Prevalence and antimicrobial resistance pattern of bacterial meningitis in Egypt

Management and prevention of Neisseria meningitidis and Neisseria gonorrhoeae infections in the context of evolving antimicrobial resistance trends

PURPOSE

To describe the relationships between Neisseria meningitidis (NM) and Neisseria gonorrhoeae (NG) at genetic, population, and individual levels; to review historical trends in antimicrobial resistance (AMR); to review the treatment and preventive landscapes and explore their potential impact on AMR.

METHODS

A narrative literature search was conducted in PubMed, with searches restricted to 2003-2023 and additional articles included based on expertise.

RESULTS

NM and NG are closely related bacterial pathogens causing invasive meningococcal disease (IMD) and gonorrhea, respectively. NM can currently be treated with most antibiotics and generally has a wild-type susceptibility profile, whereas NG is increasingly resistant even in the first line of treatment. These pathogens share 80-90% genetic identity and can asymptomatically cohabit the pharynx. While AMR has historically been rare for NM, recent reports show this to be an emerging clinical concern. Extensively drug-resistant NG are reported globally, with data available from 73 countries, and can lead to treatment failure. Importantly, Neisseria commensals within the normal microbiota in the pharynx can act as a genetic reservoir of resistance to extended-spectrum cephalosporins. Novel oral antibiotics are urgently needed to treat a growing threat from antibiotic-resistant NG, recognized as a major global concern to public health by the World Health Organization. Numerous vaccines are available to prevent IMD, but none are approved for gonorrhea. Research to identify suitable candidates is ongoing.

CONCLUSION

Holistic management of AMR in IMD and gonorrhea should couple judicious use of existing antibiotics, optimization of vaccination programs, and development of novel antibiotics and vaccines.

Meningococcal Disease and Immunization Activities in Hajj and Umrah Pilgrimage: a review

Invasive meningococcal disease (IMD) outbreaks associated with Hajj and Umrah pilgrimage events in the Kingdom of Saudi Arabia (KSA) are well recognized. Past outbreaks have been associated with substantial intercontinental spread of specific Neisseria meningitidis serogroups. The emergence of meningococcal serogroup W (MenW) was a global concern following the 2000/2001 Hajj outbreaks. Broader compulsory meningococcal serogroups A, C, W and Y (MenACWY) immunization strategies for pilgrims were introduced in response to these events and led to substantial declines in IMD cases associated with these mass gatherings. However, there remains potential for future outbreaks either within KSA during the Hajj or in local populations via pilgrim meningococcal transmission on their return. While the annual Hajj involves pilgrims from over 185 countries, two-thirds of these arrive from 13 countries, chiefly from across South-East Asia, the Middle East and North African (MENA) regions; for which we review the relevant epidemiology of IMD and meningococcal carriage. While disease surveillance is limited and data are often lacking, MenB is an important serogroup associated with IMD and carriage in a number of countries. Available literature suggests that most pilgrims receive polysaccharide MenACWY vaccines (which do not impact carriage and onward transmission) and incomplete compliance with visa/entry immunization regulations is reported. Existing preventative approaches for visiting pilgrims require continued oversight. More complete compliance and switching to the conjugated MenACWY vaccine can provide more robust and broader protection for pilgrims. Additional immunization options could also be considered.

A Systematic Review of Pneumococcal Carriage, Disease, Antimicrobial Resistance, and Vaccination in Egyptian Children Aged 18 Years and Younger

Streptococcus pneumoniae remains an important bacterial pathogen, particularly for young children in low- and middle-income countries. A systematic review was conducted of peer-reviewed literature from PubMed published as of May 13, 2020, to identify articles relevant to invasive pneumococcal disease, pneumonia, otitis media (OM), nasopharyngeal carriage (NPC), antimicrobial resistance (AMR), and vaccination coverage in Egypt, with particular focus on children ≤ 18 years of age. A total of 16 relevant articles spanning three decades were included in this review. Among studies reviewed, S. pneumoniae was the causative agent of meningitis in 21–30% of cases among hospitalized children between 1983 and 2003. One study showed that serotypes 6A and 6B predominated among meningitis cases of pediatric patients aged < 5 years. This review also revealed that S. pneumoniae was the most commonly identified bacterial pathogen of acute mastoiditis, a severe complication of acute OM, among children aged 9 months to 11 years. NPC studies showed that approximately 30% of Egyptian children were carriers of S. pneumoniae. AMR, especially to penicillin, continues to be a growing concern in low- and middle-income countries, including among Egyptian children. Several predominant serotypes were identified to be associated with penicillin resistance, such as 6B, 1, 19A, 23F, and 6A. Currently available pneumococcal vaccines (PCVs) such as PCV10 and PCV13 may provide coverage against the most prevalent circulating serotypes among Egyptian children. Comprehensive disease surveillance and immunization programs are needed to ensure that this vulnerable population is sufficiently protected against pneumococcal disease.

A Review of the Epidemiology of Invasive Meningococcal Disease and Vaccination Strategies in North Africa

OBJECTIVE

This narrative review considers the epidemiology of invasive meningococcal disease (IMD) in North Africa and the adequacy of current preventive measures to provide guidance for future vaccination strategies.

METHODS

Literature searches were conducted using PubMed for articles published from 1998 onwards to identify publications on IMD in North Africa. Additional relevant articles not included within the search results and data sources were identified from the reference lists of identified publications, authors' personal files, and publicly available government or regional surveillance data.

RESULTS

Although IMD is an endemic and notifiable disease in several North African countries, inadequacies exist regarding each country's surveillance, vaccination strategies, and disease understanding. Studies showed bacterial meningitis in North Africa caused by Neisseria meningitidis mostly affects young children (aged <5 years), with meningococcal serogroup B (MenB) being the most frequently identified serotype. Importantly, MenB isolates were genetically heterogeneous. Serogroup A incidence and meningococcal outbreaks decreased over time in Morocco and Egypt, possibly because of their nationwide or school-based vaccination programs. Within the region, meningococcal vaccines are only included in the national immunization program of Egypt.

CONCLUSIONS

Improving IMD diagnosis and surveillance would provide a reliable estimate of IMD burden, leading to better vaccination strategies.

Antimicrobial sensitivity profile and bacterial isolates among suspected pyogenic meningitis patients attending at Hawassa University Hospital: Cross-sectional study

Background

Bacterial meningitis is a serious inflammation of the meninges. Antimicrobial therapy on early cerebrospinal fluid (CSF) examination has an important role in diagnosis. The disease is still challenging in developing countries because of poor (diagnostic set-up, socioeconomic conditions, management), and misuse of antimicrobial therapy results in emerging antimicrobial-resistant strains. Therefore, this hospital based cross sectional study was aimed to assess the antimicrobial sensitivity profile and bacterial isolates among patients suspected of pyogenic meningitis at Hawassa University Hospital from February 2017 to 2018.

Results

A total of 394 patients suspected as meningitis were included. Of these 210 (53.3%) were males and 184 (46.7%) were females. The carriage rate of bacterial pathogens was 27(6.9%). The common clinical presentations were fever 330 (83.8%), headache 205 (52.0%) and neck stiffness 179(45.4%) followed by altered mental status 125(31.7%). Neck stiffness P = 0.001 (AOR = 1.18, 95% CI 1.06–6.53), Hx of seizure P = 0.043, (AOR = 1.39, 95% CI 1.15–5.99), Nuchal rigidity P = 0.001* (AOR = 1.26, 95% CI 1.06–4.48) were significantly associated with culture positivity.

The pathogens isolated in this study were N. meningitidis the most frequent isolate 12(44.4%) followed by S. pneumoniae 5 (18.5%), E. coli 4(14.8%), H. influenza 3(13.6%), S. aureus 2(11.1%) and K. pneumoniae 1(3.7%). S. pneumoniae was (100%) resistance to penicillin, (80%) amoxicillin, and (20%) Cefotaxime. S. aureus was (100%) resistant to penicillin, amoxicillin, and ciprofloxacin. N. meningitidis was (100%) resistant to penicillin, (66.7%) Ceftriaxone and (41.7%) chloramphenicol. In this study a single isolate was also resistant to a different antibiotic.

Conclusion

The prevention of bacterial meningitis needs serious attention since the isolated bacteria showed single and multiple antimicrobial susceptibility patterns and the variable nature of isolated etiological agents makes it reasonable to provide continuous future updates on local resistance of common antibiotics and optimize the most frequent bacteria associated with meningitis in the hospital. Therefore; further, survey study with a better design of antimicrobial susceptibility at large scale to control the spread of antibiotic-resistant bacteria and the change in the causative organism of bacterial meningitis in the study area and at a national level is required.

Prevalence of MDR pathogens of bacterial meningitis in Egypt and new synergistic antibiotic combinations

The aim of this study was identifying bacterial pathogens involved in meningitis, studying their antibiotic resistance profiles, investigating the antibiotic resistance genes as well as evaluating the use of various antibiotic combinations. Antibiotic susceptibility tests were evaluated according to CLSI guidelines. Antibiotic combinations were evaluated by calculating the Fractional Inhibitory Concentration (FIC) index. A total of 71 bacterial isolates were recovered from 68 culture positive CSF specimens. Sixty five of these isolates (91.5%) were recovered from single infection specimens, while 6 isolates (8.4%) were recovered from mixed infection specimens. Out of the 71 recovered isolates, 48 (67.6%) were Gram-positive, and 23 (32.4%) were Gram-negative. Thirty one of the Gram positive isolates were S. pneumoniae (64.6%, n = 48). Out of the recovered 71 isolates; 26 (36.6%) were multidrug-resistant (MDR) isolates of which, 18 (69.2%) were Gram-negative and 8 (30.8%) were Gram-positive. All MDR isolates (100%) showed resistance to penicillin and ampicillin, however, they showed lower resistance to meropenem (50%), levofloxacin (50%), amikacin (48%), pipercillin-tazobactam (45.8%). Most common antibiotic resistance genes were investigated including: tem (21.1%), shv (15.8%), ctx-m (15.8%) coding for TEM-, SHV, CTX-M extended-spectrum beta-lactamases (ESBLs), respectively; aac(6')-I b(26.3%) coding for aminoglycoside 6'-N-acetyltransferase type Ib ciprofloxacin resistant variant; and qnrA (5.3%) gene coding for quinolone resistance. The DNA sequences of the respective resistance genes of some selected isolates were PCR amplified, analyzed and submitted to the GenBank database under the accession numbers, KX214665, KX214664, KX214663, KX214662, respectively. The FIC values for ampicillin/sulbactam plus cefepime showed either additive or synergistic effect against ten tested Gram-negative MDR isolates, while doxycycline plus levofloxacin combination revealed synergism against two MDR Gram-positive isolates. The results indicate high prevalence of antibiotic resistance among MDR isolates. Therefore, new guidelines should be implemented in Egypt to rationalize the use and avoid the misuse and abuse of antimicrobial agents.

Identification of Common Bacterial Pathogens Causing Meningitis in Culture-Negative Cerebrospinal Fluid Samples Using Real-Time Polymerase Chain Reaction

Background. Meningitis is a serious communicable disease with high morbidity and mortality rates. It is an endemic disease in Egypt caused mainly by Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. In some settings, bacterial meningitis is documented depending mainly on positive cerebrospinal fluid (CSF) culture results or CSF positive latex agglutination test, missing the important role of prior antimicrobial intake which can yield negative culture and latex agglutination test results. This study aimed to utilize molecular technology in order to diagnose bacterial meningitis in culture-negative CSF samples. Materials and Methods. Forty culture-negative CSF samples from suspected cases of bacterial meningitis were examined by real-time polymerase chain reaction (real-time PCR) for the presence of lytA, bexA, and ctrA genes specific for Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, respectively. Results. Positive real-time PCR results for Streptococcus pneumoniae were detected in 36 (90%) of culture-negative CSF samples while no positive results for Haemophilus influenzae or Neisseria meningitidis were detected. Four (10%) samples were negative by real-time PCR for all tested organisms. Conclusion. The use of molecular techniques as real-time PCR can provide a valuable addition to the proportion of diagnosed cases of bacterial meningitis especially in settings with high rates of culture-negative results.

Emergence of Neoteric Serotypes Among Multidrug Resistant Strains of Streptococcus pneumoniae Prevalent in Egypt

Background

Streptococcus pneumoniae is still one of the major causes of morbidity and mortality worldwide. The prevalent serotype distribution had shown variation along different studies conducted at different time intervals. In order to efficiently assess the epidemiology of the diseases for effective preventive and treatment strategies, serotype prevalence need to be periodically reassessed.

Objectives

Conducting a reassessment of the prevalent S. pneumoniae serotypes in Egypt as an essential step in the search for a regional vaccine. In addition, monitoring the antibiotic susceptibility patterns of pneumococcal strains currently causing infections as an evaluation of therapeutic strategies applied.

Materials and Methods

A total of 100 specimens of different sources were collected in Cairo, Egypt, from 2011 to 2013, representing almost all different types of diseases caused by S. pneumoniae such as meningitis, pneumonia, otitis media and sinusitis. Conventional and molecular identification methods were performed, the antimicrobial susceptibility patterns were assessed and serotyping was done using PCR assays to identify the most prevalent types. In addition, detection of certain virulence genes for the most prevalent serotypes was carried out.

Results

Our results revealed that in Egypt, currently, the most prevalent serotypes were serogroup 6 and serotype 19F as they represented 58% of all isolates. High rates of resistance were found to different antibiotic classes. The lytA and psaA genes were found to be more sensitive for S. pneumoniae identification than ply.

Conclusions

Our study illustrates the importance of constantly monitoring the prevalent serotypes in any region in order to aid in the development of more effective vaccines.

Clinical, Paraclinical, and Antimicrobial Resistance Features of Community-Acquired Acute Bacterial Meningitis at a Large Infectious Diseases Ward in Tehran, Iran

In this study demographic, clinical, paraclinical, microbiological, and therapeutic features of patients with community-acquired acute bacterial meningitis admitted to a referral center for infectious diseases in Iran, have been evaluated. Medical records of adult (> 18 years) individuals with confirmed diagnosis of community-acquired bacterial meningitis during a 4-year period were retrospectively reviewed. All required data were obtained from patients' medical charts. Available findings about antimicrobial susceptibility of isolated bacteria from CSF and/or blood were also collected. Kirby-Bauer disc diffusion method was used to determine their antimicrobial susceptibility profile. Details of medical management including antibiotic regimen, duration, patients' outcome, and possible sequelae of meningitis were recorded. The most commonly isolated microorganism from CSF or blood of patients was Streptococcus pneumonia (33.33%) followed by Neisseria meningitidis (27.78%) and Haemophilus influenza (16.67%). The most common antimicrobial regimen was ceftriaxone plus vancomycin (69.44%) followed by ceftriaxone plus vancomycin plus ampicillin (11.11%). Neurological sequelae of meningitis including cranial nerve palsy, deafness, and hemiparesis were identified in 4 (11.11%), 2 (5.56%), and 1 (2.78%) subjects, respectively. Regarding mortality, only 3 (8.33%) patients died from bacterial meningitis and the remaining 33 individuals discharged from the hospital. In conclusion, findings of the current study demonstrated that the mean incidence of acute bacterial meningitis in a referral infectious diseases ward in Iran was 9 episodes per year. The majority cases of community-acquired acute bacterial meningitis admitted to our center had negative CSF culture and classic triad of meningitis was absent in them.

Epidemiology and Risk Factors Associated with Developing Bacterial Meningitis among Children in Gaza Strip

BACKGROUND

Bacterial meningitis is still the leading cause of high morbidity and mortality among the children. The present study was conducted to determine the epidemiology, clinical characteristics of bacterial meningitis and to evaluate the risk factors associated with developing the infection.

METHODS

This cross sectional study was conducted in three hospitals of Gaza strip -Palestine during the period 2009. All the children with clinical diagnosis of meningitis /meningoencephalitis admitted to these hospitals were included in the study. They were subjected to clinical examination as well as CSF bacteriological and serological investigations.

RESULTS

During the period (2009), 1853 patients were admitted to the hospitals with suspect of meningitis by pediatricians, 73 (3.9%) proved by culture to be acute bacterial meningitis, of these patients 62% were males and 38% were females. The common isolated pathogens were Neisseria meningitides (47.9%), Streptococcus pneumonia (15.1%), Haemophilus influenza (13.7%), E. coli (11.0%), Enterobacter spp. (6.8%), Citrobacter spp. (2.7%), Providencia spp. (1.4%), and Pseudomonas aeruginosa (1.4%). The common recorded symptoms were fever (78%), neck stiffness (47%), vomiting (37%), poor feeding (19%), and irritability (16%). Statistical analysis showed that there was statistical significance associated developing of infection with malnutrition (low hemoglobin level), high house crowdness and irritability (P-value <0.05). The ANOVA statistical analysis showed that S. pneumonia has an impact on developing low hemoglobin level and leukocytosis.

CONCLUSION

N. meningitides is still dominant and needs vaccination. The risk factors should be taken into consideration in any future plan.

A situational analysis of antimicrobial drug resistance in Africa: are we losing the battle?

BACKGROUND

The first arrival of a sizable shipment of penicillin at the North African Theatre of Operations for USA military use in 1943 was a landmark that turned a new chapter of antibiotic use in Africa. Over the past decade the expansion of resources and the technological advances have meant that much larger quantities of drugs are available in developing countries than ever before. As a result, many more individuals are receiving necessary treatment or therapy than just ten years ago. This very welcome event is accompanied by the terrible irony that increases in drug availability and use can promote drug resistance and render the same life-saving drugs ineffective.

METHODS

The study focused on bacterial pathogens. One hundred and three relevant literatures were identified from the PubMed online database. The coverage included research articles concerning antimicrobial resistance involving subjects of an African country.

RESULTS

Resistant bacteria are on a war path and evidently have acquired an edge over us. Our actions are evidently fuelling the resistance. The indiscriminate use of antibiotics in humans and livestock, wrong and substandard prescriptions by unqualified 'medical personnel' together with poor diagnosis or lack of it are all adding fuel to the already fired train of resistant microbes.

CONCLUSION

To win the war and turn tables as we did with the discovery of penicillin and other antimicrobials in the 1940s, then we must all act now. Antimicrobial stewardship programs-Education, training of laboratory personnel and investment in laboratory infrastructure development are desirable in these situations.