Dexamethasone treatment for bacterial meningitis in children and adults.

Four hundred twenty-nine patients with bacterial meningitis were assigned on a nonselective alternating basis into one of two therapeutic regimens. Patients in Group I received dexamethasone in addition to standard antibacterial chemotherapy of ampicillin and chloramphenicol whereas those in Group II received antibacterial chemotherapy alone. Dexamethasone was given intramuscularly (8 mg to children younger than 12 years and 12 mg to adults every 12 hours for 3 days). Both treatment groups were comparable with regard to age, sex, duration of symptoms and state of consciousness at the time of hospitalization. A significant reduction in the case fatality rate (P less than 0.01) was observed in patients with pneumococcal meningitis receiving dexamethasone; only 7 of 52 patients died compared with 22 of 54 patients not receiving dexamethasone. A reduction in the overall neurologic sequelae (hearing impairment and paresis) was observed in patients receiving dexamethasone. This reduction was significant only in patients with Streptococcus pneumoniae meningitis; none of the 45 surviving patients receiving steroids had hearing loss whereas 4 of 32 patients not receiving dexamethasone had severe hearing loss (P less than 0.05). No significant difference was observed between the two groups with regard to time for patients to become afebrile or to regain consciousness or in the mean admission and 24- to 36-hour cerebrospinal fluid leukocyte count, glucose or protein content.

Dexamethasone adjunctive treatment for tuberculous meningitis.

During a 5-year period, 280 of 2010 patients admitted to the meningitis ward of a referral hospital in Cairo, Egypt, were clinically diagnosed as having tuberculous meningitis and were treated with either antituberculous chemotherapy and dexamethasone or antituberculous chemotherapy alone. Fatality rates and neurologic sequelae were compared for the 2 treatment groups in the 160 patients who had cerebrospinal fluid cultures positive for Mycobacterium tuberculosis. The overall mortality rate of 51% reflects the delay in receiving appropriate therapy (79% with symptoms for more than 2 weeks) and the severity of illness on admission (56% in coma, 39% drowsy). The fatality rate was significantly lower in the group receiving dexamethasone (43% vs. 59%, P less than 0.05), particularly in the drowsy patients (15% vs. 40% P less than 0.04), and in patients surviving long enough to receive at least 10 days of treatment (14% vs. 33%, P less than 0.02). Development of neurologic complications after initiation of therapy (4 vs. 10) and permanent sequelae (6 vs. 13) were significantly lower in the dexamethasone-treated group (P less than 0.02).

Salmonella paratyphi A in hamsters concurrently infected with Schistosoma mansoni.

The present work deals with the development of an improved animal model to study the association of salmonellosis and schistosomiasis. The animal chosen was the hamster, Mesocricetus auratus, which can be readily infected with Schistosoma mansoni. Normal hamsters and schistosome-infected hamsters (SIH) were given approximately 2.0 x 10(7) Salmonella paratyphi A intracardially. It was found that S. mansoni infections enhanced and prolonged the growth of S. paratyphi A in hamsters. Animals with dual infections had increased mortality in comparison with those infected with just bacteria or parasite during the 50 days post-bacterial challenge. Further studies showed that in SIH, S. paratyphi A persisted in various organs for up to 8 weeks post infection. In contrast, concurrent Leishmania donovani infections have no effect on S. paratyphi A infections. Significant numbers of bacteria were cultured from well-washed schistosome worms recovered from SIH 6--8 weeks post-bacterial challenge. These findings suggest that a direct physical relationship between the bacteria and worms facilitates the establishment and growth of S. paratyphi A in vivo, and that a deficit in host immune response is not a major factor involved in the enhanced growth of S. paratyphi A.

Interaction of Salmonella paratyphi A and Schistosoma mansoni in hamsters.

It has previously been shown that Salmonella paratyphi A associates with adult Schistosoma mansoni worms in animal models and in patients with schistosomiasis, resulting in Salmonella infections that are difficult to manage unless the helminthic parasite is eliminated. In the present study, characteristics of this association were explored. In vitro, fresh serum, but not heat-inactivated (56 degree C, 30 minutes) serum, from normal hamsters (NH) and schistosome-infected hamsters (SIH) equally inhibited bacterial growth. When either group of animals was given S. paratyphi A intracardially, there was a decline in recoverable bacteria in the blood for 3 days, but after the third day, the number of bacteria increased in SIH whereas NH blood became sterile. Co-cultivation of S. paratyphi A in Earle's medium with live worms yielded more bacterial growth than occurred in the medium without worms, suggesting that nutritional factors are involved in the relationship. An intimate association in vivo of bacteria and trematodes was confirmed by culturing Salmonella from both worm surfaces and homogenized worms, with more bacteria being recovered from female worms. Although the bacterial infection induced a significant hepatic shift of adult worms in SIH, oogram analyses were normal and no lethal effect of bacteria on worms was noted.

Meningitis and encephalitis at the Abbassia Fever Hospital, Cairo, Egypt, from 1966 to 1989.

A total of 7,809 patients with meningitis or encephalitis were admitted to the Abbassia Fever Hospital in Cairo, Egypt from November 1, 1966 to April 30, 1989. The etiology was Neisseria meningitidis (mostly group A) in 27.3% of the patients, Mycobacterium tuberculosis in 19.7%, Streptococcus pneumoniae in 7.3%, and Haemophilus influenzae in 4.1%. Almost 27% of the cases had purulent meningitis but without detectable etiology; however, the epidemiologic data suggest that most of these had meningococcal meningitis. Encephalitis was suspected in 12.5% of the patients. Most of the meningococcal, pneumococcal, and Haemophilus cases occurred during the winter months. The number of meningococcal and culture-negative purulent cases per year reached a maximum three times during the 22.5 years of this study. There were more males than females in all etiologic groups, with the ratio for the total patient population being 1.6:1. The average age ranged between 11.7 and 16.5 years for all groups except for Haemophilus patients, who had a mean age of 2.5 years. The mortality rate was almost 55% for tuberculous patients and was approximately 40% for both pneumococcal and Haemophilus patients; it was 8.5% in patients with meningococcal disease.

Etiology of acute diarrhea among United States Embassy personnel and dependents in Cairo, Egypt.

The purpose of this study was to identify the enteropathogens causing acute diarrheal disease in Americans living in the North Africa/Middle East region during a 34-month period from February 12, 1985 to December 30, 1987 to guide preventive and therapeutic measures. Stool specimens were examined and an epidemiologic questionnaire was administered to patients with acute diarrhea at the Outpatient Health Unit of the United States Embassy in Cairo, Egypt. The subjects consisted of 126 American employees and dependents of the U. S. Embassy in Cairo, Egypt with diarrhea of less than two-weeks duration. Subjects received routine medical care administered by the U.S. Embassy Medical staff. A possible etiologic agent was detected in 41% of the subjects. Enteroadherent Escherichia coli was the most commonly isolated enteropathogen. A high degree of antimicrobial resistance was noted among the bacterial isolates, but all were susceptible to the quinolone antibiotics. Episodes of acute diarrhea occurring among American expatriates in Cairo, Egypt were primarily of bacterial etiology, but only a small portion were caused by the bacterial pathogens routinely identified in a standard clinical bacteriology laboratory. Most of the diarrheal episodes were due to noninvasive enteroadherent E. coli that may cause prolonged disease requiring antimicrobial therapy.

Ceftriaxone versus chloramphenicol in the treatment of enteric fever.

Fifty-five patients with culture-proven Salmonella typhi and paratyphi enteric fever were assigned to one of two therapeutic regimens. Group I received ceftriaxone 60-80 mg/kg/day intramuscularly for 5-7 days, those in group II received chloramphenicol 50-80 mg/kg/day orally in 4 divided doses for 12-14 days. both groups were comparable as regards age, sex, severity and duration of symptoms prior to admission. A significant reduction in the mean number of days taken for patients to become afebrile, disappearance of clinical signs and symptoms, duration of therapy and hospital stay were observed in patients receiving ceftriaxone as compared to those receiving chloramphenicol. None of the patients receiving ceftriaxone relapsed, while three patients receiving chloramphenicol relapsed. No major reactions were seen with either drug.

Travelers' diarrhea among United States military personnel during joint American-Egyptian armed forces exercises in Cairo, Egypt.

A study was conducted of travelers' diarrhea in a United States military population on deployment in Cairo, Egypt, during July and August 1987. Acute diarrhea requiring medical attention developed in 183 (4%) of 4,500 troops. A possible etiologic agent was identified in 49% of all diarrhea cases. Enteric pathogens associated with cases of diarrhea included: Enterotoxigenic Escherichia coli (17% ST-producers, 13% LT-producers, and 3% LT/ST-producers); Shigella (9%); Campylobacter spp. (2%); Salmonella (2%); and Vibrio cholerae non-01 serogroup (2%). Other enteric pathogens isolated from one episode each of diarrhea included Aeromonas hydrophila group, Plesiomonas shigelloides, and Bacillus cereus. Yersinia enterocolitica, enteroinvasive E. coli, intoxications by Clostridium perfringens and Clostridium difficile, and pathogenic enteric parasites were not found in any of the 183 patients with diarrhea. A survey of military personnel not requesting medical care indicated that up to 40% of troops may have had diarrhea during this deployment. Acute gastroenteritis is a potential cause of substantial morbidity in U.S. military personnel deployed to Egypt.

[Aeromonas hydrophila in the drinking water in Djibouti: commensal germ or diarrhea-causing agent?]. / Aeromonas hydrophila dans les eaux de boisson a Djibouti: germe commensal ou agent de diarrhée?

To investigate the bacteriological quality of drinking water used by inhabitants of the Republic of Djibouti who were not supplied with piped running water, we analysed 16 fresh-water samples from various sources. Only 3 samples were sterile; they were taken from village pumps and from a water-truck. Eleven samples yielded colonies of Aeromonas hydrophila too numerous to be counted; they were taken from water tanks, metal barrels, or wells dug in either dry river beds or along the seashore. We speculate that this high isolation frequency of Aeromonas hydrophila in fresh water samples may be related to conditions that are exceptionally favourable for the growth of the bacterium (e.g. high temperature and elevated concentrations of certain salts and minerals in the fresh water of Djibouti). We wonder nevertheless whether the infected water supplies were a source of diarrhoea for humans. Indeed, antibiotic resistance patterns were dissimilar when the 11 environmental strains were compared to 7 strains of Aeromonas hydrophila isolated from diarrhoeal patients in Djibouti during the same period. More studies are needed to determine if Aeromonas hydrophila is always a commensal inhabitant of fresh water in Djibouti, or if it can be a cause of infectious diarrhoea. Accordingly, Public Health authorities in Djibouti will be able to decide if water from wells and tanks is safe for drinking, or if it needs disinfection before consumption.

Negative cultures of cerebrospinal fluid in partially treated bacterial meningitis.

Admission cerebrospinal fluid and serum were examined for antimicrobial activity in 296 Egyptian patients hospitalized with signs of meningitis. Assays were positive in 92%; 60% had large levels of antimicrobial activity in cerebrospinal fluid. Bacterial meningitis was diagnosed in 102 patients. The negative cerebrospinal fluid cultures in 58 of these patients were in part due to the antimicrobial activity in the cerebrospinal fluid. Mortality in patients with bacterial meningitis was greatest when cultures were positive and moderate levels of antimicrobial activity were present in the cerebrospinal fluid. Survival in these patients appeared to be enhanced if their prehospitalization antimicrobial use suppressed bacterial growth in the cerebrospinal fluid.

Comparative in vitro activity of five cephalosporin antibiotics against salmonellae.

The in vitro activities of five cephalosporin antibiotics against 121 strains of salmonellae were compared. Cefamandole and cefaclor were more potent than cefazolin, and these three drugs were more active than cephalothin and cephalexin.

Rapid, economical diagnosis of enteric fever by a blood clot culture coagglutination procedure.

Coagglutination tests with Salmonella A, D, Vi, and polyvalent antiserum-sensitized staphylococcal cells were compared with conventional culture methods for detecting salmonellae in ox bile cultures of blood clots from enteric fever patients. The coagglutination tests appeared equally as effective as conventional subculture methods for detecting positive cultures (95% agreement). In addition, the coagglutination method yielded earlier results at reduced cost.

Cerebrospinal fluid and serum ampicillin levels in bacterial meningitis patients after intravenous and intramuscular administration.

28 patients with bacterial meningitis received ampicillin by the intramuscular (IM) route and 16 patients by the intravenous (IV) route. The mean cerebrospinal fluid (CSF) ampicillin levels were similar in the two groups 1 h after a dose given on the first or second day of treatment, but they were higher in the IM group on both days 4 h after a dose. CSF/serum ratios were similar in both groups but considerably higher at 4 h than at 1 h.

Epidemiology of bacterial pathogens associated with infectious diarrhea in Djibouti.

During a survey examining the causes of diarrhea in the East African country of Djibouti, 140 bacterial pathogens were recovered from 209 diarrheal and 100 control stools. The following pathogens were isolated at comparable frequencies from both diarrheal and control stools: enteroadherent Escherichia coli (EAEC) (10.6 versus 13%), enterotoxigenic E. coli (ETEC) (11 versus 10%), enteropathogenic E. coli (EPEC) (7.7 versus 12%), Salmonella spp. (2.9 versus 3%), and Campylobacter jejuni-C. coli (3.3 versus 5%). Surprisingly, the EAEC strains isolated did not correspond to well-recognized EPEC serogroups. No Yersinia spp., enteroinvasive E. coli, or enterohemorrhagic E. coli were isolated during the course of this study. Only the following two genera were recovered from diarrheal stools exclusively: Shigella spp. (7.7%) and Aeromonas hydrophila group organisms (3.3%). Shigella flexneri was the most common Shigella species isolated. Patients with Shigella species were of a higher average age than were controls (27 versus 13 years), while subjects with Campylobacter or Salmonella species belonged to younger age groups (2.6 and 1.6 years, respectively). Salmonella cases were more often in females. Shigella diarrhea was associated with fecal blood or mucus and leukocytes. ETEC was not associated with nausea or vomiting. Anorexia, weight loss, and fever were associated with the isolation of Salmonella and Aeromonas species. EAEC, ETEC, EPEC, and Shigella species were resistant to most drugs used for treating diarrhea in Africa, while the antibiotic most active against all bacteria tested was norfloxacin. We conclude that in Djibouti in 1989, Shigella and Aeromonas species must be considered as potential pathogens whenever they are isolated from diarrheal stools and that norfloxacin should be considered the drug of choice in adults for treating severe shigellosis and for diarrhea prophylaxis in travelers.

Rapid diagnosis of tuberculous meningitis by frequency-pulsed electron-capture gas-liquid chromatography detection of carboxylic acids in cerebrospinal fluid.

The frequency-pulsed electron-capture gas-liquid chromatography technique described previously by Brooks et al. was modified and applied to the studies of coded and routine clinical specimens. Uncentrifuged cerebrospinal fluid (2 ml) was extracted under acidic conditions, derivatized, and analyzed by frequency-pulsed electron-capture gas-liquid chromatography on large-bore fused silica polar and nonpolar capillary columns. The frequency-pulsed electron-capture gas-liquid chromatography profile of carboxylic acids (C2 through C22) along with identification of tuberculostearic acid, established by retention time comparison of derivatized tuberculostearic acid and derivatized sample extract, strongly suggests the presence of Mycobacterium tuberculosis in patients with lymphocytic meningitis. Results from 41 coded cases and 75 clinical cases showed that the frequency-pulsed electron-capture gas-liquid chromatography test had a specificity of 91% and a sensitivity of 95%.