Burden of bacterial meningitis in India: Preliminary data from a hospital based sentinel surveillance network

Pneumococcal serotype prevalence and antibiotic resistance in children in South and Southeast Asia, 2012-2024

This narrative review describes pneumococcal serotype prevalence for invasive disease and carriage and antibiotic resistance among specimens collected from children in countries across South and Southeast Asia from 2012 to 2024. Literature search retrieved 326 articles; 96 were included. The prevalence of pneumococcal serotypes varied geographically and over time after introduction of pneumococcal conjugate vaccine. Serotypes common in both pneumococcal carriage and disease were 6A, 6B, 14, 15B/15C, 19F, and 23F; serotypes 1, 3, 5, 19A, 15A, 10A, and 35B were also common in disease. Most of these serotypes are included in the 13-valent and 10-valent PCV. Carriage and disease isolates remained generally highly susceptible to vancomycin (mostly 100%) and levofloxacin (mostly >97%). These findings indicate that vaccine-preventable serotypes contribute significantly to pneumococcal disease burden in children in South and Southeast Asia. Consistency of national immunization programs with World Health Organization recommendations may reduce rates of pneumococcal disease in this region.

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Serotype distribution of invasive pneumococcal disease from countries of the WHO Africa, Americas, Eastern Mediterranean, South-East Asia, and Western Pacific regions: a systematic literature review from 2010 to 2021

Background

Most publications on invasive pneumococcal disease (IPD) serotype distribution are from about 20 countries (Australia, Canada, China, European Union members, Japan, New Zealand, South Korea, and USA). Here, we reviewed the literature among underrepresented countries in the Americas (AMRO), Africa (AFRO), Eastern Mediterranean (EMRO), South-East Asia (SEARO), and Western Pacific (WPRO) WHO regions.

Methods

We performed a systematic review of the most recent IPD serotype surveillance publications (from 01/01/2010 to 31/12/2021, Medline/Embase) in those WHO regions. Selection criteria were delineated by contemporality, within-country geographical scope, and number of samples. Reported serotype distributions for each country were stratified by age group, pneumococcal conjugate vaccine (PCV) serotype category (considering undifferentiated serotypes), and PCV program period (pre-PCV, intermediate, or PCVhv [higher valency PCV formulation]). Pre-PCV period pooled data estimated PCV serotype category distribution by age group across WHO regions, while for the PCVhv period, country-level dataset tables were prepared.

Results

Of 2,793 publications screened, 107 were included (58 pediatric, 11 adult, 37 all ages, and one comprising every age group). One-third of eligible countries (51/135) published serotype distribution, ranging from 30 to 43% by WHO region. Considering number of samples per WHO region, a few countries prevailed: AMRO (Brazil), AFRO (South Africa, Malawi, and Burkina Faso), and WPRO (Taiwan). In the pre-PCV period, PCV13 formulation serotypes predominated: ranging from 74 to 85% in children and 58-86% in adults in the different WHO regions. The PCVhv period represented half of the most recent IPD surveillance by countries (26/51). Undifferentiated serotypes represented >20% of IPD from most countries (34/51).

Conclusion

Ubiquity of undifferentiated serotypes among the publications could constrain estimates of PCV program impact and of serotype coverage for newer PCVhv formulations; consequently, we recommend that countries favor techniques that identify serotypes specifically and, rather than reporting PCV formulation serotype distributions, provide serotype results individually.

Systematic review registration

The protocol has been prospectively registered at PROSPERO, identifier: CRD42021278501. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278501.

Demographic profiles and risk factors for mortality in acute meningitis: A nationwide population-based observational study

Aim

Acute meningitis encompasses bacterial, viral (aseptic), fungal, tuberculous, and carcinomatous meningitis. The rate and risks of mortality in each type remain uncertain. This study aimed to elucidate these aspects in each type of meningitis.

Methods

This study utilized Japan's nationwide administrative Diagnosis Procedure Combination (DPC) database. Patients with acute meningitis, treated at 1132 DPC-covered hospitals from 2016 to 2022, were enrolled.

Results

Among 47,366,222 cumulative hospitalized patients, 48,758 (0.10%) were hospitalized with acute meningitis. The types of meningitis were as follows: 10,338 with bacterial, 29,486 with viral/aseptic, 965 with fungal, 678 with tuberculous, and 3790 with carcinomatous meningitis. Bacterial and viral meningitis exhibited bimodal age distributions, with the first peak occurring at 0-9 years. The median onset age was below 50 years only in viral meningitis. The mortality rate was the highest in carcinomatous meningitis (39%), followed by fungal meningitis (21%), and the lowest in viral meningitis (0.61%). Mortality rates increased with age across all meningitis types, but this trend was less prominent in carcinomatous meningitis. The duration from admission to mortality was longer in fungal and tuberculous meningitis compared with other types. Staphylococcus aureus in bacterial meningitis (adjusted odds ratio 1.71; p = 0.0016) and herpes simplex virus in viral meningitis (adjusted odds ratio 1.53; p = 0.0467) exhibited elevated mortality rates.

Conclusion

Distinct demographic profiles and mortality rates were observed among different meningitis types. The high mortality rates in less common types of meningitis emphasize the necessity to further optimize the required diagnostic and treatment strategies.

A scoping review on laboratory surveillance in the WHO Southeast Asia Region: Past, present and the future

Background

The South-East Asia (SEA) region bears a significant proportion of the world's communicable disease burden. The onset of the COVID-19 pandemic has further affected the situation. A well-established laboratory-based surveillance (LBS) can reduce the burden of infectious diseases. In light of this, the review collated the existing literature on LBS system in the region and the modifications adopted by the surveillance systems during the pandemic.

Methodology

We followed the guidelines for scoping review as prescribed by Arskey and O'Malley. We comprehensively searched three databases (PubMed, Scopus and CINAHL) and supplemented it with grey literature search. The screening of the articles was conducted at the title and abstract followed by full-text screening. This was followed by data extraction using a pre-tested data extraction tool by two independent reviewers. The results were presented narratively.

Results

Including 75 relevant articles and documents, we compiled a list of surveillance systems. A shift from paper to dual (paper and electronic) modalities was identified across the countries. This largely low- and middle-income countries (LMIC) area face challenges in reporting, resources, and collaboration-related issues. While some countries have well-established National Reference Laboratories; others have more private than public-owned laboratories. Given the COVID-19 pandemic, modifications to the existing laboratory capacities to enable real-time surveillance was identified. Laboratory capacity complemented with genomic surveillance can indubitably aid in disease detection and control. Limitations due to inaccessible government portals, and language barriers are acknowledged. This review identified a comprehensive list of surveillance systems in the region, challenges faced in using these surveillance systems and inform the decision makers about the benefits of integrating fragmented surveillance systems.

Conclusion

Regionally and nationally integrated genomic and laboratory surveillance systems justify capital investments, as their payoffs rationalise such costs owing to economies of scale over time. Further, as data flows are harmonized and standardized, algorithm- and computing-based pattern recognition methods allow for targeted and accurate disease prediction when integrated with, potentially, climate and weather systems data. Trained human resources are a sine qua non to optimize such investments, but in the medium to long run, such investments will buttress initiatives in other arenas at the regional level.

Meningococcal Disease Burden in India: A Systematic Review and Meta-Analysis

Objective

To perform systematic review and meta-analysis of meningococcal disease burden in India.

Methods

We searched publications on meningococcal disease in India between 1996 and 2020 using PubMed and Google Scholar. Prevalence (proportion) of Meningococcal meningitis and Case-fatality ratio (CFR) were pooled using random effects model. Other outcomes were pooled qualitatively.

Results

The prevalence of Meningococcal meningitis in epidemic and endemic conditions was 12.1% (95% CI: 5.2-21.4) and 0.76% (95% CI: 0.3-1.4), respectively, with a CFR of 12.8% (95% CI: 6.8-20.4) in epidemic settings; N. meningitis caused 3.2% (95% CI: 1.6-5.3) of Acute Bacterial Meningitis (ABM) cases in endemic settings. The disease appeared in infants, adolescents, and adults with Serogroup A prevalence. Treatment and prophylaxis were limited to antibiotics despite increased resistance.

Conclusion

The study reveals epidemic and endemic presence of the disease in India with high fatality and serogroup A prevalence. Further monitoring and immunization are required to prevent outbreaks.

Safety and immunogenicity of a multidose vial formulation of 13-valent pneumococcal conjugate vaccine administered with routine pediatric vaccines in healthy infants in India: A phase 4, randomized, open-label study

PURPOSE

This phase 4, randomized, open-label, multicenter study in healthy Indian infants and toddlers evaluated the safety, tolerability, and immunogenicity of the 13-valent pneumococcal conjugate vaccine (PCV13) formulated in a multidose vial (MDV) or single prefilled syringe (PFS).

METHODS

Healthy Indian infants (6 weeks of age) were randomized 1:1 to receive either PCV13-MDV or PCV13-PFS concomitant with routine pediatric vaccines. Subjects received a single dose of either PCV13-MDV or PCV13-PFS as a 4-dose schedule (infant series: 1 dose at 6, 10, and 14 weeks of age; toddler dose: 12 months of age). Safety was assessed, including local reactions, systemic events, and adverse events (AEs). Immunogenicity 1 month after both the infant series and toddler dose was measured by concentrations of serotype-specific immunoglobulin G (IgG) antibodies and opsonophagocytic activity titers.

RESULTS

Rates and severities of local reactions and systemic events up to 7 days after each dose of either PCV13-MDV or PCV13-PFS were generally similar, with the majority being of mild or moderate severity. PCV13-MDV had a safety profile comparable with PCV13-PFS; both groups experienced a similar frequency of AEs. PCV13-MDV elicited immune responses comparable with those induced by PCV13-PFS. Clear boosting of immune responses after the PCV13-MDV toddler dose was observed; ≥96% of subjects showed serotype-specific IgG concentrations at or above the defined thresholds 1 month after the PCV13-MDV toddler dose.

CONCLUSIONS

PCV13-MDV was safe, well tolerated, and immunogenic in healthy Indian infants and toddlers when coadministered with routine pediatric vaccinations. Safety and immunogenicity of PCV13-MDV was comparable with PCV13-PFS.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov: NCT03548337.

Differential ubiquitination as an effective strategy employed by the Blood-Brain Barrier for prevention of bacterial transcytosis

The protective mechanisms of blood-brain barrier (BBB) prohibiting entry of pathogens into central nervous system (CNS) is critical for maintenance of brain homeostasis. These include various intracellular defence mechanisms which are vital to block transcytosis of neurotropic pathogens into the CNS. However, mechanistic details of coordination between these defence pathways remain unexplored. In this study, we established that BBB driven ubiquitination acts as a major intracellular defence mechanism for clearance of S. pneumoniae (SPN), a critical neurotropic pathogen, during transit through BBB. Our findings suggest that BBB employs differential ubiquitination with either K48 or K63-Ub chain topologies as an effective strategy to target SPN towards diverse killing pathways. While K63-Ub decoration triggers autophagic killing, K48-Ub directs SPN exclusively towards proteasomes. Time-lapse fluorescence imaging involving proteasomal marker LMP2 revealed that in BBB, majority of the ubiquitinated SPN were cleared by proteasome. Fittingly, inhibition of proteasome and autophagy pathway led to accumulation of K48-Ub and K63-Ub marked SPN, respectively, and triggered significant increase in intracellular SPN burden. Moreover, genetic impairment of either K48 or K63-Ub chain formation demonstrated that though both chain types are key in disposal of intracellular SPN, K48-Ub chains and subsequent proteasomal degradation has more pronounced contribution towards intracellular SPN killing in BBB. Collectively, these observations for the first time illustrated a pivotal role of differential ubiquitination deployed by BBB in orchestrating a symphony of intracellular defence mechanisms for interception and degradation of SPN, blocking its entry into the brain which could be exploited to prevent bacterial CNS infections. IMPORTANCE Blood-Brain Barrier (BBB) represents a unique cellular barrier which provides structural integrity and protection to CNS from pathogen invasion. Recently, ubiquitination, which is key for cellular homeostasis, is shown to be involved in pathogen clearance. In this study, we deciphered that BBB deploys differential ubiquitination as an effective strategy to prevent SPN trafficking into the brain. The different ubiquitin chain topologies formed on SPN dictated the selection of downstream degradative pathways, namely, autophagy and proteasomes, amongst which the contribution of proteasomal system in SPN killing is more pronounced. Overall our study revealed how BBB deploys differential ubiquitination as a strategy for synchronization of various intracellular defence pathways, which work in tandem to ensure brain's identity as an immunologically privileged site.

The Most Influential Papers in Infectious Meningitis Research: A Bibliometric Study

Background

Bibliometric analyses allow detecting citation trends within a field, including assessments of the most cited journals, countries, institutions, topics, types of study, and authors.

Objective

The aim of this study was to perform a bibliometric analysis of the 100 most cited papers within infectious meningitis research.

Materials and Methods

The 100 most cited publications and their data were retrieved from Scopus and Web of Science during 2019.

Results

The New England Journal of Medicine had the greatest number of articles (27) and citations (12,266) in the top 100. Articles were mainly published after the late 1980s. Bacteria were the most discussed agents (72 articles and 26,362 citations), but Cryptococcus sp represented the most-discussed single agent (16 articles and 6,617 citations). Primary research represented 70 articles and 25,754 citations. Among them, the most discussed topic was Clinical Features and Diagnosis/Outcomes (22 articles and 8,325 citations). Among the 27 secondary research articles, the most common type of study was Narrative Review (18 articles and 5,685 citations). The United States was the country with the greatest number of articles (56) and citations (21,388). Centers for Disease Control and Prevention (CDC) and Yale University had the greatest number of articles (six each), being CDC the most cited (3,559).

Conclusions

The most cited articles within meningitis research are primary research studies, more frequently published in high IF journals and by North American institutions. Bacterial meningitis comprises the majority of publications. The articles were mainly published after the AIDS pandemic and after the implementation of the main vaccines for meningitis.

A phase 4 study of the safety of the 13-valent pneumococcal conjugate vaccine in children 6 to 17 years of age in India

PURPOSE

The 13-valent pneumococcal conjugate vaccine (PCV13) was recently approved in India for the prevention of pneumococcal disease in children aged 6 to 17 years based on global data as well as immunogenicity and safety findings from a phase 3 study. The current phase 4 study in India further evaluated the safety profile of PCV13 in this age group to support the positive benefit-risk profile of PCV13.

METHODS

Healthy male and female children aged 6 to 17 years in India were administered a single intramuscular injection of PCV13. Through 7 days after PCV13 administration, local reactions and systemic events were recorded daily by caregivers in an electronic diary. Adverse events (AEs) were collected from the provision of informed consent through 28-42 days postvaccination.

RESULTS

One hundred subjects enrolled in and completed the study. After PCV13 vaccination, 73.9% and 57.8% of subjects reported local reactions and systemic events, respectively. The majority of reactogenicity events were mild to moderate in severity, with injection site pain and fatigue the most frequently reported local reaction and systemic event, respectively. Six subjects reported 7 AEs, all of which were considered unrelated to PCV13. One subject reported a serious AE (acute hepatitis), which was considered unrelated to PCV13 and ultimately resolved. No subjects withdrew because of AEs, and there were no deaths.

CONCLUSION

PCV13 vaccination was well tolerated with an acceptable safety profile in healthy subjects aged 6 to 17 years in India. This work further supports the safety profile of PCV13 for prevention of pneumococcal disease in this age group in India.

Hospital-based sentinel surveillance for bacterial meningitis in under-five children prior to the introduction of the PCV13 in India

INTRODUCTION

A hospital-based sentinel surveillance network for bacterial meningitis was established in India to estimate the burden of bacterial meningitis, and the proportion of major vaccine-preventable causative organisms. This report summarises the findings of the surveillance conducted between March 2012, and September 2016 in eleven hospitals.

METHODS

We enrolled eligible children with bacterial meningitis in the age group of one to 59 months. CSF samples were collected and processed for biochemistry, culture, latex agglutination, and real-time PCR. Pneumococcal isolates were serotyped and tested for antimicrobial susceptibility.

RESULTS

Among 12 941 enrolled suspected meningitis cases, 586 (4.5%) were laboratory confirmed. S. pneumoniae (74.2%) was the most commonly detected pathogen, followed by H. influenzae (22.2%), and N. meningitidis (3.6%). Overall 58.1% of confirmed bacterial meningitis cases were children aged between one, and 11 months. H. influenzae meningitis cases had a high (12.3%) case fatality rate. The serotypes covered in PCV13 caused 72% pneumococcal infections, and the most common serotypes were 14 (18.3%), 6B (12.7%) and 19F (9.9%). Non-susceptibility to penicillin was 57%. Forty-five (43.7%) isolates exhibited multidrug resistance, of which 37 were PCV13 serotype isolates.

CONCLUSIONS

The results are representative of the burden of bacterial meningitis among under-five children in India. The findings were useful in rolling out PCV in the National Immunization Program. The non-susceptibility to penicillin and multidrug resistance was an important observation. Timely expansion of PCV across India will significantly reduce the burden of antimicrobial resistance. Continued surveillance is needed to understand the trend after PCV expansion in India.

MRI Spectrum of Haemophilus influenzae Meningoencephalitis in Children

Background and Purpose:

Haemophilus influenzae type b (Hib) infection occurs mostly in children and is transmitted from person to person through the respiratory pathway. Hib strain is associated with meningitis or encephalitis. It is not an uncommon infection, particularly, in the developing world. This prospective cohort study was done with the aim of describing imaging findings in patients with Hib meningoencephalitis.

Materials and Methods:

In a prospective cohort study, consecutive children admitted in the pediatric emergency unit with acute febrile encephalopathy were enrolled. The clinical details, CSF analysis, and microbiological and serological investigations were recorded on a case record proforma. Children with confirmed Hib meningoencephalitis were included in this study. Clinicoradiological features were assessed.

Results:

A total of 16 patients with acute febrile encephalopathy, in whom CSF latex agglutination, CSF culture, or CSF multiplex PCR were positive for H. influenzae were included in this study. All these children were investigated with magnetic resonance imaging (MRI) brain. Important imaging findings were meningitis, predominantly around frontoparietal lobes (43%), cerebritis (28%), ventriculitis (14%), and subdural collections (21.5%). One patient had features consistent with acute disseminated encephalomyelitis (ADEM) while four patients had normal MRI scan.

Conclusions:

H. influenzae is still a common cause of meningitis in infants and children in the developing world. We have tried to study the most common MRI features associated with Hib infection to help radiologists alert the treating clinicians to further investigate these patients for appropriate prognostication.

A systematic literature review on the prevalence and etiology of meningitis among critically ill and hospitalized patients in India

BACKGROUND

In India, owing to multiple factors, such as insufficient laboratory capacity, poor reporting systems due to limited access to healthcare facilities and limited disease surveillance programmes, the actual disease burden of meningitis is unknown and may be largely under-reported.

OBJECTIVE

A systematic literature review was performed to describe: (a) the prevalence of meningitis; and (b) its etiological pathogen across different regions, age groups and patients with comorbidities.

METHOD

A systematic literature search was conducted between 1990 and 2020 using PubMed and Google Scholar databases to identify Indian studies reporting the prevalence rates and etiology of meningitis. A total of 51 studies were included in the final analysis.

RESULTS

A total of 38 studies reported prevalence of meningitis and 21 studies reported data on the etiology of meningitis in India. These studies included mixed patient populations: (a) pyogenic meningitis; (b) meningitis in sick or hospitalized patients with tuberculosis, acute febrile encephalopathy syndrome, septicaemia, invasive pneumococcal disease or respiratory compromise; and (c) meningitis patients with comorbidities. The prevalence of confirmed bacterial meningitis in the pediatric population (0-14 years) ranged between 0.5% and 61.8%. A total of seven studies reported the prevalence of meningitis in patients of all age groups (0-75 years), with prevalence ranging between 8.68% and 78.85%. Cryptococcal meningitis was predominant in patients with positive HIV/AIDS, with a prevalence ranging between 2.09% and 53.1%. Streptococcus pneumoniae was found to be the predominant pathogen causing meningitis across different regions of India, with a frequency ranging from 4% to 61.8% in patients of all age groups.

CONCLUSION

This systematic literature review displayed the possible range of frequency of bacterial meningitis pathogens across a wide variety of age groups in different regions of India. Further studies are warranted to monitor meningitis cases, which may facilitate the development of prevention and treatment strategies in India.

Clinical Profile and Outcome of Children with Acute Central Nervous System Infection in Kerala, India

Background and aims: Infection of the central nervous system is a significant cause of morbidity and mortality in children. The aim of this study was to evaluate clinical profile and outcome of children aged 1 month to 15 years admitted with acute central nervous system infection between 2008 and 2020 in the Department of Pediatrics, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, India. Materials and methods: This was a case record based retrospective study. Results: Of 62 children, 44 had meningitis and 18 had encephalitis. Most patients were in the age group 1-5 years old and males were the predominant sex (70.96%). Eighteen patients with meningitis had a clinical triad of fever, headache, and vomiting, while only three with encephalitis experienced this. Seizures and altered sensorium were seen significantly more in children with encephalitis. Cerebrospinal fluid pleocytosis was seen in significantly more patients with meningitis compared with patients with encephalitis. Aetiology for meningitis included pneumococcus, Orientia tsutsugamushi (scrub typhus), meningococcus, and Angiostrongylus cantonensis infection. Causes of encephalitis included enterovirus, mumps virus, herpes simplex virus, dengue virus, and H1N1 influenza virus infection. Paediatric intensive care unit admission was more common for patients with encephalitis. One child with pneumococcal meningitis and another with dengue encephalitis died. Seizures were the most common sequelae. Conclusion: Typical clinical features were not present in most patients with meningitis; therefore, a high index of suspicion is needed for early diagnosis. Exact aetiologies could not be identified in most of the patients. Pneumococcus, scrub typhus, and meningococcus were the aetiological agents identified for meningitis. Encephalitis was attributed to dengue virus, herpes simplex virus, enterovirus, mumps virus, and H1N1 influenza virus infection.

IMPACT OF MOLECULAR METHOD FOR THE DIAGNOSIS OF ACUTE BACTERIAL MENINGITIS IN A TERTIARY HEALTH CARE CENTRE IN NORTH INDIA

Background. Acute bacterial meningitis is one of the significant infectious diseases that add an immense burden to the health system. Proper management of meningitis is an invincible need to overcome the severe consequences. Objectives. The aim of the study is detection of the etiological agents of acute bacterial meningitis by PCR. Methods. Total 267 CSF samples collected from suspected bacterial meningitis cases were processed for the detection of S. pneumoniae, H. influenzae, N. meningitidis, E. coli and Group B streptococci by conventional and molecular diagnosis method. CSF was inoculated on Blood, chocolate and MacConkey agar plates and incubated at 37 °C for 24-48 hrs. Bacteria grown were identified by Matrix assisted laser desorption/ionization time of flight (MALDI-TOF). Multiplex PCR of the enlisted bacteria was performed using DNA extracted from CSF by DNA extraction kit (Qiagen, USA). Results. 5 (1.87%) out of the total 267 CSF samples were culture positive (3 S. pneumoniae and 2 E. coli) and 28 (10.49%) had detectable DNA by conventional PCR. Out of these 28 samples, 20 (71.43%) were S. pneumoniae and 8 (28.57%) were E. coli. 15 (53.57%) out of total S. pneumoniae were present in children below 5 years of age. Similarly, E. coli was predominant in neonates. Sensitivity and specificity of the PCR was 100% and 95-98% respectively. Conclusions. Streptococcus pneumoniae is the commonest cause of community acquired bacterial meningitis in children below five years of age. Hence, for the promising outcome, PCR should be implemented for the diagnosis of acute bacterial meningitis.

A Comprehensive Review of Meningococcal Disease Burden in India

INTRODUCTION

Meningococcal disease caused by Neisseria meningitidis has a high case fatality rate. Of 12 distinct serogroups, A, B, C, W-135 (W) and Y cause the majority of infections. The meningococcal disease burden and epidemiology in India are not reliably known. Hence, we performed a narrative review with a systematically conducted search to summarize information on meningococcal disease burden and epidemiology and vaccination recommendations for meningococcal disease in India.

METHODS

A search of Medline and Embase databases was undertaken to identify relevant publications published in the last 25 years.

RESULTS

Results from 32 original publications, 11 of which were case reports, suggest a significant burden of meningococcal disease and related complications. Meningococcal disease is increasingly reported among adolescents and adults, and large outbreaks have been reported in this population. Meningococcal disease in India is caused almost exclusively by serogroup A; serogroups B, C, W and Y have also been documented. Meningococcal disease burden data remain unreliable because of limited disease surveillance, insufficient laboratory capacity, misdiagnosis and prevalence of extensive antibiotic use in India. Lack of access to healthcare also increases under-reporting, thus bringing the reliability of the data into question. Conjugate meningococcal vaccines are being used for disease prevention by national governments and immunization programs globally. In India, meningococcal vaccination is recommended only for certain high-risk groups, during outbreaks and for international travelers such as Hajj pilgrims and students pursuing studies abroad.

CONCLUSION

Meningococcal disease is prevalent in India but remains grossly underestimated and under-reported. Available literature largely presents outbreak data related to serogroup A disease; however, non-A serogroup disease cases have been reported. Reliable epidemiologic data are urgently needed to inform the true burden of endemic disease. Further research into the significance of meningococcal disease burden can be used to improve public health policy in India. Fig. 1 Plain language summary.

Antibiotic Resistance in Microbes from Street Fruit Drinks and Hygiene Behavior of the Vendors in Delhi, India

Microbial contamination of fruit juices has caused major outbreaks, leading to significant morbidity and mortality in developing countries. The inept hygiene and safety practices followed by the juice vendors are the leading risk factors of the microbial contamination of juices. In this pilot study, the five most crowded markets in urban Delhi, including Kamla Nagar, University of Delhi (north campus), Tilak Nagar, Chandni Chowk, and Rohini, were selected for a questionnaire survey on the fruit juice vendors and the sampling of water used for juice preparation as well as sugarcane, orange, and mix fruit juices collected from these markets for the enumeration of total bacterial count (TBC), Escherichia coli, Salmonella, and Vibrio. Antibiotic susceptibility tests were performed using ampicillin, cefotaxime, chloramphenicol, ciprofloxacin, and imipenem. The results indicated that the majority of the vendors were not following hygiene and safety practices when compared with the recommended standard safety practices. The use of municipal water by 95% of vendors with high TBC counts might have been the major source of microbial contamination in all types of fruit juices. E. coli and Salmonella contaminations were high in sugarcane (2 × 10⁵ colony forming units (CFU)/mL) and mix fruit (2.2 × 10⁵ CFU/mL) juice samples, respectively. On the other hand, Vibrio was found to be absent in almost all juice samples except for orange juice. All strains were found to be susceptible to chloramphenicol, but resistant to ampicillin and cefotaxime. Only a few strains were resistant to ciprofloxacin, and only E. coli strains were resistant to imipenem. Taken together, the overall microbiological standards of fruit juices served by street vendors were not within the acceptable limits, perhaps due to the poor quality of water used to prepare juices and poor hygiene and safety practices followed by the vendors. More importantly, the isolated microbes demonstrated resistance to ampicillin and cefotaxime, which may have pressing public health implications. Post hoc power analyses identified the minimum sample size required for 80% power.

Acute infectious purpura fulminans: a case series from India

Acute infectious purpura fulminans is a serious, potentially fatal condition. We present a case series of 11 patients from March 2005 to March 2017, whose clinical symptoms were fever (100%), confusion (63.6%) and headache (55%), and whose common laboratory abnormalities were thrombocytopenia (100%), elevated alkaline phosphatase (70%) and anaemia (63.6%). Three patients (27%) developed gangrene and two presented in shock. Only one grew Neisseria meningitidis in cerebrospinal fluid (CSF) culture and another confirmed by latex agglutination and polymerase chain reaction in CSF. Five others had serology confirmed spotted fever rickettsioses (SFG). All received broad spectrum antibiotics; in 9/11 patients, this included doxycycline or azithromycin. The mean hospital stay was 10.2 days and overall mortality was 18.2%.

Magnetic Resonance Imaging Cerebrospinal Fluid Hydrodynamics in Patients with Meningitis

OBJECTIVE

The objective of the study was to evaluate the cerebrospinal fluid (CSF) flow alterations in meningitis using phase-contrast magnetic resonance imaging (PCMRI).

MATERIALS AND METHODS

Fifty patients with clinically confirmed or strongly suspected infectious meningitis and 20 controls were evaluated with MRI. Quantitative CSF analysis was performed at the level of cerebral aqueduct using cardiac-gated PCMRI. Velocity encoding (Venc) was kept at 20 cm/s. Patients were subdivided into Group I (patients with hydrocephalus [n = 21]) and Group II (patients without hydrocephalus [n = 29]).

RESULTS

The mean peak velocity and stroke volume in controls were 2.49 ± 0.86 cm/s and 13.23 ± 6.84 µl and in patients were 2.85 ± 2.90 cm/s and 16.30 ± 20.02 µl, respectively. A wide variation of flow parameters was noted in meningitis irrespective of the degree of ventricular dilatation. A significant difference in peak velocity and stroke volume was noted in Group II as compared to controls. Viral meningitis showed milder alteration of CSF flow dynamics as compared to bacterial and tuberculous etiologies. At a cutoff value of 3.57 cm/s in peak CSF velocity, the specificity was 100% and sensitivity was 22.7% to differentiate between viral and non-viral meningitis.

CONCLUSION

Alteration of CSF flow dynamics on PCMRI can improve segregation of patients into viral and non- viral etiologies, especially in those in whom contrast is contraindicated or not recommended. This may aid in institution of appropriate clinical treatment.

Hospital-based sentinel surveillance for Streptococcus pneumoniae and other invasive bacterial diseases in India (HBSSPIBD): design and methodology

INTRODUCTION

Streptococcus pneumoniae is one of the frequently isolated organisms and an important aetiological agent of invasive bacterial diseases (IBD) like pneumonia, meningitis and sepsis. As a measure to control the burden of IBD, the Government of India introduced Pneumoccocal Conjugate Vaccine-13 (PCV-13) in the Universal Immunization Program in high burden districts of five states in a phased manner from 2017 onwards. It is essential to understand the trend of circulating pneumococcal serotypes associated with IBD in the prevaccination and postvaccination scenarios to decide on the expansion of vaccination programmes and PCV reformulation. This manuscript describes the protocol for hospital-based sentinel surveillance for S. pneumoniae and other organisms causing IBD across various geographical regions in India.

METHODS AND ANALYSIS

Hospital-based surveillance is established in selected hospitals to recruit children aged 1-59 months with symptoms of pneumonia and other IBD. Diagnostic criteria were adapted from standard WHO case definitions. Case Report Forms (CRFs) are used to collect data from the enrolled children. Blood, cerebrospinal fluid (CSF) and other normally sterile body fluids are collected and subjected to microscopy, cytology, latex agglutination, biochemistry, bacteriological culture and real-time PCR as applicable. Pneumococcal isolates are serotyped and tested for assessing antimicrobial resistance patterns. Data will be analysed by simple descriptive statistics to estimate the proportion of pneumonia and other IBD due to S. pneumoniae, Hemophilus influenzae type b and Neisseria meningitidis. Prevalence of bacterial infection, circulating pneumococcal serotypes, antibiotic resistance patterns, serotype variability across seasons and regions will be described in terms of percentage with 95% confidence interval.

ETHICS AND DISSEMINATION

The institutional review boards of the coordinating centre, all sentinel sites, regional and national reference laboratories approved the project. The results will be published in peer-reviewed journals and shared with stakeholders for deciding on revising vaccination strategy appropriately.

Isolation and identification of Streptococcus pneumoniae serotype 6B from a patient with bacterial meningitis infection in Jakarta, Indonesia

CNS infection is a life-threatening condition in developing countries and Streptococcus pneumoniae has been reported as the most common cause of bacterial meningitis; however, there is limited data on pneumococcal meningitis in Indonesia. This cross-sectional study aimed to isolate and identity S. pneumoniae strains from cerebrospinal fluid (CSF) specimens collected as part of routine testing from patients with clinically diagnosed central nervous system infection at a national referral hospital in Jakarta, Indonesia in 2017. S. pneumoniae isolation and identification were performed using conventional culture and molecular tools. Antibiotic susceptibility patterns were monitored through minimum inhibitory concentration testing. From 147 CSF specimens, one S. pneumoniae strain was identified from a patient with bacterial meningitis symptoms. The isolate was serotype 6B (ST5661) and susceptible to 18 antimicrobial agents tested, including penicillin, tetracycline, and the macrolide group. Our data provide insights into the epidemiology of invasive pneumococcal disease in Indonesia.

Meningococcal Meningitis: A Multicentric Hospital-based Study in Kathmandu, Nepal

Background:

The global epidemiology of meningococcal disease varies markedly by region and over time. In Nepal, information on serogroup of meningococci is not available since the 1983 serogroup A epidemic in Kathmandu.

Objective:

To provide some fundamental data on the circulating serogroups of meningococci for potential meningococcal immunization programs in Nepal.

Methods:

This cross-sectional prospective study was conducted from January 2017 to December 2018 among 387 clinically suspected meningitis cases. Cerebrospinal fluid samples were collected by lumbar puncture technique at five referral hospitals of Kathmandu and processed by conventional cultural techniques. Neisseria meningitidis was identified by colony morphology, Gram staining and oxidase test. Serogrouping of meningococci was performed by slide agglutination test. Antibiotic susceptibility testing was done by the modified Kirby Bauer disc diffusion method. The data was entered into IBM SPSS Statistics 21 software and a p-value of <0.05 was considered significant.

Results:

Thirty-two samples were positive by culture for a bacterial pathogen with 2.3% of meningococci. All except one meningococcal meningitis cases were aged below 15 years. All N.meningitidis isolates belonged to serogroup A and were susceptible to ceftriaxone, chloramphenicol, meropenem and minocycline; however, 22% isolates showed resistance to cotrimoxazole and 11% intermediate resistance to ciprofloxacin.

Conclusion:

The circulating serogroup of N. meningitidis in Kathmandu has not changed over the past 35 years. The prevalence of meningococcal meningitis in Kathmandu is low but might be underestimated due to the sole use of culture-based diagnostic methods. Detection of meningococci by alternative methods may be useful in the precise estimation of actual disease burden.

Pneumococcal vaccines

Streptococcus pneumoniae continues to take a heavy toll on childhood mortality and morbidity across the developing world. An estimated 10.6 million invasive pneumococcal diseases (IPDs) occur every year, with nearly 1 million deaths in children under 5 years of age. Introduction of vaccines in the childhood immunisation programme in developed world has brought down the incidence of the disease considerably. However, childhood immunocompromising illnesses including HIV have increased the risk of IPD several folds. There is also a growing concern on the increasing antibiotic resistance among these invasive strains to penicillin, other beta-lactams and macrolides, making treatment difficult and expensive. It is estimated that about 62% of IPD worldwide is caused by the 10 most common serotypes. Although the ranking of individual pneumococcal serotypes causing serious disease varies among nations, the 7-13 serotypes included in pneumococcal conjugate vaccines (PCVs) may prevent 50%-80% of all paediatric pneumococcal diseases globally. The World Health Organization has recommended the use of PCV-10/13 in the national immunisation programmes (NIPs) of developing countries. Four doses of PCV-13 have been recommended by the US Association of Pediatrics and Centers for Disease Control and Prevention, at intervals of each 2 months for the first 6 months and by the 12^th to 15^th months after birth. This is expected to reduce the morbidity and mortality associated with IPD and simultaneously decrease colonisation with circulating antibiotic-resistant strains in immunized communities. Nevertheless, continued surveillance of antimicrobial resistance in non-vaccine serotypes is necessary to prevent the resurgence of resistance. Other virulence factors which are not serotype specific also need to be studied to overcome the drawbacks of serotype-specific pneumococcal vaccines. PCV-13 was launched during May 2017 under the NIP of five Indian states with the highest pneumococcal diseases in the country and is expected to be rolled out in the other parts of the country in the coming days.