Bacteriological profile of community acquired acute bacterial meningitis: a ten-year retrospective study in a tertiary neurocare centre in South India

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.

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.

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.

Next generation rapid diagnostic tests for meningitis diagnosis

Rapid diagnostic tests (RDTs) are increasingly recognized as valuable, transformative tools for the diagnosis of infectious diseases. Although there are a variety of meningitis RDTs currently available, certain product features restrict their use to specific levels of care and settings. For this reason, the development of meningitis RDTs for use at all levels of care, including those in low-resource settings, was included in the "Defeating Meningitis by 2030" roadmap. Here we address the limitations of available meningitis RDTs and present test options and specifications to consider when developing the next generation of meningitis RDTs.

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.

National, regional, and state-level burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in India: modelled estimates for 2000-15

Background

India accounts for a disproportionate burden of global childhood illnesses. To inform policies and measure progress towards achieving child health targets, we estimated the annual national and state-specific childhood mortality and morbidity attributable to Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) between 2000 and 2015.

Methods

In this modelling study, we used vaccine clinical trial data to estimate the proportion of pneumonia deaths attributable to pneumococcus and Hib. The proportion of meningitis deaths attributable to each pathogen was derived from pathogen-specific meningitis case fatality and bacterial meningitis case data from surveillance studies. We applied these proportions to modelled state-specific pneumonia and meningitis deaths from 2000 to 2015 prepared by the WHO Maternal and Child Epidemiology Estimation collaboration (WHO/MCEE) on the basis of verbal autopsy studies from India. The burden of clinical and severe pneumonia cases attributable to pneumococcus and Hib was ascertained with vaccine clinical trial data and state-specific all-cause pneumonia case estimates prepared by WHO/MCEE by use of risk factor prevalence data from India. Pathogen-specific meningitis cases were derived from state-level modelled pathogen-specific meningitis deaths and state-level meningitis case fatality estimates. Pneumococcal and Hib morbidity due to non-pneumonia, non-meningitis (NPNM) invasive syndromes were derived by applying the ratio of pathogen-specific NPNM cases to pathogen-specific meningitis cases to the state-level pathogen-specific meningitis cases. Mortality due to pathogen-specific NPNM was calculated with the ratio of pneumococcal and Hib meningitis case fatality to pneumococcal and Hib meningitis NPNM case fatality. Census data from India provided the population at risk.

Findings

Between 2000 and 2015, estimates of pneumococcal deaths in Indian children aged 1–59 months fell from 166 000 (uncertainty range [UR] 110 000–198 000) to 68 700 (44 600–86 000), while Hib deaths fell from 82 600 (52 300–112 000) to 15 600 (9800–21 500), representing a 58% (UR 22–78) decline in pneumococcal deaths and an 81% (59–91) decline in Hib deaths. In 2015, national mortality rates in children aged 1–59 months were 56 (UR 37–71) per 100 000 for pneumococcal infection and 13 (UR 8–18) per 100 000 for Hib. Uttar Pradesh (18 900 [UR 12 300–23 600]) and Bihar (8600 [5600–10 700]) had the highest numbers of pneumococcal deaths in 2015. Uttar Pradesh (9300 [UR 5900–12 700]) and Odisha (1100 [700–1500]) had the highest numbers of Hib deaths in 2015. Less conservative assumptions related to the proportion of pneumonia deaths attributable to pneumococcus indicate that as many as 118 000 (UR 69 000–140 000) total pneumococcal deaths could have occurred in 2015 in India.

Interpretation

Pneumococcal and Hib mortality have declined in children aged 1–59 months in India since 2000, even before nationwide implementation of conjugate vaccines. Introduction of the Hib vaccine in several states corresponded with a more rapid reduction in morbidity and mortality associated with Hib infection. Rapid scale-up and widespread use of the pneumococcal conjugate vaccine and sustained use of the Hib vaccine could help accelerate achievement of child survival targets in India.

Funding

Bill & Melinda Gates Foundation.

Study of Invasive Pneumococcal Infection in Adults with Reference to Penicillin Resistance

Background:

Invasive pneumococcal infections often prove rapidly fatal, even where good medical treatment is readily available. In developed countries, up to 20% of people who contract pneumococcal meningitis die; however, in developing world, mortality is closer to 50%, even among hospitalized patients. The World Health Organization estimated 600,000–800,000 adult deaths each year from pneumococcal pneumonia, meningitis, and sepsis.

Aims:

This study aims to estimate isolation rate of invasive pneumococcal infection in adults, to determine the antimicrobial susceptibility profile of Streptococcus pneumoniae isolates and to study the associated risk factors.

Materials and Methods:

A total of 120 patients with suspected invasive infection such as meningitis, septicemia, and pleural effusion, were included in the study. Various clinical specimens such as pus, cerebrospinal fluid, and other sterile body fluids were processed for isolation and identification of S. pneumoniae. Kirby–Bauer disc diffusion method was performed to determine the antimicrobial susceptibility profile. Minimum inhibitory concentration test was performed to determine the penicillin resistance.

Results:

Of 120 patients, 40 (33.33%) cases were proven by culture to have an invasive pneumococcal infection. The most common clinical condition observed was meningitis followed by pneumonia with pleural effusion and sepsis. Pneumococcal isolates exhibited 40% resistance to cotrimoxazole and 12.73% to chloramphenicol. Two meningeal isolates exhibited penicillin resistance. Comorbidities observed in 21 (52.5%) cases were mainly Diabetes mellitus, smoking, and alcoholism.

Conclusions:

Invasive pneumococcal infection has poor prognosis and penicillin-resistant strains have become increasingly common. This study emphasizes the importance of judicious use of antibiotics, especially to refrain their use in mild self-limiting upper respiratory infections.

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.

Epidemiology of Meningitis in Oman-Implications for Future Surveillance

Objectives:

This study aimed to understand the epidemiology of meningitis cases admitted to hospitals in Oman and to identify any changing microbial patterns from the introduction of the new vaccines.

Methods:

A retrospective analysis of all cases of meningitis reported through a national surveillance system. Meningitis is a notifiable disease.

Results:

Of a total of 581 cases of meningitis from the period between January 1, 2005 and December 31, 2013, 15% (88) were confirmed to be bacterial in origin and 7.2% (42/581) viral. In 50.9% (296) of patients with suspected pyogenic meningitis, no specific bacterial pathogen were identified, and in 26% of cases (151) a cerebrospinal fluid study could not be undertaken. Among 88 cases with confirmed bacterial pathogens the organisms identified were Streptococcus pneumoniae (65.9%), Neisseria meningitides (18.2%), Haemophilus influenzae (6.8%), and other organisms (9.1%). The peak incidence was in children <2 years of age (39.4%). It showed notable decline in H. influenzae cases as well as pneumococcal meningitis cases, possibly indicative of the successful immunization program.

Conclusion:

A drop in H. Influenzae and pneumococcal meningitis cases was possibly the effect of the introduction of vaccines. It shows the need for improving diagnostic accuracy, laboratory capacities, and quality of surveillance reporting.

Impact of the introduction of the Haemophilus influenzae type b conjugate vaccine in an urban setting in southern India

INTRODUCTION

Haemophilus influenzae type b was the leading cause of bacterial meningitis in infants and children below the age of two years prior to the introduction of H. influenzae type b conjugate vaccines. In December 2011, the Indian government introduced H. influenzae b vaccine in the state of Tamilnadu. A prospective surveillance for bacterial meningitis was established at the Institute of Child Health in Chennai to evaluate the etiology of meningitis and impact of the vaccine.

MATERIAL AND METHODS

Infants aged one to 23 months who were admitted to the hospital with symptoms of suspected bacterial meningitis were enrolled and lumbar puncture was performed. Cerebrospinal fluid samples were analyzed for white blood cells, protein, and glucose. Bacterial culture and a latex agglutination test for common bacterial pathogens were performed.

RESULTS

Between January 2009 and March 2014, 4,770 children with suspected bacterial meningitis were enrolled. Prior to the introduction of the vaccine, an average of 11.7 cases of H. influenzae b meningitis and 31.1 cases of probable meningitis with no etiology were identified each year. After introduction, the number of cases were reduced by 79% and 44% respectively. The average H. influenzae b vaccine coverage after introduction was 69% among all children with clinically suspected meningitis. In contrast, the mean number of aseptic meningitis and pneumococcal meningitis cases remained stable throughout the pre and post vaccination period; 28.2 and 4.8 per year, respectively.

CONCLUSIONS

H. influenzae b conjugate vaccine reduced the number of cases of H. influenzae b meningitis and probable meningitis within the first two years of its introduction. The impact against meningitis was higher than the vaccination rate, indicating indirect effects of the vaccine. India has recently scaled up the use of Hib conjugate vaccine throughout the country which should substantially reduce childhood meningitis rates further in the country.

Incidence and aetiology of bacterial meningitis among children aged 1-59 months in South Asia: systematic review and meta-analysis

BACKGROUND

Bacterial meningitis is a significant cause of morbidity and mortality worldwide among children aged 1-59 months. We aimed to describe its burden in South Asia, focusing on vaccine-preventable aetiologies.

METHODS

We searched five databases for studies published from January 1, 1990, to April 25, 2017. We estimated incidence and aetiology-specific proportions using random-effects meta-analysis. In secondary analyses, we described vaccine impact and pneumococcal meningitis serotypes.

RESULTS

We included 48 articles cumulatively reporting 20,707 cases from 1987 to 2013. Mean annual incidence was 105 (95% confidence interval [CI], 53-173) cases per 100,000 children. On average, Haemophilus influenzae type b (Hib) accounted for 13% (95% CI, 8-19%) of cases, pneumococcus for 10% (95% CI, 6-15%), and meningococcus for 1% (95% CI, 0-2%). These meta-analyses had substantial between-study heterogeneity (I² > 78%, P < 0.0001). Among studies reporting only confirmed cases, these three bacteria caused a median of 78% cases (IQR, 50-87%). Hib meningitis incidence declined by 72-83% at sentinel hospitals in Pakistan and Bangladesh, respectively, within two years of implementing nationwide vaccination. On average, PCV10 covered 49% (95% CI, 39-58%), PCV13 covered 51% (95% CI, 40-61%), and PPSV23 covered 74% (95% CI, 67-80%) of pneumococcal meningitis serotypes. Lower PCV10 and PCV13 serotype coverage in Bangladesh was associated with higher prevalence of serotype 2, compared to India and Pakistan.

CONCLUSIONS

South Asia has relatively high incidence of bacterial meningitis among children aged 1-59 months, with vaccine-preventable bacteria causing a substantial proportion. These estimates are likely underestimates due to multiple epidemiological and microbiological factors. Further research on vaccine impact and distribution of pneumococcal serotypes will inform vaccine policymaking and implementation.

Salmonella typhimurium Meningitis in an Infant Presenting with Recurrent Meningitis

Salmonella typhimurium meningitis in infancy is very uncommon and does not respond to usual duration of empirical antibiotic therapy. A 5-mo-old infant presented with clinical picture of acute pyogenic meningitis and was treated with empirical antibiotic therapy for 14 d. But, 2 wk after the discharge, the child presented again with similar complaints. CSF culture had grown Salmonella typhimurium following which dual antibiotic therapy was given for 6 wk.

Invasive pneumococcal disease in Indian adults: 11 years' experience

PURPOSE

To investigate the epidemiology of invasive pneumococcal disease (IPD), prevalent serotypes, and pattern of antimicrobial resistance (AMR) in Indian adults.

METHODS

Prospective laboratory based surveillance of IPD was carried out in >18 years age group between January 2007 and July 2017, from a tertiary care hospital in South India. All Streptococcus pneumoniae culture positives from blood, CSF and sterile body fluids were characterized to identify the serotypes and AMR.

RESULTS

A total of 408 IPD cases were characterized in this study. The overall case fatality rate in this study was 17.8% (95% confidence interval (CI): 14.1, 22.4). Pneumonia (39%), meningitis (24.3%), and septicaemia (18.4%) were the most common clinical conditions associated with IPD. Serotypes 1, 3, 5, 19F, 8, 14, 23F, 4, 19A and 6B were the predominant serotypes in this study. Penicillin non-susceptibility was low with 6.4% CONCLUSION: Serotype data from this study helped in accurate estimation of pneumococcal conjugate vaccine-13 and pneumococcal polysaccharide vaccine-23 protective coverage against serotypes causing IPD in India as 58.7% (95% CI: 53.8, 63.4) and 67.4% (95% CI: 62.7, 71.8) respectively. Penicillin non-susceptibility in meningeal IPD cases is 27.4%. Empirical therapy for meningeal IPD must be cephalosporin in combination with vancomycin since cefotaxime non-susceptibility in meningeal IPD is 9.9.

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

BACKGROUND

Worldwide, acute bacterial meningitis is a major cause of high morbidity and mortality among under five children, particularly in settings where vaccination for H. influenzae type b, S. pneumoniae and N. meningitidis is yet to be introduced in the national immunization programs. Estimation of disease burden of bacterial meningitis associated with these pathogens can guide the policy makers to consider inclusion of these newer vaccines in the immunization programs. A network of hospital based sentinel surveillance was established to generate baseline data on the burden of bacterial meningitis among children aged less than 5 years in India and to provide a platform for impact assessment following introduction of the Pentavalent and Pneumococcal Conjugate Vaccines (PCV).

METHODS

During surveillance carried out in select hospitals across India in 2012-2013, information regarding demographics, immunization history, clinical history, treatment details and laboratory investigations viz. CSF biochemistry, culture, latex agglutination and PCR was collected from children aged 1 to 59 months admitted with suspected bacterial meningitis.

RESULTS

A total of 3104 suspected meningitis cases were enrolled from 19,670 children admitted with fever at the surveillance hospitals. Of these, 257 cases were confirmed as cases of meningitis. They were due to S. pneumoniae (82.9%), H. influenzae type b (14.4%) and N. meningitidis (2.7%). Highest prevalence (55.3%) was observed among children 1 to 11 months. Antimicrobial susceptibility testing revealed considerable resistance among S. pneumoniae isolates against commonly used antibiotics such as cotrimoxazole, erythromycin, penicillin, and cefotaxime. More commonly prevalent serotypes of S. pneumoniae in circulation included 6B, 14, 6A and 19F. More than 90% of serotypes identified were covered by Pneumococcal Conjugate Vaccine 13.

CONCLUSIONS

We observed that S. pneumoniae was the commonest cause of bacterial meningitis in hospitalized children under five years of age in India. Continued surveillance is expected to provide valuable information and trends in future, to take an informed decision on introduction of pneumococcal vaccination in Universal Immunization Programme in India and will also eventually help in post-vaccination impact evaluation.

Rapid and Accurate Diagnosis of Acute Pyogenic Meningitis Due to Streptococcus Pneumoniae, Haemophilus influenzae Type b and Neisseria meningitidis Using A Multiplex PCR Assay

INTRODUCTION

Acute bacterial meningitis is one of the major causes of morbidity and mortality in children and geriatric population, especially in developing countries. Methods of identification are standard culture and other phenotypic tests in many resource poor settings.

AIM

To use molecular methods for the improvement of aetiological diagnosis of acute pyogenic meningitis in patients.

MATERIALS AND METHODS

CSF samples of 125 patients were included for the study. Gram staining and culture were performed according to standard procedures. Antigen was detected using commercial latex agglutination test kit. Multiplex PCR was performed using previously published primers and protocols. Fischer's exact test was used for finding association between presence of the disease and clinical/biochemical parameters, considering two tailed p<0.05 as statistically significant. Sensitivity, specificity, positive and negative predictive values were calculated using Graphpad QuicCalc software.

RESULTS

A total of 39 cases (31.2%) were confirmed to be of acute pyogenic meningitis based on biochemical methods. Only 10/39 was positive for the three organisms tested. Multiplex PCR was able to detect one additional isolate each of Streptococcus pneumoniae and Haemophilus influenzae type b. When compared with multiplex PCR as the gold standard, culture and latex agglutination tests had same sensitivity (80%), specificity (100%), PPV (100%) and NPV (97.8%), whereas Gram stain had poor sensitivity (40%) and good specificity (95.6%). Detection rates were higher in multiplex PCR for the two organisms Streptococcus pneumoniae and Haemophilus influenzae type b.

CONCLUSION

Multiplex PCR was more sensitive than culture or antigen detection, and employing this assay can significantly increase the speed and accuracy of identification of the pathogen.

Nested PCR Assay for Eight Pathogens: A Rapid Tool for Diagnosis of Bacterial Meningitis

PURPOSE

Bacterial meningitis is a dreadful infectious disease with a high mortality and morbidity if remained undiagnosed. Traditional diagnostic methods for bacterial meningitis pose a challenge in accurate identification of pathogen, making prognosis difficult. The present study is therefore aimed to design and evaluate a specific and sensitive nested 16S rDNA genus-based polymerase chain reaction (PCR) assay using clinical cerebrospinal fluid (CSF) for rapid diagnosis of eight pathogens causing the disease.

METHODS

The present work was dedicated to development of an in-house genus specific 16S rDNA nested PCR covering pathogens of eight genera responsible for causing bacterial meningitis using newly designed as well as literature based primers for respective genus. A total 150 suspected meningitis CSF obtained from the patients admitted to Central India Institute of Medical Sciences (CIIMS), India during the period from August 2011 to May 2014, were used to evaluate clinical sensitivity and clinical specificity of optimized PCR assays.

RESULTS

The analytical sensitivity and specificity of our newly designed genus-specific 16S rDNA PCR were found to be ≥92%. With such a high sensitivity and specificity, our in-house nested PCR was able to give 100% sensitivity in clinically confirmed positive cases and 100% specificity in clinically confirmed negative cases indicating its applicability in clinical diagnosis.

CONCLUSIONS

Our in-house nested PCR system therefore can diagnose the accurate pathogen causing bacterial meningitis and therefore be useful in selecting a specific treatment line to minimize morbidity. Results are obtained within 24 h and high sensitivity makes this nested PCR assay a rapid and accurate diagnostic tool compared to traditional culture-based methods.

Retrospective analysis of multiplex polymerase chain reaction-based molecular diagnostics (SES) in 70 patients with suspected central nervous system infections: A single-center study

Background:

Central nervous system (CNS) infections present a grave health care challenge due to high morbidity and mortality. Clinical findings and conventional laboratory assessments are not sufficiently distinct for specific etiologic diagnosis. Identification of pathogens is a key to appropriate therapy.

Aim:

In this retrospective observational study, we evaluated the efficacy and clinical utility of syndrome evaluation system (SES) for diagnosing clinically suspected CNS infections.

Materials and Methods:

This retrospective analysis included inpatients in our tertiary level neurointensive care unit (NICU) and ward from February 2010 to December 2013. Cerebrospinal fluid (CSF) samples of 70 patients, clinically suspected of having CNS infections, were subjected to routine laboratory tests, culture, imaging, and SES. We analyzed the efficacy of SES in the diagnosis of CNS infections and its utility in therapeutic decision-making.

Results:

SES had a clinical sensitivity of 57.4% and clinical specificity of 95.6%. Streptococcus pneumoniae and Pseudomonas aeruginosa were the top two bacterial pathogens, whereas Herpes simplex virus (HSV) was the most common viral pathogen. Polymicrobial infections were detected in 32.14% of SES-positive cases. SES elicited a change in the management in 30% of the patients from initial empiric therapy. At discharge, 51 patients recovered fully while 11 patients had partial recovery. Three-month follow-up showed only six patients to have neurological deficits.

Conclusion:

In a tertiary care center, etiological microbial diagnosis is central to appropriate therapy and outcomes. Sensitive and accurate multiplex molecular diagnostics play a critical role in not only identifying the causative pathogen but also in helping clinicians to institute appropriate therapy, reduce overuse of antimicrobials, and ensure superior clinical outcomes.

Frequency of Pathogenic Paediatric Bacterial Meningitis in Mozambique: The Critical Role of Multiplex Real-Time Polymerase Chain Reaction to Estimate the Burden of Disease

BACKGROUND

In Sub-Saharan Africa, including Mozambique, acute bacterial meningitis (ABM) represents a main cause of childhood mortality. The burden of ABM is seriously underestimated because of the poor performance of culture sampling, the primary method of ABM surveillance in the region. Low quality cerebrospinal fluid (CSF) samples and frequent consumption of antibiotics prior to sample collection lead to a high rate of false-negative results. To our knowledge, this study is the first to determine the frequency of ABM in Mozambique using real-time polymerase chain reaction (qPCR) and to compare results to those of culture sampling.

METHOD

Between March 2013 and March 2014, CSF samples were collected at 3 regional hospitals from patients under 5 years of age, who met World Health Organization case definition criteria for ABM. Macroscopic examination, cytochemical study, culture, and qPCR were performed on all samples.

RESULTS

A total of 369 CSF samples were collected from children clinically suspected of ABM. qPCR showed a significantly higher detection rate of ABM-causing pathogens when compared to culture (52.3% [193/369] versus 7.3% [27/369], p = 0.000). The frequency of Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococci, and Neisseria meningitidis were 32.8% (121⁄369), 12.2%, (45⁄369), 3.0% (16⁄369) and 4.3% (11⁄369), respectively, significantly higher compared to that obtained on culture (p < 0.001 for each).

CONCLUSION

Our findings demonstrate that culture is less effective for the diagnosis of ABM than qPCR. The common use of culture rather than qPCR to identify ABM results in serious underestimation of the burden of the disease, and our findings strongly suggest that qPCR should be incorporated into surveillance activities for ABM. In addition, our data showed that S. pneumoniae represents the most common cause of ABM in children under 5 years of age.

Rapid diagnosis and simultaneous identification of tuberculous and bacterial meningitis by a newly developed duplex polymerase chain reaction

The present study describes the development and evaluation of a duplex polymerase chain reaction (D-PCR) for diagnosis and simultaneous identification of tuberculous meningitis (TBM) and bacterial meningitis (BM) in a single reaction. A D-PCR with primers amplifying portions of the Mycobacterium tuberculosis IS6110 and the eubacteria 16SrDNA sequence in a same reaction mix was developed and tested on DNA extracted from 150 clinical CSF samples from different categories (TBM = 39, BM = 26, control infectious and non-infectious category = 85). The results indicate a clear differentiation between bands for eubacteria and M. tuberculosis with an analytical sensitivity of 10(3) cfu/ml for eubacteria and 10(2) cfu/ml for M. tuberculosis. When evaluated in clinical samples, D-PCR overall diagnosed 100 % confirmed TBM and 100 % confirmed BM cases with overall specificity of 96.5 %. D-PCR can be an effective tool for diagnosis and simultaneous identification of TBM or BM in a single PCR reaction. It saves time, cost, labour and sample amount and help in administration of appropriate antimicrobial therapy. The proposed diagnostic assay would be helpful in correct and rapid management of TBM and BM patients.

Burden of invasive pneumococcal disease in children aged 1 month to 12 years living in South Asia: a systematic review

Objective

The primary objective was to estimate the burden of invasive pneumococcal disease (IPD) in children aged 1 month to 12 years in South Asian countries.

Methods

We searched three electronic databases (PubMed, Embase and the Cochrane Library) using a comprehensive search strategy, we manually searched published databases (Index Medicus and Current Contents) and we also searched the bibliographies of the included studies and retrieved reviews. The searches were current through June 2013. Eligible studies (community-based and hospital-based) were pooled and a separate analysis for India was also completed. A meta-regression analysis and heterogeneity analysis were performed. The protocol was registered with PROSPERO registration number CRD42013004483.

Results

A total of 22 studies surveying 36,714 children were included in the systematic review. Hospital-based prospective studies from South Asia showed that 3.57% of children had IPD, and 15% of all bacterial pneumonia cases were due to Streptococcus pneumoniae. Indian studies showed that the incidence of IPD was 10.58% in children admitted to hospitals with suspected invasive bacterial diseases, and 24% of all bacterial pneumonia cases were due to S. pneumonia. Population-based studies from South Asian countries showed that 12.8% of confirmed invasive bacterial diseases were caused by S. pneumonia whereas retrospective hospital-based studies showed that 28% of invasive bacterial diseases were due to S. pneumoniae. Meta-regression showed that there was a significant influence of the antigen testing method for diagnosing IPD on IPD prevalence.

Conclusion

S. pneumoniae is responsible for a substantial bacterial disease burden in children of South Asian countries including India despite the presence of high heterogeneity in this meta-analysis. Treatment guidelines must be formulated, and preventive measures like vaccines must also be considered.

Role of Clinical Presentations and Routine CSF Analysis in the Rapid Diagnosis of Acute Bacterial Meningitis in Cases of Negative Gram Stained Smears

Background and Aim. Bacterial meningitis is a lethal, disabling endemic disease needing prompt antibiotic management. Gram stained smears is rapid accurate method for diagnosis of bacterial meningitis. In cases of negative gram stained smears diagnosis is delayed till culture results. We aim to assess the role of clinical presentations and routine CSF analysis in the cost-effective rapid diagnosis of negative gram stained smears bacterial meningitis. Methods. Cross sectional study including 623 acute meningitis patients divided into two groups: bacterial meningitis and nonbacterial meningitis groups. The clinical presentations, systemic inflammatory parameters, and CSF analysis were evaluated and compared in both groups. Results. Altered conscious level, localizing neurological signs, Kernig's and Brudzinski's signs together with peripheral leucocytosis (>10.000/mm(3)), high CRP (>6) together with high CSF protein (>50 gl/dL), CSF neutrophilic count (≥50% of total CSF leucocytic count), and low CSF glucose level (<45 gm/dL) and CSF/serum glucose ≤0.6 were significantly diagnostic in bacterial meningitis patients. From the significant CSF analysis variables CSF protein carried the higher accuracy of diagnosis 78% with sensitivity 88% and specificity 72%. Conclusions. High CSF protein (>50 mg/dL) together with plasma inflammatory markers and CSF cytochemical parameters can diagnose bacterial meningitis in gram stain negative smear till culture results.

Phenotypic Characterization and Antibiogram of CSF Isolates in Acute Bacterial Meningitis

CONTEXT

Acute bacterial meningitis (ABM) is a medical emergency, which warrants an early diagnosis and an aggressive therapy. Despite the availability of potent newer antibiotics, the mortality rate caused by acute bacterial meningitis remains significantly high in India and in other developing countries, which ranges from 16 - 32%. There is a need of a periodic review of bacterial meningitis worldwide, since the pathogens which are responsible for the infection may vary with time, geography and the age of the patient.

AIMS

Our aim was to study the bacterial profiles and antimicrobial susceptibility patterns of the CSF isolates which were obtained from patients of acute bacterial meningitis in our area.

SETTINGS AND DESIGN

Two hundred and fifty two clinically diagnosed cases of acute bacterial meningitis, who were admitted to the wards of a tertiary medical centre in Patna, during the period from August 2011 to December 2012, were included in this study.

MATERIAL AND METHODS

Two hundred and fifty two CSF samples from as many patients of ABM were processed for cell counts, biochemical analysis, gram staining, culture, antigen detection by latex agglutination test (LAT) and antibiotic susceptibility tests, as per the standard techniques.

RESULTS

In this study, 62.3% patients were males and 37.7% were females The most common age group of presentation was 12-60 years (80.2%). Gram stained smears were positive in 162 (64.3%) samples, while culture yielded positive growth in 200 (79.4%) patients. Streptococcus pneumoniae was the most common pathogen which was isolated in 120 (60%) culture positive cases. Cell counts showed the predominance of neutrophils in all cases with ABM. High protein and low sugar levels correlated well with the features of ABM. All gram positive isolates were sensitive to vancomycin. All the gram negative isolates were sensitive to imipenem. Twenty two (8.7%) patients expired during the course of study. Deaths were caused by N.meningitidis in 9 (40.9%) cases, by S.pneumoniae in 3 (13.6%) cases and by H.influenzea in 1 (4.5%) case. In the remaining 9 (40.9%) mortality cases, the organism could not be identified.

CONCLUSION

Simple, rapid, inexpensive tests like gram staining remain significant means for diagnosis of ABM in developing countries. LAT for pneumococcal antigen should be performed first, since Streptococcus pneumoniae remains the major aetiological agent of ABM, both in adults and children. The final diagnosis of ABM depends upon a comprehensive analysis of CSF smears, cultures, LAT, cytological, biochemical and clinical findings of the cases, and a single test or parameter cannot be used to decide the course of management in the patients. However, empirical therapy is advocated, considering the potentially high rate of mortality in these patients.

Aetiologies of central nervous system infections in adults in Kathmandu, Nepal: a prospective hospital-based study

We conducted a prospective hospital based study from February 2009-April 2011 to identify the possible pathogens of central nervous system (CNS) infections in adults admitted to a tertiary referral hospital (Patan Hospital) in Kathmandu, Nepal. The pathogens of CNS infections were confirmed in cerebrospinal fluid (CSF) using molecular diagnostics, culture (bacteria) and serology. 87 patients were recruited for the study and the etiological diagnosis was established in 38% (n = 33). The bacterial pathogens identified were Neisseria meningitidis (n = 6); Streptococcus pneumoniae (n = 5) and Staphylococcus aureus (n = 2) in 13/87(14%). Enteroviruses were found in 12/87 (13%); Herpes Simplex virus (HSV) in 2/87(2%). IgM against Japanese encephalitis virus (JEV) was detected in the CSF of 11/73 (15%) tested samples. This is the first prospective molecular and serology based CSF analysis in adults with CNS infections in Kathmandu, Nepal. JEV and enteroviruses were the most commonly detected pathogens in this setting.

Salmonella typhimurium meningitis in infancy

We report a case of meningitis due to Salmonella typhimurium in a four-month-old female infant. The child was brought to the pediatric emergency department with complaints of fever, cold, and generalized convulsion. On examination, the child was febrile and was having seizures. The anterior fontanelle was not bulging. Lumbar puncture was done and Salmonella typhimurium was isolated from cerebrospinal fluid. Initially the infant improved clinically with appropriate management, but had a fatal outcome due to nosocomial pneumonia.

Diagnostic value of latex agglutination test in diagnosis of acute bacterial meningitis

Objectives:

To know the incidence of bacterial meningitis in children below five years of age. To compare conventional culture and antigen detection methods (Latex agglutination test).

Materials and Methods:

100 CSF samples of clinically suspected meningitis cases in children below 5 years of age were included. The samples were subjected to cell count, Gram stain, culture and LAT. The organisms isolated in the study were characterized according to standard procedures.

Results:

Of the 100 cases studied, 31 cases were diagnosed as ABM by Gram stain, culture and latex agglutination test as per WHO criteria. The hospital frequency of ABM was 1.7%. 15 (48.38) cases were culture positive. Gram stain was positive in 22(70.96) cases and LAT in 17(54.83) cases. Haemophilus influenzae was the most common causative agent of acute bacterial meningitis followed by S.pneumoniae. Case fatality rate was 45.16%. The sensitivity and specificity of LAT was 66.66% and 87.91% respectively.

Conclusion:

Bacterial meningitis is a medical emergency and early diagnosis and treatment is life saving and reduces chronic morbidity. LAT was more sensitive compared to conventional Gram stain and Culture technique in identifying the fastidious organisms like H.influenzae, S.pneumoniae and Group B Streptococcus. However, the combination of Gram stain, Culture and LAT proved to be more productive than any of the single tests alone.

Computational approaches to identify common subunit vaccine candidates against bacterial meningitis

Bacterial meningitis, an infection of the membranes (meninges) and cerebrospinal fluid (CSF) surrounding the brain and spinal cord, is a major cause of death and disability all over the world. From perinatal period to adult, four common organisms responsible for most of the bacterial meningitis are Streptococcus pneumonia, Neisseria meningitidis, Haemophilus influenza and Staphylococcus aureus. As the disease is caused by more organisms, currently available vaccines for bacterial meningitis are specific and restricted to some of the serogroups or serotypes of each bacterium. In an effort to design common vaccine against bacterial meningitis, proteomes of the four pathogens were compared to extract seven common surface exposed ABC transporter proteins. Pro-Pred server was used to investigate the seven surface exposed proteins for promiscuous T-cell epitopes prediction. Predicted 22 T-cell epitopes were validated through published positive control, SYFPEITHI and immune epitope database to reduce the epitope dataset into seven. T-cell epitope 162-FMILPIFNV-170 of spermidine/putrescine ABC transporter permease (potH) protein was conserved across the four selected pathogens of bacterial meningitis. Hence, structural analysis was extended for epitope 162-FMILPIFNV-170. Crystal structures of HLA-DRB alleles were retrieved and structure of potH was modeled using Prime v3.0 for structural analysis. Computational docking of HLA-DRB alleles and epitope 162-FMILPIFNV-170 of potH was performed using Glide v5.7. RMSD and RMSF of simulation studies were analyzed by Desmond v3.2. The docking and simulation results revealed that the HLA-DRB-epitope complex was stable with interaction repressive function of HLA. Thus, the epitope would be ideal candidate for T-cell driven subunit vaccine design against bacterial meningitis.

Regional epidemiology of invasive pneumococcal disease in Asian adults: epidemiology, disease burden, serotype distribution, and antimicrobial resistance patterns and prevention

OBJECTIVES

To summarize published data on the clinical and economic burden, epidemiology, antimicrobial resistance levels, serotype prevalence, and prevention strategies for pneumococcal disease among adults in Asia.

METHODS

We performed a systematic search of the PubMed database for relevant, peer-reviewed articles published between January 1995 and December 2011, covering China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam.

RESULTS

Taiwan and Thailand had the most comprehensive epidemiological data on adult pneumococcal disease. Very little relevant data were found for Indonesia, Pakistan, the Philippines, and Vietnam; surveillance is urgently needed in these countries. The emergence and spread of resistance emphasize the importance of vaccination to prevent infection in adults at increased risk for serious pneumococcal disease. Vaccination policies and opinions on the efficacy of vaccination vary widely in Asian countries, although a new option in the form of a pneumococcal conjugate vaccine is now available.

CONCLUSIONS

Increased awareness of the public health and economic benefits of pneumococcal vaccination is critically needed to help both the public and policymakers in making changes to vaccination policies in the region. Maximizing access to pneumococcal vaccines will decrease the number of hospitalizations, complications, and deaths associated with pneumococcal disease.

Comparison of cerebrospinal fluid in newborns and in infants ≤ 2 months old with or without meningitis

BACKGROUND

The aim of the present study was to evaluate the characteristics and accuracy of cerebrospinal fluid (CSF) parameters for neonatal meningitis, by comparing CSF data in newborns and in infants ≤ 2 months of age, with or without meningitis.

METHODS

This case-control study was performed on 120 newborns and infants ≤ 2 months old. 60 patients with meningitis were considered as the case group and 60 ill patients without meningitis were defined as the control group. Each of the two groups was divided into 0-1 months and 1-2 months old. CSF characteristics were compared in newborns in the case and control groups; in infants ≤ 2 months old in the case and control groups; and in healthy newborns and healthy infants ≤ 2 months old.

RESULTS

The mortality rate was 16.7% in the case group. The differences of CSF parameters in the case and control groups were mostly not significant, except for CSF glucose only in term newborns <7 days old (P= 0.04), and white cell count (WBC) only in 0-7-day-old term and preterm neonates (P= 0.04 and P= 0.01, respectively). Polymorphonuclear leukocyte (PMNL) level in the case group was significantly higher than in the control group (P= 0.02). CSF characteristics in healthy newborns were nearly the same as in healthy infants ≤ 2 months old. Prevalence of positive CSF culture was 31.7% in the case group. The most common pathogen was Neisseria meningitidis in the two age groups. The concomitant positive blood culture in the case group was 26.3%.

CONCLUSION

In the case of meningitis with negative CSF culture and Gram stain, diagnosis can be made on CSF parameters, clinical and laboratory findings and suspicion of meningitis. Therefore, a clinical prediction rule to classify risk for bacterial meningitis on evaluation of CSF parameters in any region should be established. More regional trials are needed to enhance the probability of diagnosis according to CSF parameters.

Meningococcal disease in Asia: an under-recognized public health burden

A literature search traced existing information on meningococcal disease in Asia. Reviewed data describing the epidemiology of meningococcal disease in Asia are incomplete, due in part to absence of surveillance in many countries, poor bacterial detection methods and social and healthcare barriers to disease reporting. This suggests that meningococcal disease in some Asian countries may be under-recognized, with a need to introduce/improve existing surveillance and case identification systems. Nevertheless, in some developing Asian countries, the disease burden may be significant. Serogroup A meningococcal epidemics are responsible for high morbidity and mortality in some countries and continue to be an ongoing threat, particularly in developing countries. There is an increasing role played by serogroups C, Y, and W-135 in invasive disease, indicating evolving meningococcal disease epidemiology in some countries. Multivalent meningococcal conjugate vaccines offer new opportunities in the region for reducing the meningococcal disease burden.

The epidemiology of meningococcal disease in India

OBJECTIVE

To undertake a review of the literature on the epidemiology of meningococcal disease in India, with a view to informing future control policies.

METHODS

We searched the PUBMED, EMBASE, Global Health, IMSEAR and MedIND databases for observational studies relating to the burden of endemic meningococcal disease in India, the occurrence and epidemiological characteristics of epidemics, and the prevalence of individual meningococcal serogroups.

RESULTS

The relatively few reports identified suggest that the incidence of endemic meningococcal disease in India is low, but that occasional epidemics of meningococcal disease have been recorded for at least 100 years. The larger epidemics have affected mainly the cities of northern India and have almost universally been caused by meningococci belonging to serogroup A. These epidemics have showed a few characteristics, including a marked seasonality, which are similar to those of epidemic meningococcal A disease in Africa.

CONCLUSIONS

New serogroup A-containing meningococcal conjugate vaccines are now being developed and reaching the market, including an affordable monovalent serogroup A vaccine manufactured in India, but intended primarily for use in Africa. These new tools may have a role in containing future Indian epidemics, but their usefulness is dependent on early identification of epidemics. This will require a functional disease surveillance system with adequate laboratory support throughout India.

A systematic review and critical evaluation of invasive Haemophilus influenzae type B disease burden studies in Asia from the last decade: lessons learned for invasive bacterial disease surveillance

In Asia, questions regarding the burden of Haemophilus influenzae type b (Hib) disease have delayed decision-making on introduction of Hib vaccine. However, over the past decade many studies have been published regarding Hib disease burden in Asia. We conducted a systematic literature review of all reports of Hib disease burden in Asia between 1998 and 2009, and critically reviewed their methods and data quality. We identified 94 studies from 28 countries in Asia presenting data on Hib disease burden. Of the 94 studies reviewed, 49 (52%) used a case definition consistent with World Health Organization standards, and 47 (50%) described laboratory methodology used. Twenty-seven surveillance studies presented data on incidence of Hib disease, with 8 (30%) accounting for missed cases, 6 (15%) accounting for cases with missed diagnostic tests, and 2 (7%) that considered prior antibiotic use. Of the 21 studies that provided incidence data for Hib meningitis, 10 (48%) used active, prospective, population-based surveillance, and found unadjusted incidence rates of Hib meningitis ranging from a low of 0.98 per 100,000 child-years in children aged less than 5 years in China to a high of 28 per 100,000 child-years in children less than 5 years in Mongolia. Of 49 studies that reported the etiology of bacterial meningitis, 30 (60%) identified Hib as the most common cause. This review highlights the importance of using rigorous methodologies, including standardized surveillance methods and appropriate laboratory diagnostic tests, when conducting studies measuring the burden of invasive bacterial diseases including those caused by Hib. When poorly conducted, studies can underestimate disease burden and lead to inappropriate decisions about vaccine introduction.

Staphylococcus aureus disease and drug resistance in resource-limited countries in south and east Asia

By contrast with high-income countries, Staphylococcus aureus disease ranks low on the public-health agenda in low-income countries. We undertook a literature review of S aureus disease in resource-limited countries in south and east Asia, and found that its neglected status as a developing world pathogen does not equate with low rates of disease. The incidence of the disease seems to be highest in neonates, its range of clinical manifestations is as broad as that seen in other settings, and the mortality rate associated with serious S aureus infection, such as bacteraemia, is as high as 50%. The prevalence of meticillin-resistant S aureus (MRSA) infection across much of resource-limited Asia is largely unknown. Antibiotic drugs are readily and widely available from pharmacists in most parts of Asia, where ease of purchase and frequent self-medication are likely to be major drivers in the emergence of drug resistance. In our global culture, the epidemiology of important drug-resistant pathogens in resource-limited countries is inextricably linked with the health of both developing and developed communities. An initiative is needed to raise the profile of S aureus disease in developing countries, and to define a programme of research to find practical solutions to the health-care challenges posed by this important global pathogen.

Pathogens associated with sepsis in newborns and young infants in developing countries

INTRODUCTION

Knowledge of pathogens causing infections in young infants (up to 90 days of life) is essential for devising community-based management strategies. Most etiological data from developing countries are hospital-based and may have little relevance to communities in which most babies are born at home.

METHODS

We searched the literature for studies from developing countries reporting etiology of community-acquired infections (sepsis, pneumonia, meningitis) published since 1980. Hospital-based studies reporting early onset sepsis, sepsis among babies admitted from, or born at home were included.

RESULTS

Of 63 studies, 13 focused on community-acquired infections, but limited data were available from home-born neonates. In the first week of life (3209 isolates), Klebsiella species (25%), Escherichia coli (15%), and Staphylococcus aureus (18%) were major pathogens. Group B streptococci (GBS) were relatively uncommon (7%), although regional differences existed. After the first week of life (835 isolates), S. aureus (14%), GBS (12%), Streptococcus pneumoniae (12%), and nontyphoidal Salmonella species (13%) were most frequent. S. pneumoniae (27%) was most common in the postneonatal period (among 141 isolates). Gram-negatives predominated (77%) among home-delivered babies (among 170 isolates).

CONCLUSIONS

Limited information is available on etiology of serious bacterial infections in community settings. Hospital-based studies suggest that most infections in the first week of life are due to Gram-negative pathogens, and many may be environmentally rather than maternally-acquired, owing to unhygienic delivery practices. Such practices may also explain the predominance of Gram-negative infections among home-born infants, although data from home settings are limited. These findings have implications for developing prevention and management strategies in communities and hospitals.