The causative organisms of bacterial meningitis in Korean children in 1996-2005

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

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

Conclusions and Relevance

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

Neonatal meningococcal disease: an update

Purpose of the review: Neisseria meningitidis is a common cause of sepsis in the pediatric population but is only rarely observed in neonates. The true incidence of the disease in that age group remains undefined. The purpose of this review is to summarize the published data on meningococcal disease in the neonatal period.Materials and methods: All published studies reporting data on neonatal meningococcal disease were included for data extraction. Results: Published cases from around the world show that, while rare, neonatal meningococcal disease is characterized by a high mortality rate and serious neurodevelopmental complications. The initial clinical presentation is atypical and there is a rapid clinical deterioration. Predisposing factors have been described and they include immune deficiencies and maternal genitourinary tract colonization by the pathogen. Transmission can be intrauterine, intrapartum or postpartum. Intrapartum transmission has been linked to conjunctivitis, which serves as a point of entry for the pathogen. Conclusions: Neonatal meningococcal disease remains a rare but potentially fatal disease, whose true incidence is not known. Genitourinary colonization of the mother and nasopharyngeal carriage of both parents should be assessed, especially in early onset cases. N. meningitidis should be suspected in cases of neonatal sepsis and seizures, even in the absence of typical symptoms associated with meningococcemia. A high level of clinical suspicion and quick initiation of therapy are needed to improve the clinical outcome, and patients who survive require long term follow-up to detect possible neurodevelopmental sequelae. Transmission can be intrauterine, intrapartum or postpartum. Intrapartum transmission has been linked to conjunctivitis, which serves as a point of entry for the pathogen. Published case reports from around the world show that, while rare, neonatal meningococcal disease is characterized by a high mortality rate and serious neurodevelopmental complications. The initial clinical presentation is atypical and there is a rapid clinical deterioration within less than 12 h. The objective of this review is to summarize the latest literature on N. meningitidis infections in the neonatal period.

Outcome of acute bacterial meningitis among children in Kandahar, Afghanistan: A prospective observational cohort study

BACKGROUND

Acute bacterial meningitis (ABM) is an important cause of morbidity and mortality in children but there are no published data on the treatment outcomes of ABM in Afghanistan.

METHODS

We conducted a prospective observational cohort study over one year, February 2020 to January 2021 in a tertiary care hospital in Kandahar, Afghanistan. AMB was diagnosed clinically and on lumbar puncture findings. Binary logistic regression assessed factors for death.

RESULTS

A total of 393 ABM children of mean age 4.8 years were recruited. Most were males [231 (58.8%)], living in rural areas [267 (67.9%)] and in households of >10 inhabitants [294 (74.8%)]. Only 96 (24.4%) had received against both Haemophilus influenzae type b (Hib) or pneumococcal (PCV) vaccines. Children were treated with combination of ceftriaxone and ampicillin and 169/321 (52.6%) received dexamethasone. Of the 321 children with a known outcome, 69 (21.5%) died. Death was significantly associated with: not receiving dexamethasone [adjusted odds ratio (AOR) 4.9 (95% CI 2.6-9.5, p <0.001)], coma on admission [AOR 4.6 (I 2.3-9.5, p <0.001)], no PCV [AOR 2.8 (1.2-6.6, p = 0.019)] or Hib vaccine [AOR 2.8 (1.2-6.6, p = 0.019)], and being male [AOR 2.7 (1.4-5.5, p = 0.005).

CONCLUSIONS

ABM causes significant morbidity and mortality in Afghan children that may be improved by greater use of PCV and Hib vaccines. Adjunct dexamethasone should be evaluated formally in our setting.

Development and validation of machine learning-driven prediction model for serious bacterial infection among febrile children in emergency departments

Serious bacterial infection (SBI) in children, such as bacterial meningitis or sepsis, is an important condition that can lead to fatal outcomes. Therefore, since it is very important to accurately diagnose SBI, SBI prediction tools such as ‘Refined Lab-score’ or ‘clinical prediction rule’ have been developed and used. However, these tools can predict SBI only when there are values of all factors used in the tool, and if even one of them is missing, the tools become useless. Therefore, the purpose of this study was to develop and validate a machine learning-driven model to predict SBIs among febrile children, even with missing values. This was a multicenter retrospective observational study including febrile children <6 years of age who visited Emergency departments (EDs) of 3 different tertiary hospitals from 2016 to 2018. The SBI prediction model was trained with a derivation cohort (data from two hospitals) and externally tested with a validation cohort (data from a third hospital). A total of 11,973 and 2,858 patient records were included in the derivation and validation cohorts, respectively. In the derivation cohort, the area under the receiver operating characteristic curve (AUROC) of the RF model was 0.964 (95% confidence interval [CI], 0.943–0.986), and the area under the precision-recall curve (AUPRC) was 0.753 (95% CI, 0.681–0.824). The conventional LR (CLR) model showed corresponding values of 0.902 (95% CI, 0.894–0.910) and 0.573 (95% CI, 0.560–0.586), respectively. In the validation cohort, the AUROC (95% CI) of the RF model was 0.950 (95% CI, 0.945–0.956), the AUPRC was 0.605 (95% CI, 0.593–0.616), and the CLR presented corresponding values of 0.815 (95% CI, 0.789–0.841) and 0.586 (95% CI, 0.553–0.619), respectively. We developed a machine learning-driven prediction model for SBI among febrile children, which works robustly despite missing values. And it showed superior performance compared to CLR in both internal validation and external validation.

Epidemiology of Pediatric Meningitis in South Korea From 2010 to 2018: A Population-based Retrospective Cohort Study

BACKGROUND

Studies evaluating the epidemiology of pediatric meningitis are limited in our region. This study aimed to describe recent trends in the incidence of pediatric meningitis.

METHODS

We estimated national trends in hospitalization rates for pediatric meningitis (<18 years) by analyzing data from the Health Insurance Review and Assessment database between 2010 and 2018. Meningitis cases were identified based on International Classification of Diseases, Tenth Revision (ICD-10) codes and hospitalization rates were calculated.

RESULTS

In this national population-based study, a total of 119,644 hospitalizations and 58 deaths due to pediatric meningitis were identified. The hospitalization rates of pediatric bacterial meningitis have declined by 50.0%, from 3.4 per 100,000 in 2010 to 1.7 per 100,000 in 2018. The mortality rates for bacterial and viral meningitis were 2.0% and 0.002%, respectively. Despite the decreased annual incidence of bacterial meningitis, its mortality rate did not change significantly during the study period. The only risk factor identified for mortality in bacterial meningitis patients among age group, sex, region of residence, and season was age below 1 year (P < 0.001). As children under 1 year have a high-mortality rate (4.2%), patients in this age group require close monitoring. The reasons behind indistinct seasonal patterns of bacterial meningitis warrant further investigation.

CONCLUSIONS

Childhood bacterial meningitis has shown a significant decline in incidence from 2010 to 2018. In contrast, viral meningitis has not shown a trend over time. Knowledge of these changes may aid clinicians in the decision-making process and management of meningitis patients.

Prevalence of Invasive Streptococcus pneumoniae Infections among Iranian Children: A Systematic Review and Meta-Analysis

Background:

Streptococcus pneumoniae is an important pathogen of children, mostly in developing countries. We aimed to investigate the prevalence of invasive S. pneumoniae among Iranian children using a systematic review and meta-analysis.

Methods:

A systematic search was carried out to identify papers published by Iranian authors in the Web of Science, PubMed, Scopus, and Google Scholar electronic databases from January of 2010 to December of 2017. Then, seven publications that met our inclusion criteria were selected for data extraction and analysis.

Results:

Totally, one study was multicenter, and six were single-center based studies. Meanwhile, all of the included studied performed among hospitalized patients. Seven studies reported the prevalence of invasive S. pneumoniae isolated from children, of these the pooled prevalence of S. pneumoniae was 2.5% (95% CI: 0.7%–9.1%).

Conclusion:

The overall prevalence of invasive S. pneumoniae infections among Iranian children is low (2.5%). However, further clinical studies are required to elucidate the burden of infections among Iranian children, especially in eastern regions.

A hospital-based study on etiology and prognosis of bacterial meningitis in adults

Bacterial meningitis is a neurological emergency with high morbidity and mortality. We herein investigated clinical features, etiology, antimicrobial susceptibility profiles, and prognosis of bacterial meningitis in adults from a single tertiary center. We retrospectively reviewed medical records of patients with laboratory-confirmed bacterial meningitis from 2007 to 2016. Patients with recent neurosurgery, head trauma, or indwelling neurosurgical devices were classified as having healthcare-related meningitis. Causative microorganisms were identified by analyzing cerebrospinal fluid (CSF) and blood cultures, and antimicrobial susceptibility profiles were evaluated. We performed multiple logistic regression analysis to identify factors associated with unfavorable outcomes. We identified 161 cases (age, 55.9 ± 15.5 years; male, 50.9%), of which 43 had community-acquired and 118 had healthcare-related meningitis. CSF and blood culture positivity rates were 91.3% and 30.4%, respectively. In community-acquired meningitis patients, Klebsiella pneumoniae (25.6%) was the most common isolate, followed by Streptococcus pneumoniae (18.6%) and Listeria monocytogenes (11.6%). The susceptibility rates of K. pneumoniae to ceftriaxone, cefepime, and meropenem were 85.7%, 81.3%, and 100%, respectively. Among healthcare-related meningitis patients, the most common bacterial isolates were coagulase-negative staphylococci (28.0%), followed by Staphylococcus aureus (16.1%) and Enterobacter spp. (13.6%). Neurological complications occurred in 39.1% of the patients and the 3-month mortality rate was 14.8%. After adjusting for covariates, unfavorable outcome was significantly associated with old age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00–1.06), neurological complications (OR 4.53, 95% CI 1.57–13.05), and initial Glasgow coma scale ≤ 8 (OR 19.71, 95% CI 4.35–89.40). Understanding bacterial pathogens and their antibiotic susceptibility may help optimize antimicrobial therapy in adult bacterial meningitis.

The Causative Organisms of Bacterial Meningitis and their Antimicrobial Resistance Profiles in Iranian Children in 2011-2016

OBJECTIVES

The study aimed to describe the identity and antimicrobial resistance patterns of the causative agents of bacterial meningitis in children referred to Children's Medical Center (CMC) Hospital, Tehran, Iran.

METHODS

This retrospective study was performed at CMC Hospital during a six-year period from 2011 to 2016. The microbiological information of the patients with a diagnosis of bacterial meningitis was collected and the following data were obtained: patients' age, sex, hospital ward, the results of CSF and blood cultures, and antibiotic susceptibility profiles of isolated organisms.

RESULTS

A total of 118 patients with bacterial meningitis were admitted to CMC hospital. Sixty-two percent (n=73) of the patients were male. The median age of the patients was ten months (interquartile range [IQR]: 2 months-2 years) and the majority of them (n=92, 80%) were younger than two years of age. The highest number of patients (n=47, 40%) were admitted to the surgery department. Streptococcus epidermidis was the most frequent isolated bacterium (n=27/127, 21%), followed by Klebsiella pneumoniae (n=20/127, 16%), and Staphylococcus aureus (n=16/127, 12.5%). Blood culture was positive in 28% (n=33/118) of patients. Ampicillin-sulbactam and imipenem were the most effective antibiotics against Gram-negative bacteria isolated from CSF cultures. In the case of Gram-positive organisms, ampicillinsulbactam, vancomycin, and linezolid were the best choices. Imipenem was the most active drug against Gram-negative blood pathogens. Also, ampicillin and vancomycin had the best effect on Gram-positive bacteria isolated from blood cultures.

CONCLUSION

Results of this study provide valuable information about the antibiotic resistance profiles of the etiologic agents of childhood meningitis, which can be used for prescription of more effective empirical therapies.

Clinical features and outcomes of community-acquired late-onset sepsis: Focusing on group B Streptococcus and Escherichia coli

BACKGROUND

Group B Streptococcus (GBS) and Escherichia coli are leading causes of late-onset sepsis (LOS) and bacterial meningitis in neonates and infants. This study aimed to describe clinical characteristics and outcomes of community-acquired (CA) LOS caused by GBS and E. coli.

METHODS

A retrospective observational study was performed in three university hospitals in Korea. All infants aged <90 days who were diagnosed with GBS or E coli CA-LOS from 2011 to 2017 were enrolled. Data on the clinical characteristics and outcomes of GBS and E. coli CA-LOS were compared.

RESULTS

Forty GBS and 43 E. coli CA-LOS cases were identified, which mostly (82/83) included term or near-term infants. Meningitis was identified in 54.1% of GBS CA-LOS cases and in 30.3% of E. coli CA-LOS cases, and 88.4% of E. coli CA-LOS cases involved urosepsis. Ten percent each of GBS and non-uropathogenic E. coli (non-UPEC) meningitis cases and all uropathogenic E. coli (UPEC) meningitis cases were diagnosed by pleocytosis without bacterial growth in the cerebrospinal fluid (CSF). Patients with non-culture-proven meningitis had lower CSF pleocytosis and protein levels and higher CSF/serum glucose ratios than patients with culture-proven meningitis (P < 0.05 for all). One patient died of CA-LOS, which was accompanied by meningitis with extended-spectrum β-lactamase-producing non-UPEC. Neurological complications developed in 22.5% of GBS CA-LOS cases and in 2.3% of E. coli CA-LOS cases.

CONCLUSIONS

Neurological complications were frequently observed in GBS CA-LOS cases, although no mortality was observed. Escherichia coli CA-LOS generally developed as urosepsis, which caused non-culture-proven meningitis and had a favorable outcome.

Evaluation of the BioFire FilmArray meningitis/encephalitis panel for the detection of bacteria and yeast in Chinese children

Background

Meningitis and encephalitis are life-threatening syndromes with high morbidity and mortality in children. Due to limitations of traditional laboratory approaches in etiological diagnosis, the rate of misdiagnoses is unacceptably high.

Methods

We retrospectively compared the potential clinical impact of the FilmArray meningitis/encephalitis (ME) panel vs. conventional cerebrospinal fluid (CSF) culture in children with central nervous system (CNS) infections. Sixty-eight pediatric patients (<18 years of age) with an initial diagnosis of meningitis or encephalitis were enrolled at 2 children's hospital from January to October 2017.

Results

Fifteen specimens were found to be positive after CSF culture, with a positive rate of 22.1% (15/68). For the FilmArray ME panel, 26 bacteria and fungi from 25 samples were detected, and the positive rate was 36.8% (25/68). The FilmArray ME panel identified 14 pathogens in previously pathogen-negative patients.

Conclusions

This study demonstrated the capability of the FilmArray ME panel in the diagnosis of bacterial and fungal meningitis and therefore its potential use in facilitating enhanced patient care.

The etiology of acute meningitis and encephalitis syndromes in a sentinel pediatric hospital, Shenzhen, China

Background

Acute meningitis and encephalitis syndromes (AMES) is a severe neurological infection which causes high case fatality and severe sequelae in children. To determine the etiology of childhood AMES in Shenzhen, a hospital-based study was undertaken.

Methods

A total of 240 cerebrospinal fluid (CSF) samples from 171 children meeting the case definition were included and screened for 12 common causative organisms. The clinical data and conventional testing results were collected and analyzed. Whole genome sequencing was performed on a Neisseria meningitidis isolate.

Results

A pathogen was found in 85 (49.7%) cases; Group B Streptococcus (GBS) was detected in 17 cases, Escherichia coli in 15, Streptococcus pneumoniae in 14, enterovirus (EV) in 13, herpes simplex virus (HSV) in 3, N. meningitidis in 1, Haemophilus influenzae in 1, and others in 23. Notably, HSV was found after 43 days of treatment. Twelve GBS and 6 E. coli meningitis were found in neonates aged less than 1 month; 13 pneumococcal meningitis in children aged > 3 months; and 12 EV infections in children aged > 1 year old. The multilocus sequence typing of serogroup B N. meningitidis isolate was ST-3200/CC4821. High resistance rate to tetracycline (75%), penicillin (75%), and trimethoprim/sulfamethoxazole (75%) was found in 4 of S. pneumoniae isolates; clindamycin (100%) and tetracycline (100%) in 9 of GBS; and ampicillin (75%) and trimethoprim/sulfamethoxazole (67%) in 12 of E. coli.

Conclusions

The prevalence of N. meningitidis and JEV was very low and the cases of childhood AMES were mainly caused by other pathogens. GBS and E. coli were the main causative organisms in neonates, while S. pneumoniae and EV were mainly found in older children. HSV could be persistently found in the CSF samples despite of the treatment. A better prevention strategy for GBS, the introduction of pneumococcal vaccine, and incorporation of PCR methods were recommended.

Diosmetin Suppresses Neuronal Apoptosis and Inflammation by Modulating the Phosphoinositide 3-Kinase (PI3K)/AKT/Nuclear Factor-κB (NF-κB) Signaling Pathway in a Rat Model of Pneumococcal Meningitis

Bacterial meningitis has a high mortality rate and can be challenging to diagnose and manage. This study aimed to evaluate the effect of diosmetin in a rat model of Streptococcus pneumoniae meningitis and to investigate the mechanism of action.

Forty rats included a treatment group (n=30) that underwent intracisternal injection with S. pneumoniae, and a sham group (n=10) that underwent intracisternal injection with normal saline. In the treatment group, four days before the inoculation of the bacteria, rats were pre-treated with oral diosmetin 100 mg/kg (n=10) and 200 mg/kg (n=10), and the negative control was pre-treated with normal saline (n=10). Bacterial meningitis was confirmed one day after inoculation by cerebrospinal fluid (CSF) bacterial titer and neurological score. In rat brain tissue, levels of inflammatory mediators were determined by enzyme-linked immunosorbent assay (ELISA) and western blot for protein kinase B (Akt), phosphoinositide 3-kinase (PI3K), myeloid differentiation primary response 88 (MyD88), and nuclear factor-κB (NF-κB), and the TUNEL assay for apoptosis was performed.

In the diosmetin-treated group compared with negative control group, the CSF bacterial titer and the level of pro-inflammatory mediators, and the neurological score, were significantly reduced (p<0.01). In the rat hippocampal tissue, levels of Akt, PI3K, MyD88 and NF-κB, and the number of TUNEL-positive apoptotic cells were significantly reduced in the diosmetin-treated group compared with negative control group (p<0.01).

In a rat model of bacterial meningitis due to S. pneumoniae, diosmetin reduced neuroinflammation, and neuronal apoptosis by modulating the PI3K/AKT/NF-κB signaling pathway.

Relevant analyses of pathogenic bacteria and inflammatory factors in neonatal purulent meningitis

Pathogenic bacteria and inflammatory factors in neonatal purulent meningitis (PM) were investigated to explore the diagnostic value of inflammatory factors in PM, to clarify the etiology, and to provide evidence for rational clinical treatment. Seventy-four neonates who were diagnosed with PM and were bacteriogically positive in Daqing Longnan Hospital from January 2012 to December 2015 were retrospectively analyzed and used as observation group. Another 74 neonates simultaneously hospitalized with non-PM factors were selected as control group. The levels of C-reactive protein (CRP) and β 2 microglobulin (β2MG) in cerebrospinal fluid in pediatric patients were measured, and the separation culture and identification of pathogenic bacteria were carried out at the same time. The results showed that i) neonatal PM often lacked specific clinical manifestations; ii) high risk factors of neonatal PM included gestational age, body weight <2,500 g, neonatal asphyxia, premature rupture of membranes, and umbilical or pulmonary infection; iii) the levels of CRP and β2MG in the cerebrospinal fluid in the neonatal PM group were significantly higher than those in the control group (P<0.05), and the neonatal PM group had obviously decreased levels of CRP and β2MG in the cerebrospinal fluid after treatment compared with those before treatment (P<0.05); iv) the positive rate of Gram-negative bacilli (G-bacilli) showed an increasing trend year by year in the past 4 years. Seventy-four strains of bacteria were isolated from the cerebrospinal fluid in neonatal PM group, including 45 strains of Gram-positive cocci (G+cocci, accounting for 60.81%) and 29 strains of G-bacilli (accounting for 39.19%). Among them, the top three were Escherichia coli, coagulase-negative staphylococci (CNS) and Streptococcus. These findings indicated that for suspected PM pediatric patients with high risk factors, the inflammatory factors in cerebrospinal fluid and the etiology should be investigated via lumbar puncture as early as possible to confirm the diagnosis. Pathogenic bacteria of meningitis mainly are Escherichia coli, CNS and Streptococcus, and the characteristics of pathogenic bacteria should be considered during experiential medication. The incidence rate of PM due to Streptococcus has an upward tendency and great damage, needing to arouse high attention in clinic.

Infant Group B Streptococcal Disease Incidence and Serotypes Worldwide: Systematic Review and Meta-analyses

Background

Group B Streptococcus (GBS) remains a leading cause of neonatal sepsis in high-income contexts, despite declines due to intrapartum antibiotic prophylaxis (IAP). Recent evidence suggests higher incidence in Africa, where IAP is rare. We investigated the global incidence of infant invasive GBS disease and the associated serotypes, updating previous estimates.

Methods

We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data regarding invasive GBS disease in infants aged 0–89 days. We conducted random-effects meta-analyses of incidence, case fatality risk (CFR), and serotype prevalence.

Results

We identified 135 studies with data on incidence (n = 90), CFR (n = 64), or serotype (n = 45). The pooled incidence of invasive GBS disease in infants was 0.49 per 1000 live births (95% confidence interval [CI], .43–.56), and was highest in Africa (1.12) and lowest in Asia (0.30). Early-onset disease incidence was 0.41 (95% CI, .36–.47); late-onset disease incidence was 0.26 (95% CI, .21–.30). CFR was 8.4% (95% CI, 6.6%–10.2%). Serotype III (61.5%) dominated, with 97% of cases caused by serotypes Ia, Ib, II, III, and V.

Conclusions

The incidence of infant GBS disease remains high in some regions, particularly Africa. We likely underestimated incidence in some contexts, due to limitations in case ascertainment and specimen collection and processing. Burden in Asia requires further investigation.

Seroprevalence of Opsonophagocytic Antibodies against Serotype Ia, Ib, II, III, and V Group B Streptococcus among Korean Population

BACKGROUND

Invasive Streptococcus agalactiae (group B streptococcus, GBS) infection most commonly occurs in infants; however, cases of GBS infection in adults, particularly in the elderly with significant underlying diseases, are being increasingly reported. We analyzed the serotype specific opsonophagocytic antibodies (the major mechanism of protection against GBS) in infants, adults, and the elderly.

METHODS

The opsonization indices (OIs) of antibodies against serotype Ia, Ib, II, III, and V GBS were studied in 89 infants, 35 adults (age, 30-50 years), and 62 elderly individuals (age, 65-85 years) according to the University of Alabama at Birmingham GBS opsonophagocytic killing assay protocol (www.vaccine.uab.edu).

RESULTS

In infants, adults, and elderly groups respectively, geometric mean of OI against GBS serotype Ia were 3, 7, and 32; against GBS serotype Ib were 7, 242, and 252; against serotype II were 93, 363, and 676; against serotype III were 8, 212, and 609; and against serotype V were 4, 639, and 610. The seropositive rate (% of subjects with OI ≥ 4) increased significantly in older age group for all five serotypes.

CONCLUSION

During infancy, only a limited proportion of infants have functional immunity against serotype Ia, Ib, II, III, and V GBS. Furthermore, a lack of opsonic activities against GBS observed in some adults and the elderly might predispose such individuals to the risk of invasive GBS infection. Epidemiological monitoring and development of suitable vaccine for these populations are needed.

Cost-effectiveness analysis of infant pneumococcal vaccination with PHiD-CV in Korea

Background: Streptococcus pneumoniae and non-typeable Haemophilus influenzae (NTHi) can cause invasive pneumococcal diseases (IPD), pneumonia, and acute otitis media (AOM). Both the 10-valent pneumococcal NTHi protein D conjugate vaccine (PHiD-CV) and the 13-valent pneumococcal conjugate vaccine (PCV-13) are included in the National Immunization Program for infants in Korea. This study aimed to evaluate the cost-effectiveness of the 3+1 schedule of PHiD-CV versus that of PCV-13 for National Immunization Program in Korea.

Methods: A published Markov model was adapted to evaluate the cost-effectiveness of vaccinating the 2012 birth cohort with PHiD-CV vs. PCV-13 from the Korean government perspective over 10 y. Best available published data were used for epidemiology, vaccine efficacy and disutilities. Data on incidence and direct medical costs were taken from the national insurance claims database. Sensitivity analyses were conducted to explore the robustness of the results.

Results: PHiD-CV was projected to prevent an additional 195,262 cases of pneumococcal diseases and NTHi-related diseases vs. PCV-13, with a substantially greater reduction in NTHi-related AOM and a comparable reduction in IPD and community-acquired pneumonia. Parity-priced PHiD-CV generated a health gain of about 844 quality-adjusted life years and a total cost-saving of approximately 4 million United States Dollars (USD) over 10 y. 93% of probabilistic simulations found PHiD-CV 3+1 to be the dominant vaccine option.

Conclusion: Compared to PCV-13, PHiD-CV was projected to provide similar prevention against IPD and community-acquired pneumonia but would prevent more cases of AOM. Parity-priced PHiD-CV was anticipated to generate substantial cost-savings and health benefits vs. PCV-13 in Korea.

Neisseria Meningitidis Causing Multiple Cerebral Abscesses in Early Neonatal Period: Case Report and Review of Literature

Neisseria meningitidis is a rare cause of meningitis and septicemia in neonates. There are few published case reports of neonatal meningococcal meningitis complicated by subdural empyema, cerebral abscess and hydrocephalus. Few cases of neonatal meningococcal meningitis have been reported in the literature with none of them having the complication of multiple cerebral abscesses in early neonatal period (<seven days of life). We report a case of meningococcal meningitis with multiple cerebral abscesses which presented on fifth day of life and developed hydrocephalus at five weeks of life requiring a Ventriculo Peritoneal (VP) shunt. To the best of our knowledge, this is the first documented case of neonatal meningococcal meningitis with multiple cerebral abscesses.

Acute bacterial meningitis in children presenting to The Children's Hospital Lahore before and after pneumococcal vaccine in Pakistan National Immunization Program; A comparison

OBJECTIVE

To describe bacteriological profile, morbidity and mortality of acute bacterial meningitis (ABM) in children and to compare these parameters before and after the introduction of Pneumococcal vaccine in Pakistan National Immunization Program.

METHODS

The present descriptive study was conducted at the Department of Paediatric Medicine of The Children's Hospital Lahore from January 2012 to December 2015. A total of 503 children one month to five years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry, culture sensitivity and blood culture sensitivity were performed.

RESULTS

Frequency of meningitis decreased by 50% in 2013-2015 (199 [2012] vs 304 [2013-2015). Most children in both groups were under one year of age. More neurological complications were seen in the group 2, 20% vs 17%. CSF culture positivity decreased from 12% to 6.6%. Streptococcus pneumoniae isolation decreased from 5 (2.5%) in 2012 to 4 (1.3%) in 2013-2015. Refusal to take feed (p=0.002), impaired sensorium (p=<0.001), severe malnutrition (p=0.001), prolonged duration of symptoms (p=<0.001) and incomplete vaccination status (0.005) were associated with mortality. Mortality rate decreased from 20 (10%) in 2012 to 17 (5.6%) in 2013-2015 but more children developed neurological sequelae 2.7% versus 1%.

CONCLUSION

Acute bacterial meningitis mostly affected children <1 year. Frequency of Streptococcus pneumoniae and mortality of meningitis decreased significantly after PCV but more neurological complications developed in those children who were unvaccinated in 2013-2015 compared to 2012.

Detection of Haemophilus influenzae type b, Streptococcus agalactiae, Streptococcus pneumoniae and Neisseria meningitidis in CSF specimens of children suspicious of Meningitis in Ahvaz, Iran

Meningitis is a life-threatening infection associated with a high mortality and morbidity worldwide. Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae are the most prevalent infectious agents that cause bacterial meningitis (BM). The objective of this study was to determine the frequencies of these three bacteria using bacterial cultures and polymerase chain reaction (PCR). In our cross-sectional study, cerebrospinal fluid (CSF) specimens were obtained from 196 patients who were suspected of having BM and referred to the pediatric ward of Abuzar Hospital (Ahvaz, Iran). The samples were monitored by gram stain, cultures, and the PCR method. The patients' age mean was 23 ± 0.56 months. The 196 patients comprised 92 (46.9%) boys and 104 (53.06%) girls. Based on bacterial cultures, just three isolates of H. influenzae were detected. However, PCR detected this bacterium in eight patients. Streptococcus pneumoniae was detected in five (2.5%) patients by the amplification of the lytA gene and in one (0.5%) patient by ply. In this study, no N. meningitidis isolate was in the CSF samples, based on the bacterial culture or PCR results. Streptococcus agalactiae was detected only in one patient, based on PCR. In conclusion, in the present study, the PCR method was more sensitive and rapid than culture for detecting the infectious agents in BM. For this reason, this diagnosis method is recommended for BM.

A 15-year retrospective analysis of prognostic factors in childhood bacterial meningitis

AIM

This retrospective chart review aimed to identify factors in childhood bacterial meningitis that predicted disease severity and long-term outcome.

METHODS

The study included 112 episodes of microbiologically confirmed bacterial meningitis in children aged three days to 15 years who were admitted to a Singapore hospital from 1998 to 2013.

RESULTS

The mortality rate was 6%, and 44% required intensive care unit (ICU) admission. Predictive factors associated with ICU admission included pneumococcal meningitis, with an odds ratio (OR) of 5.2 and 95% confidence interval (CI) of 1.5-18.2, leukopenia (OR 5.6, 95% CI 1.7-17.9) and a cerebrospinal fluid (CSF):serum glucose ratio <0.25 (OR 4.5, 95% CI 1.4-14.4). An initial CSF white blood cell count >1000/mm(3) (OR 0.26, 95% CI 0.086-0.76) was negatively associated with ICU admission. Five years after meningitis, 32% had residual sequelae, and the associated prognostic factors were Haemophilus influenzae type b (Hib) meningitis (OR 29.5, 95% CI 2-429), seizures during their inpatient stay (OR 10.6, 95% CI 1.9-60.2) and septic shock (OR 8.4, 95% CI 1.1-62.1).

CONCLUSION

As mortality was low in this bacterial meningitis study, ICU admission was used as a marker of disease severity. These findings underscore the importance of the pneumococcal and Hib meningitis vaccines.

High-throughput sequencing of 16S rDNA amplicons characterizes bacterial composition in cerebrospinal fluid samples from patients with purulent meningitis

Purulent meningitis (PM) is a severe infectious disease that is associated with high rates of morbidity and mortality. It has been recognized that bacterial infection is a major contributing factor to the pathogenesis of PM. However, there is a lack of information on the bacterial composition in PM, due to the low positive rate of cerebrospinal fluid bacterial culture. Herein, we aimed to discriminate and identify the main pathogens and bacterial composition in cerebrospinal fluid sample from PM patients using high-throughput sequencing approach. The cerebrospinal fluid samples were collected from 26 PM patients, and were determined as culture-negative samples. The polymerase chain reaction products of the hypervariable regions of 16S rDNA gene in these 26 samples of PM were sequenced using the 454 GS FLX system. The results showed that there were 71,440 pyrosequencing reads, of which, the predominant phyla were Proteobacteria and Firmicutes; and the predominant genera were Streptococcus, Acinetobacter, Pseudomonas, and Neisseria. The bacterial species in the cerebrospinal fluid were complex, with 61.5% of the samples presenting with mixed pathogens. A significant number of bacteria belonging to a known pathogenic potential was observed. The number of operational taxonomic units for individual samples ranged from six to 75 and there was a comparable difference in the species diversity that was calculated through alpha and beta diversity analysis. Collectively, the data show that high-throughput sequencing approach facilitates the characterization of the pathogens in cerebrospinal fluid and determine the abundance and the composition of bacteria in the cerebrospinal fluid samples of the PM patients, which may provide a better understanding of pathogens in PM and assist clinicians to make rational and effective therapeutic decisions.

Group B streptococcal meningitis in children beyond the neonatal period in sub-Himalayan India

Objectives:

To evaluate clinicolaboratory profile and the outcomes in children (1 to 59 months) diagnosed with Group B streptococcus (GBS) meningitis over a period of 1 year.

Materials and Methods:

Cerebrospinal fluid (CSF) samples of 250 pediatric patients (1 to 59 months) admitted with suspected acute bacterial meningitis(ABM)were subjected to cell count, biochemical profile, culture, latex particle agglutination (LPA) and polymerase chain reaction (PCR). They were also evaluated for complications and were followed-up till 6 months after discharge.

Results:

Forty patients (25 boys and 15 girls), 16% of total suspected cases of ABM were diagnosed with GBS by LPA method and 30 (75%) out of these were above 3 months of age. The median duration of hospital stay was 7 days (range 1 to 72 days). State of coma was observed in two (5%) and one (2.5%) died, while 20 (50%) patients recovered completely.

Conclusion:

GBS should be considered as an important cause of ABM in Indian children beyond the neonatal period and further studies are warranted to determine the actual problem of the disease in our country.

Group B streptococcal meningitis in infants beyond the neonatal period

OBJECTIVES

To describe the clinico-bacteriological profile, and early outcomes of infants diagnosed with Group B streptococcus (GBS) meningitis.

METHODS

This was a retrospective review of infants (aged 1 mo to 2 y) diagnosed with GBS meningitis in a tertiary care hospital in New Delhi from October 2010 through January 2012. The clinico-bacteriological data and early outcomes of infants with suspected bacterial meningitis and a positive CSF latex agglutination test for GBS were studied. The CSF samples were subjected to PCR for broad spectrum 16s ribosomal DNA and the GBS species specific gene, the scpB.

RESULTS

Twenty seven patients (13 boys, and 14 girls) were diagnosed with GBS meningitis during the study period. Broad spectrum 16s ribosomal DNA PCR was performed on 18 of the 27 CSF samples. Sixteen were positive. All these 16 were also positive for the species specific scpB gene. The median duration of hospital stay was 7 d (range 1-72 d). Nine patients died. One patient each developed ventriculitis, optic atrophy and hydrocephalus. Overall, 12 patients had a complete recovery at discharge.

CONCLUSIONS

GBS must be considered in the etiology of bacterial meningitis in Indian infants.

Neutrophilic bacterial meningitis: pathology and etiologic diagnosis of fatal cases

The frequency of fatalities due to acute bacterial meningitis has decreased significantly due to vaccinations, early diagnoses, and treatments. We studied brain tissues of patients with fatal neutrophilic meningitis referred to the Centers for Disease Control for etiologic diagnosis from 2000-2009 to highlight aspects of the disease that may be preventable or treatable. Demographic, clinical, and laboratory data were extracted from records. Of 117 cases in the database with a diagnosis of meningitis or meningoencephalitis, 39 had neutrophilic inflammation in the meninges. Inflammatory cells infiltrated the superficial cortex in 16 of 39 (41%) cases. Bacteria were found using Gram and bacterial silver stains in 72% of cases, immunohistochemistry in 69% (including two cases where the meningococcus was found outside the meninges), and PCR in 74%. Streptococcus pneumoniae was the cause of the meningitis in 14 patients and Neisseria meningitidis in 9. In addition, Streptococcus spp. were found to be the cause in six cases, while Staphylococcus aureus, Staphylococcus spp., Enterococcus spp., and Fusobacterium were the cause of one case each. There were six cases in which no specific etiological agent could be determined. The mean age of the patients with S. pneumoniae was 39 years (range 0-65), with N. meningitidis was 19 years (range 7-51), whereas that for all others was 31 years (range 0-68). In summary, our study shows that S. pneumoniae continues to be the most frequent cause of fatal neutrophilic bacterial meningitis followed by N. meningitidis, both vaccine preventable diseases.

The changing epidemiology of childhood pneumococcal disease in Korea

The wide use of antimicrobial agents and 7-valent pneumococcal conjugate vaccine (PCV7) has led to major changes in the epidemiology of childhood pneumococcal diseases. In Korea, data on the population-based incidence of childhood invasive pneumococcal diseases (IPD) are not available; however, institution-based surveillance data suggest a substantial burden of childhood IPD. Following the introduction of the PCV7 in Korea in 2003, the proportion of IPD caused by vaccine-type pneumococci has decreased, while non-PCV7 serotypes, especially serotypes 19A and 6A, whose proportions had been increasing before the introduction of the vaccine, became predominant among childhood IPD isolates. This article reviews the overall impact of PCV7 utilization and summarizes the results obtained so far. Continuous monitoring and gathering of scientific evidence for the epidemiological transition of pneumococcal carriage and IPD will be important for the management of pneumococcal infections in Korea.

Immunogenicity and safety of 13-valent pneumococcal conjugate vaccine given to korean children receiving routine pediatric vaccines

BACKGROUND

The immunogenicity and safety of 13-valent and 7-valent pneumococcal conjugate vaccines (PCV13 and PCV7) were compared when administered with routine vaccines in Korea.

METHODS

Healthy infants (n = 180) were randomly assigned (1:1) to receive PCV13 or PCV7 at 2, 4, 6 (infant series) and 12 months (toddler dose). Immune responses 1 month after the infant series and toddler dose were measured by enzyme-linked immunosorbent assay and opsonophagocytic activity (OPA) assay. IgG antibody geometric mean concentrations and OPA functional antibody geometric mean titers were calculated. Safety was assessed.

RESULTS

After the infant series, for the 7 common serotypes, proportions of responders with IgG concentrations ≥0.35 µg/mL were comparable (≥97.6%) between groups; IgG geometric mean concentrations and OPA geometric mean titers were generally similar, but tended to be lower in the PCV13 group for some serotypes. For the 6 serotypes unique to PCV13, IgG geometric mean concentrations and OPA geometric mean titers were notably higher in the PCV13 group. Importantly, although PCV7 elicited IgG antibodies to PCV13 serotypes 5 and 19A, OPA responses were minimal, whereas serotype 6A elicited both IgG and OPA responses. These observations are consistent with at least some protection by PCV7 against 6A-mediated invasive pneumococcal disease, but no cross-protection for serotypes 5 and 19A. The toddler dose elicited higher IgG and OPA responses than postinfant series responses for most serotypes; however, for serotypes 3 and 14 only OPA responses were increased posttoddler dose. Vaccine safety profiles were similar.

CONCLUSIONS

PCV13 is safe and immunogenic in Korean children. PCV13 should provide broader protection than PCV7.

An expanded age range for meningococcal meningitis: molecular diagnostic evidence from population-based surveillance in Asia

Background

To understand epidemiologic patterns of meningococcal disease in Asia, we performed a retrospective molecular analysis of cerebrospinal fluid (CSF) specimens collected in prospective surveillance among children aged < 5 years of age in China, South Korea, and Vietnam.

Methods

A total of 295 isolates and 2,302 CSFs were tested by a meningococcal species- and serogroup-specific polymerase chain reaction (PCR) assay targeting the Neisseria meningitidis (Nm) ctrA gene. Multi-locus sequence typing (MLST) was performed in Nm gene amplification analysis and incidence rates for meningococcal meningitis were estimated.

Results

Among 295 isolates tested, 10 specimens from Vietnam were confirmed as serogroup B and all were Sequence Type (ST) 1576 by MLST. Among the 2,032 CSF specimen tested, 284 (14%) were confirmed by PCR (ctrA gene), including 67 (23.6%) from China, 92 (32.4%) from Korea, and 125 (44.0%) from Vietnam. Neonates and infants aged < 6 months of age accounted for more than 50% of Nm-PCR positive CSF. Two CSF specimens from Vietnam were identified as serogroup B using MLST. In addition, 44 specimens underwent sequencing to confirm meningococcal serogroup; of these, 21 (48%) were serogroup C, 12 (27%) were serogroup X, 9 (20%) were serogroup Y and 2 (5%) were serogroup B. The incidence rates of meningococcal meningitis among children < 5 years of age was highest in Vietnam (7.4/100,000 [95% CI, 3.6—15.3] followed by Korea (6.8/100,000 [95% CI, 3.5-13.5] and China (2.1/100,000) [95% CI, 0.7-6.2]).

Conclusions

These results suggest that there is a previously undetected, yet substantial burden of meningococcal meningitis among infants and young children. Standardized, sensitive and specific molecular diagnostic assays with Nm serogrouping capacity are needed throughout Asia to understand the true burden of N. meningitidis disease.

Aetiologies of central nervous system infection in Viet Nam: a prospective provincial hospital-based descriptive surveillance study

Background

Infectious diseases of the central nervous system (CNS) remain common and life-threatening, especially in developing countries. Knowledge of the aetiological agents responsible for these infections is essential to guide empiric therapy and develop a rational public health policy. To date most data has come from patients admitted to tertiary referral hospitals in Asia and there is limited aetiological data at the provincial hospital level where most patients are seen.

Methods

We conducted a prospective Provincial Hospital-based descriptive surveillance study in adults and children at thirteen hospitals in central and southern Viet Nam between August 2007– April 2010. The pathogens of CNS infection were confirmed in CSF and blood samples by using classical microbiology, molecular diagnostics and serology.

Results

We recruited 1241 patients with clinically suspected infection of the CNS. An aetiological agent was identified in 640/1241 (52%) of the patients. The most common pathogens were Streptococcus suis serotype 2 in patients older than 14 years of age (147/617, 24%) and Japanese encephalitis virus in patients less than 14 years old (142/624, 23%). Mycobacterium tuberculosis was confirmed in 34/617 (6%) adult patients and 11/624 (2%) paediatric patients. The acute case fatality rate (CFR) during hospital admission was 73/617 (12%) in adults and to 42/624 (7%) in children.

Conclusions

Zoonotic bacterial and viral pathogens are the most common causes of CNS infection in adults and children in Viet Nam.

Group B streptococcal disease in infants aged younger than 3 months: systematic review and meta-analysis

BACKGROUND

Despite widespread use of intrapartum antibiotic prophylaxis, group B streptococcus remains a leading cause of morbidity and mortality in infants in Europe, the Americas, and Australia. However, estimates of disease burden in many countries outside of these regions is not available. We aimed to examine the current global burden of invasive disease and the serotype distribution of group B streptococcus isolates.

METHODS

We searched Medline, Embase, and Wholis databases for studies on invasive early-onset (day 0-6) and late-onset (day 7-89) group B streptococcal disease. Eligible studies were those that described incidence, deaths, or serotypes. We also reviewed reference lists and contacted experts to seek unpublished data and data missed by our search. Random effects meta-analysis was used to pool data.

FINDINGS

74 studies met the inclusion criteria; 56 studies reported incidence, 29 case fatality, and 19 serotype distribution. An additional search for studies that reported serotype distribution from Jan 1, 1980, yielded a total of 38 articles. Only five low-income countries were represented in the review and contributed 5% weight to the meta-analysis. 47 (69%) studies reported use of any intrapartum antibiotic prophylaxis. Substantial heterogeneity existed between studies. Mean incidence of group B streptococcus in infants aged 0-89 days was 0·53 per 1000 livebirths (95% CI 0·44-0·62) and the mean case fatality ratio was 9·6% (95% CI 7·5-11·8). Incidence of early-onset group B streptococcus (0·43 per 1000 livebirths [95% CI 0·37-0·49]) and case fatality (12·1%, [6·2-18·3]) were two-times higher than late-onset disease. Serotype III (48·9%) was the most frequently identified serotype in all regions with available data followed by serotypes Ia (22·9%), Ib (7·0%), II (6·2%), and V (9·1%). Studies that reported use of any intrapartum antibiotic prophylaxis were associated with lower incidence of early-onset group B streptococcus (0·23 per 1000 livebirths [95% CI 0·13-0·59]) than studies in which patients did not use prophylaxis (0·75 per 1000 livebirths [0·58-0·89]).

INTERPRETATION

More high-quality studies are needed to accurately estimate the global burden of group B streptococcus, especially in low-income countries. A conjugate vaccine incorporating five serotypes (Ia, Ib, II, III, V) could prevent most global group B streptococcal disease.

FUNDING

Child Epidemiology Reference Group (CHERG), WHO.

Correlations of clinical assessment tools with written examinations

PURPOSE

Despite the goal of medical education, which is 'training to be a primary care physician,' only written examinations (WEs) generally have been used to assess medical student ability. We assessed clinical competence using the CPX (clinical performance examination), PA (portfolio assessment), VMA (video-monitoring assessment), CGD (case group discussion), and PCP (primary clinical practice) during students' clerkships in family medicine and correlated these clinical assessment tools with WEs. Also, we correlated these tools with each other to determine the feasibility of each as a replacement of the other tools.

METHODS

Thirty-nine fourth year students at University of Ulsan College of Medicine took part in their clerkship in family medicine for 2 weeks during the first session of 2005. They took 1 CPX, 2 VMAs, 6 CGDs, and 2 PCPs and were required to submit their portfolios at the end of the clerkship. We evaluated the correlations of these tools and WEs by the overall scores of each class year and in each subject.

RESULTS

The CPX, VMA, and PCP showed no significant correlation,while PA showed strong correlation with 4th year students' overall WEs. The CGD showed strong correlation with all overall scores and with almost all subjects. In addition, the PA correlated significantly with CGD.

CONCLUSION

New clinical assessment tools, such as CPX, PA, and VMA, have no significant correlation with WE, even though these tools closely correspond with real clinical practice. Therefore, these tools should be considered as complementary instruments to better assess clinical competence.