Etiology, risks factors, therapy of nosocomial cerebrovascular infections.

Nosocomial cerebrovacsular infections are substantial cause of mortality and morbidity in patients after neurosurgery. Risk factors, etiology, treatment strategies and outcome of nosocomial meningitis and brain abscess are briefly reviewed.

Nosocomial meningitis caused by Enterobacteriaceae: risk factors and outcome in 18 cases in 1992-2007.

Nosocomial neuroinfections due to Enterobacteriaceae represented 9.5% in our cohort of 171 cases of paediatric meningitis within last 15 years. Commonest etiologic agents was E. coli - 9 (50%) followed by Klebsiella pneumoniae - 3 (16,7%) and Enterobacter cloacae. Citrobacter freundii, Proteus mirabilis and Salmonella enteritidis (1 each). Commonest risk factors were neonatal age 13 - (72.2%), very low birth weight 5 (27.8%), craniocerebral trauma - 4 (22.2%) and neurosurgery - 5 (27.8%). All but 1 case were treated with antibiotics: 8 with III-rd and 3 with IV-th generation cephalosporins (ceftazidim, cefotaxim and cefepim) 2 with meropenem and 4 with ciprofloxacin: Nosocomial meningitis due to enterobacteriaceae was associated with significantly high mortality (29.9% vs. 15.1% in all cohort of pediatric meningitis - p<0.02).

Nosocomial meningitis in neonates caused by Streptococcus agalactiae.

Streptococcus agalactiae is a rare cause of neonatal meningitis in the era of peripartum prophylaxis with prophylaxis with ampicillin in colonized/infected mothers. However 5 cases of meningitis among 171 cases of pediatric nosocomial meningitis database within last 15 years occurred. All 5 children were neonates (one VLBW and early gestation newborn), 2 after neurosurgery. All 5 cases were successfully cured with a combination of cefotaxim (or ceftazidim) plus aminoglycosides, in one case also with addition of vancomycin or ampicillin. However 3 of 5 cured patients had neurologic sequellae, two of them reversible hydrocephalus and in speech retardation.

Neuroinfections due to Enterococcus faecalis in children.

Enterococcal meningitis is a rare complication of neurosurgical procedure or high technology treatment of children and occurs mainly imunocompromised neonates with very low birth weight, severe prematurity and complicates sometime ventriculoperitoneal shunt insertion or perinatal trauma. E. faecalis caused 10 nosocomial meningitis and all strains were susceptible to vancomycin and chloramphenicol, and in our database 90% also to gentamicin and ampicillin. Mortality in our group of 10 children was 20% what is insignificantly higher than overall mortality in the whole cohort of meningitis within last 15 years in our database (15.1%). Early empiric therapy should include also ampicillin or vancomycin, if enterococcal etiology is suspected.

Infectious diseases in disaster areas/catastrophes.

There is very little data and no prospective research possible in the field of catastrophic medicine (disaster medicine) including infectious diseases. This minireview tries to contribute to the pathogenesis and outcome of infectious diseases in areas after anthropogenic (war, genocide, terrorist attack, industrial disasters) and non anthropogenic (natural) catastrophes (earthquake, floods, tsunamis, hurricanes, volcano eruptions). Therefore ISC received a proposal to create a working group on infectious diseases in areas after catastrophes, better to understand epidemiology, prevention and therapy of infectious diseases occurring in conjunction to various anthropogenic and non anthropogenic (natural) disasters.

Antimicrobial susceptibility of cerebrospinal isolates from patients with meningitis.

Str. pneumoniae isolates were susceptible to penicillin, all to also ofloxacin and chloramphenicol and cefotaxim and 39 (100%) to cotrimoxazol. Concerning S. aureus, all isolates 22 were susceptible to oxacillin and chloramphenicol, and 21 also to cotrimoxazol. All N. meningitidis isolates but one-10 of all were susceptible to penicillin, all to cefotaxim, chloramphenicol and cotrimoxazol. All H.influenzae isolates were susceptible to ampicillin and chloramphenicol, as well as to ofloxacin and cotrimoxazol. Those surprisingly high susceptibilities to rather "old" antibiotics may be explained by low antibiotic consumption, accessibility and therefore low usage which is a key promoter of resistance both in community and hospital.

Is combination therapy with betalactam plus aminoglycoside (AGL) improving the outcome of nosocomial meningitis in children?

We have been unable to document a benefit of a combination of aminoglycosides with betalactam or carbapenem antibiotics in nosocomial meningitis. This was similar to the cases of sepsis, where survival of patients did not improve with combination therapy. Combination therapy did not increase the chance of appropriateness of the therapy. 30% of those on combination therapy were considered as inappropriately treated in comparison to 2.8% of those on monotherapy (p<0.01).

Postsurgical meningitis caused by Acinetobacter baumannii associated with high mortality.

Twenty five (25) cases of nosocomial postsurgical meningitis due to Acinetobacter baumannii meningitis were compared to other 146 cases of meningitis after surgery caused by other pathogens. Prior neurosurgical ventriculo-peritoneal shunt insertion and CNS abnormality as well as very low birth weight were significant risk factors for acquisition of Acinetobacter baumannii meningitis. Mortality - 40% among children with nosocomial meningitis was unacceptably high and significantly higher than among meningitis caused by microorganisms other than Acinetobacter baumannii.

National 14 years survey of 171 cases nosocomial meningitis in children and comparison of two periods 1993-1998 to 1999-2006.

In 1993-1998 and in 1999-2004 we have performed two surveys of pediatric bacterial meningitis in all 8 neurosurgery/pediatrics and infectious diseases departments in Slovakia. We have detected 101 and another 54 cases with attributable mortality of 15% and sequellae in 18%.

Pseudomonas aeruginosa causing nosocomial meningitis in neonates and children: overview of 15 cases within 10 years.

Risk factors, therapy and outcome of 15 cases of nosocomial meningitis due to Pseudomonas aeruginosa is reviewed. No difference in risk factors was found, however mortality for Ps. aeruginosa was significantly higher (33.3 vs 15.1% p<0.04).

Infectious embolisation to the central nervous system from endocarditis: analyses of 99 cases.

Within a cohort of 606 cases of infective endocarditis, 263 were complicated and 99 embolizing, of them 32 to the central nervous system (CNS). Significant predictors of CNS embolisation were inappropriate therapy (p<0.01) and enterococcal etiology (p<0.01). Mortality in patients with CNS emboli was 65% what was significantly higher than in cases without embolisation - 15% (p<0.01).

Bacteremic meningitis is associated with inferior outcome in comparison to community acquired meningitis without bacteremia.

Meningitis associated with bacteremia is rare. Bacteremic form of meningitis occurred in 28 of 201 cases of community acquired meningitis (14%) in Slovakia within last 17 years. Bacteremic meningitis was associated with diabetes (21.4% vs. 7.5%, p=0.02) and with higher treatment failures (32.1% vs. 9.5%, p=0.01) and higher mortality (25% vs. 12.4%, NS). In univariate analysis comparing 28 cases of bacteremic community acquired bacterial meningitis (BCBM) to all CBM, no significant risk factor concerning underlying disease (cancer, ENT infection, alcohol abuses, trauma, splenectomy, etc.) or etiology was observed apart of diabetes mellitus, which was more common among bacteremic meningitis (21.4% vs. 7.5%, p=0.02). Mortality (25% vs. 12.4%, NS) insignificantly but therapy failure (32.1% vs. 9.5%, p=0.01) was significantly more frequently observed among meningitis with bacteremia. N. meningitis was the commonest causative agent (8 of 28 cases) followed by Str. pneumoniae (6), gram-negative bacteria (6), S. aureus (4) and H. influenzae (2).

Neuroinfections complicating foreign body implants after perinatal trauma or meningitis in 60 children.

Meningitis after artificial implants in 60 children, mainly after foreign body infections (FBI) was caused more frequently by coagulase negative staphylococci and Ps. aeruginosa than other organisms and was significantly associated with perinatal trauma, hydrocephalus, haemorrhage or VLBW and had more neurologic sequels despite mortality was similar to other nosocomial meningitis.

Gram-negative bacillary community acquired meningitis is not a rare entity in last two decades.

The aim of this short note is to assess gram-negative bacillary community acquired meningitis (CBM) and nosocomial meningitis (NM) within 17 years nationwide survey. All cases of gram-negative bacillary CBM within 1990-2007 were assessed in national database of 372 patients with bacterial meningitis: 69 of gram-negative cases were nosocomial and 24 of gram-negative meningitis cases were CBM. Those 24 cases were compared with all CBM (201 cases) for risk factors and outcome. Among nosocomial gram-negative pathogens, A. baumannii in 23 cases, Ps. aeruginosa in 15 cases and Enterobacteriaceae in 31 cases were isolated. Among CBM, in 13 cases Enterobacteriaceae (Escherichia coli 6, Klebsiella pneumoniae 3, Proteus mirabilis 2, Enterobacter cloacae 2), in 5 cases Ps. aeruginosa and in 6 cases Acinetobacter baumannii were isolated from cerebrospinal fluid (CSF). The only significant risk factor for CBM due to gram-negative bacilli was neonatal age (12.5% vs. 3.5%, p=0.04) as underlying disease. However, mortality among gram-negative bacillary meningitis was significantly higher (12.4% vs. 37.5%, p=0.001) in comparison to other meningitis.

Haemophillus influenzae community acquired meningitis occurrence in children despite 10 years vaccination.

Despite of 10 years vaccination of all children within 1st year in Slovakia against H. influenzae, this severe infection still occurs. Among 201 cases of community acquired bacterial meningitis, 14 (7%) were caused by H. influenzae serotype B. Outcome however, after early institution of treatment was fortunately positive - only 1 patient died (7.1% mortality) and in 2 other neurologic sequellae occurred (14.3%), which were transient and mild.

Nosocomial meningitis caused by Staphylococcus other than S. aureus in children: multicentre study.

Analysing 101 cases of nosocomial meningitis due to staphylococci other than S. aureus within last 15 years, coagulase negative staphylococci represented the commonest pathogen. Major risk factor for staphylococcal meningitis was prior neurosurgery, mainly ventriculoperitoneal shunt insertion. Ten of 101 cases were caused by glycopeptide intermediate resistant strains in patients pretreated with multiple combination of antibiotics including vancomycin and shunt exchanges: 76% of strains were also oxacillin resistant.

Bacterial meningitis after sinusitis and otitis media: ear, nose, throat infections are still the commonest risk factors for the community acquired meningitis.

We investigated how many cases of bacterial meningitis in our national survey were associated with sinusitis or otitis media. Among 372 cases of bacterial meningitis within our nationwide 17 years survey, 201 cases were community acquired (CBM) and in 40 (20%) otitis media or sinusitis acuta/chronica were reported 1-5 weeks before onset of CBM. Diabetes mellitus (20% vs. 7.5%, p=0.01), alcohol abuse (35% vs. 15.4%, p=0.003) and trauma (30% vs. 14.9%, p=0.02) were significantly associated with CBM after ENT infections. Concerning etiology, CBM after sinusitis/otitis was insignificantly associated with pneumococcal etiology (50% vs. 33.8 %, NS) and significantly associated with other (L. monocytogenes, Str. agalactiae) bacterial agents (9.9 % vs. 25 %, p=0.008) . However those significant differences for new ENT related CBM had no impact on mortality (12.4 % vs. 5%, NS), failure after initial antibiotics (10 % vs. 9.5%, NS) and neurologic sequellae (12.5 % vs. 15.4 %, NS).

Predictors of inferior outcome in community acquired bacterial meningitis.

The aim of this study was to assess mortality and sequellae within cases from Nationwide survey of community acquired meningitis and identify risk factors for inferior outcome. Risk factors such as underlying disease (diabetes mellitus, cancer, trauma, neonatal age, splenectomy, alcoholism, sepsis, other infections), etiology, clinical symptoms and outcome (death, improvement and cured after modifications of ATB therapy, cured without change of therapy, cured with neurologic sequellae) were recorded and analysed with univariate analysis (chi2 or t test for trends, CDC Atlanta 2004). Analysing risk factors for inferior outcome (death or cured with neurologic sequellae), we compared patients who died or survived with neurologic sequellae to all patients with community acquired bacterial meningitis. Univariate analysis showed that trauma (p<0.05), alcohol abuse (p<0.05), diabetes, S. aureus (p<0.05) and gram-negative etiology (A. baumannii, Ps. aeruginosa or Enterobacteriaceae) (36% vs. 11,9%, p<0.05) were predicting inferior outcome. Analysing risk factors for treatment failure (death or failed but cured after change of antibiotic treatment) prior sepsis (34.1% vs. 13.9%, p<0.01) and gram-negative etiology (25% vs. 11.9%, p<0.02) were statistically significant predictors of treatment failure. Neisseria meningitis had less failures (p<0.05). Concerning infection associated mortality again diabetes mellitus (p<0.05), alcoholism (p<0.05) staphylococcal and gram-negative etiology (p<0.05) were significant predictors of death. N. meningitis had surprisingly less treatment failures (appropriate and rapid initial therapy). Neurologic sequellae were more common in patients with alcohol abuse (p<0.05), craniocerbral trauma (p<0.05) and less common in meningitis with pneumococcal etiology (p<0.05).

Comparison of postsurgical and community acquired bacterial meningitis--analysis of 372 cases within a nationwide survey.

The aim of this study was to assess if differences in etiology and risk factors among 372 cases of bacterial meningitis acquired after surgery (PM) or in community (CBM) have impact on outcome of infected patients. Among 372 cases of bacterial meningitis within last 17 years from 10 major Slovak hospitals, 171 were PM and 201 CBM. Etiology, risk factors such as underlying disease, cancer, diabetes alcoholism, surgery, VLBW, ENT infections, trauma, sepsis were recorded and mortality, survival with sequellae, therapy failure were compared in both groups. Significant differences in etiology and risk factors between both groups were reported. Those after neurosurgery had more frequently Coagulase negative staphylococci (p<0.001), Enterobacteriaceae (p=0.01) and Acinetobacter baumannii (p=0.0008) isolated from CSF and vice versa Streptococcus pneumoniae (p<0.001), Neisseria meningitis (p<0.001) and Haemophillus influenza (p=0.0009) were more commonly isolated from CSF in CBM. Neurosurgery (p<0.001), sepsis (p=0.006), VLBW neonates (p=0.00002) and cancer (p=0.0007) were more common in PM and alcohol abuse (p<0.001) as well as otitis/sinusitis (p<0.001) and Roma ethnic group (p=0.001) in CAM. Initial treatment success was significantly more frequently observed among CAM (p<0.001) but cure after modification was more common in PM (p=0.002). Therefore outcome in both groups was similar (14.6% vs. 12.4%, p=NS).

Bacterial meningitis after craniocerebral trauma in the community.

Craniocerebral trauma is one of major risk factors for development of meningitis. We reviewed 30 cases of bacterial meningitis occurring in community after craniocerebral trauma. Alcohol abuse was significant risk factor occurring in trauma patients with meningitis present in 50% in our cohort (p=0.0001). The most common pathogen in posttraumatic meningitis was Str. pneumoniae (90% vs. 33.8%, p=0.0001). However mortality was very low, only 5% probably because of early diagnosis and treatment of patients at risk for bacterial meningitis but neurologic sequellea were significantly more common (p=0.00001) in patients after craniocerebral trauma.