. The investigation of expression with caspase-3 revealed a positive reaction of individual neurons. A positive reaction with antibodies to NeuN and Doublecortin was detected in most neurons; moreover, Glial fibrillary acidic protein (GFAP)-positive astrocytes and their processes were visualized in all layers of the brain substance. The reaction with neuron-specific enolase (NSE), microtubule-associated protein 2 (MAP-2), CD 31, and CD 34 was negative. Typical structure and pictures pointed to an intact brain and purulent meningitis in the first and second groups. The microscopic image and the changes revealed during immunohistochemistry by dual corticosteroid antibodies and neuronal nuclear protein were characterized by predominantly cytoplasmic and perinuclear reactions, respectively. Some neurons are positive for caspase-3 and are related to changes in the characteristic of premature aging.

Epidemiology Profile of Viral Meningitis Infections Among Patients in Qatar (2015-2018)

Background: Little is known about the etiology of meningitis in the MENA region, including Qatar. Viral agents are considered the major cause for meningitis worldwide. Here, we present primary data about the etiology and clinical and demographic characteristics of viral meningitis (VM) in Qatar between 2015 and 2018.

Methods: We retrospectively collected data from Hamad Medical Corporation (HMC), which provides about 80% of healthcare services in Qatar. Data were collected for the period between 2015 and 2018. During this time period, 6,705 specimens were collected from patients with suspected meningitis attending HMC and primary healthcare centers. These specimens were tested for a panel of viruses using the “FTD Viral meningitis” multiplex real-time PCR kit that detects Adenovirus (ADV), Human herpesvirus 1&2 (HSV1 and HSV2), Epstein–Barr virus (EBV), Enteroviruses (EV), Cytomegalovirus (CMV), Varicella zoster virus (VZV), and Parechovirus (PV).

Results: Only 10.9% (732/6,705) of all suspected meningitis cases were caused by viral agents. 60.9% of the reported cases were males, compared to 39.1% in females. Most of the infections (73.9%) were reported in children younger than 10 years of age. EV were identified as the main causative agent (68.7%), followed by EBV (7.5%) and ADV (6.8%). Other viral agents including VZV, PV, HSV-1, and HSV-2 were also detected with a lower frequency. Confirmed VM were more prevalent among Qatari subjects compared to other nationalities. We observed no specific seasonality of viral agents, but a slight rise was recorded during the spring seasons (March to June). Fever (59.4%, 435/732) and acute central nervous system (CNS) infection (15.6%, 114/732) were initial symptoms of most cases.

Conclusion: This is the first report about the molecular epidemiology of VM in Qatar. In line with the international records, our data showed that EV is responsible for 68.7% of Qatar's VM cases. Further studies are needed to genotype and serotype the identified viruses.

Etiology of acute meningitis and encephalitis from hospital-based surveillance in South Kazakhstan oblast, February 2017-January 2018

Encephalitis and meningitis (EM) are severe infections of the central nervous system associated with high morbidity and mortality. The etiology of EM in Kazakhstan is not clearly defined, so from February 1, 2017 to January 31, 2018 we conducted hospital-based syndromic surveillance for EM at the Shymkent City Hospital, in the South Kazakhstan region. All consenting inpatients meeting a standard case definition were enrolled. Blood and cerebrospinal fluid (CSF) samples were collected for bacterial culture, and CSF samples were additionally tested by PCR for four bacterial species and three viruses using a cascading algorithm. We enrolled 556 patients. Of these, 494 were of viral etiology (including 4 probable rabies cases), 37 were of bacterial etiology, 19 were of unknown etiology and 6 were not tested. The most commonly identified pathogens included enterovirus (73%, n = 406 cases), herpes simplex virus (12.8%, n = 71), and Neisseria meningitidis (3.8%, n = 21). The incidence rates (IRs) for enteroviral and meningococcal EM were found to be 14.5 and 0.7 per 100,000 persons, respectively. The IR for bacterial EM using both PCR and culture results was 3–5 times higher compared to culture-only results. Antibacterial medicines were used to treat 97.2% (480/494) of virus-associated EM. Incorporation of PCR into routine laboratory diagnostics of EM improves diagnosis, pathogen identification, ensures IRs are not underestimated, and can help avoid unnecessary antibacterial treatment.

Long Term Impact of Conjugate Vaccines on Haemophilus influenzae Meningitis: Narrative Review

H. influenzae serotype b (Hib) used to be the commonest cause of bacterial meningitis in young children. The widespread use of Hib conjugate vaccine has profoundly altered the epidemiology of H. influenzae meningitis. This short review reports on the spectrum of H. influenzae meningitis thirty years after Hib conjugate vaccine was first introduced into a National Immunization Program (NIP). Hib meningitis is now uncommon, but meningitis caused by other capsulated serotypes of H. influenzae and non-typeable strains (NTHi) should be considered. H. influenzae serotype a (Hia) has emerged as a significant cause of meningitis in Indigenous children in North America, which may necessitate a Hia conjugate vaccine. Cases of Hie, Hif, and NTHi meningitis are predominantly seen in young children and less common in older age groups. This short review reports on the spectrum of H. influenzae meningitis thirty years after Hib conjugate vaccine was first introduced into a NIP.

The Prevalence of Viruses in the Cerebrospinal Fluid of Children with Aseptic Meningitis in Shiraz, Iran

Objectives: The current study aimed to evaluate the causative agents of viral meningitis through real-time PCR among children with aseptic meningitis. Methods: Children aged 1 month to 16 years with suspected viral meningitis were enrolled in this study (March 2014-February 2015). Cerebrospinal fluid samples were analyzed by real-time PCR for detection of enterovirus, mumps, measles, adenovirus, EBV, CMV, VZV, hhv 6, and rubella viruses. Demographic information, laboratory data, and clinical presentations of patients were also collected. Results: Of 56 patients suspected to viral meningitis, 21 (38.9 %) had a positive PCR result. Enterovirus (42.85%) and mumps (38.1%) were the most prevalent viruses, and VZV and measles were not detected. Three children were coinfected with enterovirus/hhv6, enterovirus/EBV, and mump/adenovirus. Fever, headache, and nausea/vomiting were the most common symptoms in children. The rates of symptoms were not statistically significant among children with positive and negative PCR tests. Conclusions: In the present study Enterovirus and mumps viruses were the most common causes of viral meningitis in children. PCR, as a rapid test for the diagnosis of viral meningitis, can be used to decrease hospitalization length.

Factors associated with early complications in inpatients who were treated in our clinic between 1992 and 2011 with a diagnosis of acute bacterial meningitis

Aim:

To evaluate factors associated with the development of early complications in acute bacterial meningitis.

Material and Methods:

In our study, 389 patients diagnosed with acute bacterial meningitis between January 1992 and January 2011 at Cerrahpaşa Medical Faculty were retrospectively analyzed to determine the risk factors for the development of early complications.

Results:

The causative agent was N. meningitidis in 17% of cases, S. pneumoniae in 13.6%, and H. influenzae type b in 6.4%. In 55.5% of cases, the causative agent could not be identified. The mortality rate was found as 1% and the early complication rate was 27.8%. The complications observed included septic shock and disseminated intravascular coagulation (33.3%), hydrocephalus (23.1%), subdural effusion (19.4%), and epilepsy (12%). Risk factors for early complications included being aged below two years (p<0.010), restlessness (p<0.010), rash (p<0.010), leukocytosis in complete blood count (p<0.010), and a cerebrospinal fluid glucose level of <45 mg/dL (p<0.010). Three of the four patients who died were male. The incidence of hydrocephalus was higher in patients who used ampicillin-cefotaxime and who did not receive steroid therapy before treatment (p<0.050).

Conclusion:

When acute bacterial meningitis is treated properly and adequately, recovery without sequela is possible. Knowing the risk factors for early complications will guide in the monitoring of patients and decrease morbidity and mortality rates.

Early Entry Events in Echovirus 30 Infection

Echovirus 30 (E30), a member of the enterovirus B species, is a major cause of viral meningitis, targeting children and adults alike. While it is a frequently isolated enterovirus and the cause of several outbreaks all over the world, surprisingly little is known regarding its entry and replication strategy within cells. In this study, we used E30 strain Bastianni (E30B) generated from an infectious cDNA clone in order to study early entry events during infection in human RD cells. E30B required the newly discovered Fc echovirus receptor (FcRn) for successful infection, but not the coxsackievirus and adenovirus receptor (CAR) or decay-accelerating factor (DAF), although an interaction with DAF was observed. Double-stranded RNA replication intermediate was generated between 2 and 3 h postinfection (p.i.), and viral capsid production was initiated between 4 and 5 h p.i. The drugs affecting Rac1 (NSC 23766) and cholesterol (filipin III) compromised infection, whereas bafilomycin A1, dyngo, U-73122, wortmannin, and nocodazole did not, suggesting the virus follows an enterovirus-triggered macropinocytic pathway rather than the clathrin pathway. Colocalization with early endosomes and increased infection due to constitutively active Rab5 expression suggests some overlap and entry to classical early endosomes. Taken together, these results suggest that E30B induces an enterovirus entry pathway, leading to uncoating in early endosomes.IMPORTANCE Echovirus 30 (E30) is a prevalent enterovirus causing regular outbreaks in both children and adults in different parts of the world. It is therefore surprising that relatively little is known of its infectious entry pathway. We set out to generate a cDNA clone and gradient purified the virus in order to study the early entry events in human cells. We have recently studied other enterovirus B group viruses, like echovirus 1 (EV1) and coxsackievirus A9 (CVA9), and found many similarities between those viruses, allowing us to define a so-called "enterovirus entry pathway." Here, E30 is reminiscent of these viruses, for example, by not relying on acidification for infectious entry. However, despite not using the clathrin entry pathway, E30 accumulates in classical early endosomes.

Global, regional, and national burden of meningitis, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Acute meningitis has a high case-fatality rate and survivors can have severe lifelong disability. We aimed to provide a comprehensive assessment of the levels and trends of global meningitis burden that could help to guide introduction, continuation, and ongoing development of vaccines and treatment programmes.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study estimated meningitis burden due to one of four types of cause: pneumococcal, meningococcal, Haemophilus influenzae type b, and a residual category of other causes. Cause-specific mortality estimates were generated via cause of death ensemble modelling of vital registration and verbal autopsy data that were subject to standardised data processing algorithms. Deaths were multiplied by the GBD standard life expectancy at age of death to estimate years of life lost, the mortality component of disability-adjusted life-years (DALYs). A systematic analysis of relevant publications and hospital and claims data was used to estimate meningitis incidence via a Bayesian meta-regression tool. Meningitis deaths and cases were split between causes with meta-regressions of aetiological proportions of mortality and incidence, respectively. Probabilities of long-term impairment by cause of meningitis were applied to survivors and used to estimate years of life lived with disability (YLDs). We assessed the relationship between burden metrics and Socio-demographic Index (SDI), a composite measure of development based on fertility, income, and education.

FINDINGS

Global meningitis deaths decreased by 21·0% from 1990 to 2016, from 403 012 (95% uncertainty interval [UI] 319 426-458 514) to 318 400 (265 218-408 705). Incident cases globally increased from 2·50 million (95% UI 2·19-2·91) in 1990 to 2·82 million (2·46-3·31) in 2016. Meningitis mortality and incidence were closely related to SDI. The highest mortality rates and incidence rates were found in the peri-Sahelian countries that comprise the African meningitis belt, with six of the ten countries with the largest number of cases and deaths being located within this region. Haemophilus influenzae type b was the most common cause of incident meningitis in 1990, at 780 070 cases (95% UI 613 585-978 219) globally, but decreased the most (-49·1%) to become the least common cause in 2016, with 397 297 cases (291 076-533 662). Meningococcus was the leading cause of meningitis mortality in 1990 (192 833 deaths [95% UI 153 358-221 503] globally), whereas other meningitis was the leading cause for both deaths (136 423 [112 682-178 022]) and incident cases (1·25 million [1·06-1·49]) in 2016. Pneumococcus caused the largest number of YLDs (634 458 [444 787-839 749]) in 2016, owing to its more severe long-term effects on survivors. Globally in 2016, 1·48 million (1·04-1·96) YLDs were due to meningitis compared with 21·87 million (18·20-28·28) DALYs, indicating that the contribution of mortality to meningitis burden is far greater than the contribution of disabling outcomes.

INTERPRETATION

Meningitis burden remains high and progress lags substantially behind that of other vaccine-preventable diseases. Particular attention should be given to developing vaccines with broader coverage against the causes of meningitis, making these vaccines affordable in the most affected countries, improving vaccine uptake, improving access to low-cost diagnostics and therapeutics, and improving support for disabled survivors. Substantial uncertainty remains around pathogenic causes and risk factors for meningitis. Ongoing, active cause-specific surveillance of meningitis is crucial to continue and to improve monitoring of meningitis burdens and trends throughout the world.

FUNDING

Bill & Melinda Gates Foundation.

Development and Assessment of a Diagnostic DNA Oligonucleotide Microarray for Detection and Typing of Meningitis-Associated Bacterial Species

Meningitis is commonly caused by infection with a variety of bacterial or viral pathogens. Acute bacterial meningitis (ABM) can cause severe disease, which can progress rapidly to a critical life-threatening condition. Rapid diagnosis of ABM is critical, as this is most commonly associated with severe sequelae with associated high mortality and morbidity rates compared to viral meningitis, which is less severe and self-limiting. We have designed a microarray for detection and diagnosis of ABM. This has been validated using randomly amplified DNA targets (RADT), comparing buffers with or without formamide, in glass slide format or on the Alere ArrayTube^TM (Alere Technologies GmbH) microarray platform. Pathogen-specific signals were observed using purified bacterial nucleic acids and to a lesser extent using patient cerebral spinal fluid (CSF) samples, with some technical issues observed using RADT and glass slides. Repurposing the array onto the Alere ArrayTube^TM platform and using a targeted amplification system increased specific and reduced nonspecific hybridization signals using both pathogen nucleic and patient CSF DNA targets, better revealing pathogen-specific signals although sensitivity was still reduced in the latter. This diagnostic microarray is useful as a laboratory diagnostic tool for species and strain designation for ABM, rather than for primary diagnosis.

Clinical Outcomes and Risk Factors of Meningitis among Children in Referral Hospital, Ethiopia, 2016: A Retrospective Chart Review

BACKGROUND

Meningitis remains a major cause of mortality and morbidity in patients in many countries of the world including Ethiopia. Information on clinical outcomes of meningitis, susceptibility of the causative microorganism to rationalize treatment and associated risk factors is scare. The objective of this study was to assess the risk factors and clinical outcomes of meningitis among children in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia.

METHOD

A retrospective cross sectional study was conducted in Felege Hiwot Referral Hospital from January 2016 to May 2016. Data were checked for completeness, inconsistencies and entered into SPSS for windows version 20.0. Lottery method was used to select charts. One hundred seventy-nine pediatric patient files were used in the study.

RESULT

About 15% children with meningitis developed poor outcomes: developed complication, referred to higher facility, died and left against medical advice. In this study, season of admission [AOR= 5 (1.191, 20.991)], immunization status [AOR= 20.912 (3.325, 131.502)], clinical presentations [AOR= 8.779 (1.599, 48.192)] and corticosteroid administration [AOR= 8.215 (1.220, 55.328)] were the determinant factors for clinical outcome of meningitis.

CONCLUSION

In this study, about 15% of children with meningitis developed poor outcomes. The determinant factors for poor outcome of meningitis were: season of admission, immunization status, clinical presentations and corticoid administration. Creating community awareness about risk factors of meningitis, early diagnosis and treatment of cases, improving vaccination coverage and use of corticosteroids are recommended to improve the clinical outcome of children affected with meningitis.

A prospective study of enterovirus D68 in a regional UK center

Aim: A prospective study was undertaken to establish the prevalence of enterovirus D68 (EV-D68) in the northwest of England. Patients & samples: In the period 24 October through 31 December 2014, respiratory samples were screened by a specific real-time PCR and EV-D68 was identified by nucleotide sequence-based typing. Results: Enterovirus was detected in 7.4% of samples and EV-D68 was confirmed in 32 cases. Phylogenetic analysis showed that EV-D68 strains corresponded to clades A and B. Clinical presentation of cases ranged from mild to severe respiratory infection. The majority of cases had comorbidities that might predispose to severe infection. Conclusion: EV-D68 was circulating in our region during late 2014 and has the potential to cause severe disease.

The History and Current Relevance of the Eponymous Signs of Meningitis

During the past several decades, researchers have shown that the eponymous signs of meningitis have reduced sensitivity and specificity compared with when they were originally described. This may be because of the changing epidemiology of meningitis and its treatment or it may be because of variations in performance of the maneuvers. For example, in the original descriptions, the Kernig sign (resistance of leg extension) is best elicited with the patient sitting and the Brudzinski nape of the neck sign involves holding down the patient's chest as the neck is flexed. These and other lesser-known signs of meningitis by Amoss, Bikeles and Edelmann all relate to the mechanics of stretching inflamed meninges, and this review will allow the clinician to understand how the history related to these maneuvers is still germane to clinical practice today.

Enteroviral Meningitis in Neonates and Children of Mashhad, Iran

Background

The highest incidence of meningitis occurs during the neonatal period and (then) infancy. Although Bacterial agents are the most dangerous cause of neonatal and childhood meningitis yet viruses especially, enteroviruses (EV), are by far the most common cause of meningitis in this age group.

Objectives

The aim of the current study was to evaluate the role of EVs in neonatal and childhood meningitis in the Mashhad city of Iran.

Materials and Methods

This was a descriptive study that was performed at Imam Reza hospital in a period of six months (March to September 2007), during which all of the cerebral spinal fluid (CSF) samples from the neonatal intensive care unit (NICU) and pediatrics ward were collected and real time-polymerase chain reaction (RT-PCR) for EVs was done on these samples. Clinical data were collected retrospectively from hospital files.

Results

We collected 58 CSF samples (35 neonates and 23 children) during six months. Pleocytosis of CSF was seen in 51.1% of the subjects (28% of neonates, and 66.6% of infants and children). Enteroviruses PCR was positive in 37.1% (13) of neonates and 34.7% (8) of children. Pleocytosis of CSF was seen in 23% and 75% of EV positive neonates and children, respectively. Polymorphonuclear (PMN) dominance (PMN > 50%) of CSF was seen in 50% and 33% of EV positive neonates and children, respectively. There were three cases of bacterial meningitis in our group; EV PCR result was positive for one of these subjects. Concomitant bacterial infection (meningitis and sepsis) was seen in 9.5% (two cases) of EV positive CSFs in our study. Almost half of the available neonates (four of nine) with pure enteroviral meningitis (EVM) were discharged (in good condition) with final diagnosis of culture negative sepsis (CNS) and mean length of hospital stay (MLOS) of 4.3 days. One (12.5%) of the neonates with EVM, who had a very low birth weight (< 1500 mg), was expired, and two (25%) cases were discharged with brain damage and final diagnosis of severe asphyxia. The MLOS for children with pure EVM was 1.6 days (one to four days); they didn't have any sign of brain damage or mortality. Qualitative c-reactive protein (CRP) of serum was negative in 72.7% and 37.5% of EV positive neonates and children, respectively. The mean white blood cell count and PMN percentage in the peripheral blood was 11416/mm³ and 60.8% for EV positive neonates, and 14500/mm³ and 77.1% for EV positive children, respectively. Hyponatremia, due to possible syndrome of inappropriate antidiuretic hormone (SIADH), was seen in 30% of neonates and 57% of children with EVM.

Conclusions

Enteroviruses were a common cause (> 30%) of meningitis in our study group. Concomitant bacterial infection is not rare in neonates and children with EVM. Many of the neonates (50%) and almost all of the children with EVM did not require prolonged hospitalization. Both normal CSF and PMN dominancy of CSF was common in neonates and children with EVM. Positive qualitative CRP of serum (up to two plus) was common especially in children with EVM. Non-symptomatic mild hyponatremia/SIADH was common in early life EVM.

A Population-Based Acute Meningitis and Encephalitis Syndromes Surveillance in Guangxi, China, May 2007-June 2012

Objectives

Acute meningitis and encephalitis (AME) are common diseases with the main pathogens being viruses and bacteria. As specific treatments are different, it is important to develop clinical prediction rules to distinguish aseptic from bacterial or fungal infection. In this study we evaluated the incidence rates, seasonal variety and the main etiologic agents of AME, and identified factors that could be used to predict the etiologic agents.

Methods

A population-based AME syndrome surveillance system was set up in Guigang City, Guangxi, involving 12 hospitals serving the study communities. All patients meeting the case definition were investigated. Blood and/or cerebrospinal fluid were tested for bacterial pathogens using culture or RT-PCR and serological tests for viruses using enzyme-linked immunosorbent assays. Laboratory testing variables were grouped using factor analysis. Multinomial logistic regression was used to predict the etiology of AME.

Results

From May 2007 to June 2012, the annual incidence rate of AME syndrome, and disease specifically caused by Japanese encephalitis (JE), other viruses, bacteria and fungi were 12.55, 0.58, 4.57, 0.45 and 0.14 per 100,000 population, respectively. The top three identified viral etiologic agents were enterovirus, mumps virus, and JE virus, and for bacteria/fungi were Streptococcus sp., Cryptococcus neoformans and Staphylococcus sp. The incidence of JE and other viruses affected younger populations and peaked from April to August. Alteration of consciousness and leukocytosis were more likely to be caused by JE, bacteria and fungi whereas CSF inflammation was associated with bacterial/fungal infection.

Conclusions

With limited predictive validity of symptoms and signs and routine laboratory tests, specific tests for JE virus, mumps virus and enteroviruses are required to evaluate the immunization impact and plan for further intervention. CSF bacterial culture cannot be omitted in guiding clinical decisions regarding patient treatment.

Etiology and antimicrobial resistance patterns of acute bacterial meningitis in children: a 10-year referral hospital-based study in northwest iran

Background:

Bacterial meningitis is still considered as one of the most dangerous infectious diseases, which causes numerous complications and high mortality if not diagnosed and treated timely.

Objectives:

This study was performed to determine antimicrobial resistance patterns of bacterial pathogens isolated from acute bacterial meningitis at Tabriz Children Educational-Health Care Center in Iran.

Patients and Methods:

In a retrospective study (from 2003 through 2013), all patients with bacterial meningitis were identified by cerebrospinal fluids with positive results in culture (107 cases). Patients' necessary data was recorded in a questionnaire. Furthermore, the results of simultaneous blood culture were also examined. Ultimately, antimicrobial susceptibility of isolates was determined using the disc diffusion method.

Results:

One hundred and seven patients with bacterial meningitis were identified by cerebrospinal fluids with positive results in culture. All of patients (100%) had fever (male/female = 1.27/1). The most prevalent pathogens isolated from CSF culture were Streptococcus pneumoniae (34.5%), Haemophilus influenzae type b (23.36%), Neisseria meningitidis (6.54%), Serratia spp. (6.54%), and Klebsiella pneumoniae (5.6%), respectively. Moreover, the patients' blood culture had positive results in 36.44% of cases with H. influenzae type b (20.65%) and S. pneumoniae (6.54%) as the main bacteria isolated from blood. Meningitis occurred mostly in children under two years (P = 0.001). According to antimicrobial susceptibility test, a relatively high resistance was reported against some conventional cephalosporins and other antibiotics.

Conclusions:

S. pneumoniae and H. influenzae type b were the main pathogens of bacterial meningitis in children in the area under study. Most species had relatively high resistance to conventional antibiotics as compared to the past.

Current concepts in the treatment of bacterial meningitis beyond the neonatal period

The epidemiology and treatment approach to bacterial meningitis has changed dramatically since the advent of antimicrobial therapy. New vaccines against meningeal pathogens have been implemented into national immunization programs successfully around the world. Antibiotic resistance has had a considerable impact on the efficacy of several therapeutic agents. In this review, the authors will discuss the principles of antibiotic chemotherapy, focusing on new agents for the treatment of penicillin-resistant pneumococci and adjunctive treatments to reduce the inflammatory response to bacterial infection of the meninges.

Antimicrobial sensitivity patterns of cerebrospinal fluid (CSF) isolates in Namibia: implications for empirical antibiotic treatment of meningitis

OBJECTIVE

Bacterial meningitis is a medical emergency associated with high mortality rates. Cerebrospinal fluid (CSF) culture is the "gold standard" for diagnosis of meningitis and it is important to establish the susceptibility of the causative microorganism to rationalize treatment. The Namibia Standard Treatment Guidelines (STGs) recommends initiation of empirical antibiotic treatment in patients with signs and symptoms of meningitis after taking a CSF sample for culture and sensitivity. The objective of this study was to assess the antimicrobial sensitivity patterns of microorganisms isolated from CSF to antibiotics commonly used in the empirical treatment of suspected bacterial meningitis in Namibia.

METHODS

This was a cross-sectional descriptive study of routinely collected antibiotic susceptibility data from the Namibia Institute of Pathology (NIP) database. Results of CSF culture and sensitivity from January 1, 2009 to May 31, 2012, from 33 state hospitals throughout Namibia were analysed.

RESULTS

The most common pathogens isolated were Streptococcus species, Neisseria meningitidis, Haemophilus influenzae, Staphylococcus, and Escherichia coli. The common isolates from CSF showed high resistance (34.3% -73.5%) to penicillin. Over one third (34.3%) of Streptococcus were resistance to penicillin which was higher than 24.8% resistance in the United States. Meningococci were susceptible to several antimicrobial agents including penicillin. The sensitivity to cephalosporins remained high for Streptococcus, Neisseria, E. coli and Haemophilus. The highest percentage of resistance to cephalosporins was seen among ESBL K. pneumoniae (n = 7, 71%-100%), other Klebsiella species (n = 7, 28%-80%), and Staphylococcus (n = 36, 25%-40%).

CONCLUSIONS

The common organisms isolated from CSF were Streptococcus Pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Staphylococcus, and E. coli. All common organisms isolated from CSF showed high sensitivity to cephalosporins used in the empirical treatment of meningitis. The resistance of the common isolates to penicillin is high. Most ESBL K. pneumoniae were isolated from CSF samples drawn from neonates and were found to be resistant to the antibiotics recommended in the Namibia STGs. Based on the above findings, it is recommended to use a combination of aminoglycoside and third-generation cephalosporin to treat non-ESBL Klebsiella isolates. Carbapenems (e.g., meropenem) and piperacillin/tazobactam should be considered for treating severely ill patients with suspected ESBL Klebsiella infection. Namibia should have a national antimicrobial resistance surveillance system for early detection of antibiotics that may no longer be effective in treating meningitis and other life-threatening infections due to resistance.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Comparison of the probability of target attainment between ceftriaxone and cefepime in the cerebrospinal fluid and serum against Streptococcus pneumoniae

Although the disposition of ceftriaxone and cefepime in the cerebrospinal fluid (CSF) has been described, the ability of these agents to achieve critical pharmacodynamic targets against Streptococcus pneumoniae in CSF has not been reported. Plasma and CSF pharmacokinetic data were obtained from hospital patients with external ventricular drains and receiving ceftriaxone or cefepime. Concentration-time profiles in plasma and CSF were modeled using a 3-compartment model with 0-order infusion and 1st-order elimination and transfer. The model parameters were identified with population pharmacokinetic analysis (Big Non-Parametric Adaptive Grid with adaptive gamma). A Monte Carlo Simulation (9999 subjects) estimated the probability of target attainment (PTA) for total drug CSF concentrations at 50% and 100% T>MIC for ceftriaxone 2G IV Q12H and cefepime 2G IV Q8H. The S. pneumoniae bloodstream infection isolates from the SENTRY Antimicrobial Surveillance Program (USA) provided the distribution of contemporary (2003-2004) MICs. Post-Bayesian measures of bias and precision, observed-predicted plots, and R2 values were highly acceptable for both drugs. The probabilities of achieving 50% and 100% T>MIC in the CSF for ceftriaxone were 76% and 65%, respectively. For cefepime, the PTA at 50% and 100% T>MIC in the CSF were 91.8% and 82%, respectively. The CSF pharmacodynamics against S. pneumoniae for cefepime were superior to that of ceftriaxone. The implications of these findings need to be reexamined in the clinical setting.

T-cell-stimulating protein A elicits immune responses during meningococcal carriage and human disease

In recognition of the need for immunological memory-inducing components for future Neisseria meningitidis group B vaccines, we previously searched the proteome of N. meningitidis and identified T-cell-stimulating protein A (TspA). This study was designed to confirm the immunogencity of TspA and to examine the subset of T-helper cell responses to the protein in patients and nasopharyngeal carriers. The tspA gene was reconstructed, cloned, and expressed in Escherichia coli, and the recombinant TspA (rTspA) protein was affinity purified. T-cell proliferative responses to rTspA were detected in the peripheral blood mononuclear cells (PBMCs) of convalescent patients and carriers, confirming that TspA-specific T-cell responses were stimulated by invasive disease and nasopharyngeal colonization. Following stimulation of PBMCs with meningococcal lysate, increased frequencies of both Th1 and Th2 cells were observed, indicating that, as during carriage, invasive meningococcal disease induced an unbiased T-helper subset response. A similar unbiased T-helper response was also detected against rTspA in the PBMCs of convalescent patients. The response of PBMCs from the carriers to TspA stimulation, however, was very weak, and the frequencies of cytokine-positive CD4 cells were not significantly greater than the frequencies in unstimulated control cultures. All of the patients and carriers responded with serum antimeningococcal immunoglobulin G (IgG) antibodies, while four of six samples from patients and 5 of 14 samples from carriers contained detectable anti-rTspA IgG antibodies. Taken together, the results of this study confirmed the immunogenicity of TspA in humans during natural meningococcal infection, and therefore, TspA is worthy of further investigation as a possible T-cell stimulating component of future vaccines.

Prevalence of antimicrobial resistance in bacteria isolated from central nervous system specimens as reported by U.S. hospital laboratories from 2000 to 2002

Background

Bacterial infections of the central nervous system, especially acute infections such as bacterial meningitis require immediate, invariably empiric antibiotic therapy. The widespread emergence of resistance among bacterial species is a cause for concern. Current antibacterial susceptibility data among central nervous system (CNS) pathogens is important to define current prevalence of resistance.

Methods

Antimicrobial susceptibility of pathogens isolated from CNS specimens was analyzed using The Surveillance Database (TSN^®) USA Database which gathers routine antibiotic susceptibility data from >300 US hospital laboratories. A total of 6029 organisms derived from CNS specimen sources during 2000–2002, were isolated and susceptibility tested.

Results

Staphylococcus aureus (23.7%) and Streptococcus pneumoniae (11.0%) were the most common gram-positive pathogens. Gram-negative species comprised approximately 25% of isolates. The modal patient age was 1 or <1 year for most organisms. Prevalence of MRSA among S. aureus from cerebrospinal fluid (CSF) and brain abscesses were 29.9–32.9%. Penicillin resistance rates were 16.6% for S. pneumoniae, 5.3% for viridans group streptococci, and 0% for S. agalactiae. For CSF isolates, ceftriaxone resistance was S. pneumoniae (3.5%), E. coli (0.6%), Klebsiella pneumoniae (2.8%), Serratia marcescens (5.6%), Enterobacter cloacae (25.0%), Haemophilus influenzae (0%). Listeria monocytogenes and N. meningitidis are not routinely susceptibility tested.

Conclusions

Resistance is commonly detected, albeit still at relatively low levels for key drugs classes such as third-generation cephalosporins. This data demonstrates the need to consider predominant resistance phenotypes when choosing empiric therapies to treat CNS infections.

Vaccines against bacterial meningitis

Meningitis remains an important cause of morbidity and mortality among children >5 years of age and is especially prevalent in developing countries. Effective routine immunization against Hib, pneumococcus and serogroupC meningococcus has had a significant impact on both invasive disease and carriage caused by these encapsulated bacteria. The major challenge in prevention of meningitis remains the delivery of vaccines worldwide, especially to resource-poor regions with the greatest disease burden.