Meningite bacteriana: uma revisão / Bacterial meningitis: a review

A meningite bacteriana é uma inflamação das leptomeninges que envolvem o Sistema Nervoso Central. Essa patologia, que possui diversos agentes etiológicos, apresenta-se na forma de síndrome, com quadro clínico grave. Entre as principais bactérias que causam a meningite, estão a Neisseria meningitis e Streptococcus pneumoniae. A transmissão ocorre através das vias aéreas por meio de gotículas, sendo a corrente sanguínea a principal rota para as bactérias chegarem à barreira hematoencefálica e, a partir dessa, até as meninges. Atualmente existem vários métodos de diagnóstico precisos, onde a cultura de líquido cefalorraquidiano (LCR) é o método padrão ouro. Ademais, a melhora na qualidade do tratamento com beta-lactâmicos e a maior possibilidade de prevenção, devido à elevação do número e da eficácia de vacinas, vem contribuindo para redução dos casos da doença e de sua gravidade. Porém, apesar desses avanços, ainda há um elevado número de mortalidades e sequelas causadas por essa síndrome.

Bacterial meningitis is an inflammation of the leptomeninges that surround the Central Nervous System. This pathology, which has several etiological agents, is presented as a syndrome with a severe clinical scenario. The main bacteria causing meningitis include Neisseria meningitis and Streptococcus pneumoniae. It can be transmitted by droplets through the airways, with the bacteria using the bloodstream as the main route to reach the blood-brain barrier, and from there to the meninges. There are currently several accurate diagnostic methods, with CSF culture being the gold standard. In addition, the improvement in the quality of beta-lactam treatment and the greater possibility of prevention due to the increased number and effectiveness of vaccines have contributed to reducing the number of cases and severity of the disease. Nevertheless, despite these advances, this syndrome still presents a high number of mortalities and sequelae.

Meningitis crónica autoinmune secundaria a meningitis aguda por neumococo: caso clínico / Autoimmune chronic meningitis secondary to pneumococcal meningitis: report of one case

Pneumococcal meningitis produces several inflammatory disorders in susceptible subjects. A worsening of meningitis can occur on the fourth day of evolution in relation with the withdrawal of steroids. Other complications include the development of inflammatory signs in the post-acute stage of infection associated with disseminated vasculitis of the cerebral blood vessels and, even later, an autoimmune chronic meningitis. All these inflammatory complications are well controlled with the use of steroids. We report a 53-year-old woman with pneumococcal meningitis that had a good response to treatment with antibiotics and steroids. On the four day, after the steroids were discontinued, she complained of headache, became confused, and had an abnormal cerebrospinal fluid (CSF), report CT angiography showed signs of arteritis. She improved when the steroids were re-started. She was discharged in good condition but after slow tapering of the steroids over a four-month period she had a relapse of all her symptoms and had a gait disturbance. On readmission, she had an inflammatory CSF, there were no signs of infection and the cerebral MRI showed meningeal thickening with ventricular space enlargement. She improved again with steroids and she is now well on high-dose steroids but deteriorates each time the steroids are stopped. She experienced both acute and sub-acute inflammatory responses and finally developed a chronic meningitis responsive, and is dependent on steroids.

Meningitis por Streptococcus pneumoniae resistente a ceftriaxona: reporte de un caso / Ceftriaxone-resistant Streptococcus pneumoniae meningitis: case report

RESUMEN La meningitis infecciosa es una emergencia médica. Dentro del espectro de agentes infecciosos, el más importante es el Streptococcus pneumoniae, agente etiológico más frecuente de la meningitis bacteriana. El inicio de tratamiento antimicrobiano empírico es de gran importancia y considera a las cefalosporinas de tercera generación como la primera alternativa. Sin embargo, casos de resistencia a ceftriaxona han sido reportados en diversas partes del mundo, siendo un problema emergente, por lo que necesita una reconsideración de los esquemas antibióticos empíricos actuales. Presentamos el caso de un varón de 56 años que presenta meningitis aguda infecciosa por Streptococcus pneumoniae resistente a ceftriaxona, que respondió favorablemente al tratamiento empírico combinado con ceftriaxona y vancomicina y que durante su estadía hospitalaria se detectó la presencia de hipotiroidismo y megacisterna magna.

ABSTRACT Infectious meningitis is a medical emergency. Within the spectrum of infectious agents, the most important is Streptococcus pneumoniae, the most frequent etiological agent of bacterial meningitis. The initiation of empirical antimicrobial treatment bears great importance and considers third-generation cephalosporins as the first alternative. However, cases of ceftriaxone resistance have been reported in several regions of the world. This has become an emerging problem in need of reconsideration of the current empirical antibiotic treatment schemes. We present the case of a 56-year old man with acute infectious meningitis caused by ceftriaxone-resistant Streptococcus pneumoniae, who responded favorably to combined empirical treatment with ceftriaxone and vancomycin and to whom, during his hospital stay, the presence of hypothyroidism and mega cisterna magna was diagnosed.

Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

Meningitis neumocóccica por serotipo 19 A, de curso fatal: ¿Un caso prevenible? / Fatal pneumococcal meningitis due to serotype 19 A: A preventable case?

Invasive pneumococcal disease (IPD) remains as an important cause of morbidity in the world and in our country, while in Chile the incidence has decreased after the incorporation of the 10 valent pneumococcal conju-gate vaccine, in the routine infant inmunization schedule (EPI). One of the expected effects of the program after vaccination with 10-valent pneumococcal vaccine is the likely replacement serotype phenomenon that means the presence of ENI caused by serotypes not included in the vaccine. In this context, we present the case of a child with pneumococcal meningitis caused by serotype 19 A of fatal course. The occurrence of ENI in a later stage of pneumococcal vaccine incorporation in Chile reinforces the importance of active surveillance, in order to know in detail the impact of vaccination, distribution of circulating serotypes and their correlation with the different clinical disease and their severity.

La enfermedad neumocóccica invasora (ENI) sigue siendo una causa importante de morbilidad en el mundo y en nuestro país, si bien en Chile la incidencia ha disminuido luego de la incorporación de la vacuna neumocóccica conjugada 10-valente al Programa Nacional de Inmunizaciones (PNI). Uno de los efectos esperables luego de la vacunación programática con la vacuna antineumocóccica 10-valente es el probable fenómeno de reemplazo, que corresponde a la presencia de ENI por serotipos no incluidos en la vacuna. En este contexto, se presenta el caso de un pre-escolar con meningitis neumocóccica causada por el serotipo 19 A, de curso fatal. La presencia de casos de ENI en una etapa posterior a la implementación de la vacuna anti-neumocóccica en el PNI de Chile, demuestra la importancia de realizar una vigilancia activa, con el objetivo de conocer en forma detallada el impacto de la vacunación, la distribución de los serotipos circulantes y su correlación con los diferentes cuadros clínicos y su evolución.

Meningitis neumocócica: experiencia de 12 años en un hospital pediátrico, previa a la inmunización universal con vacuna conjugada / Pneumococcal meningitis: A 12 year experience in a children's hospital prior to the universal immunization with a conjugate vaccine

Introducción. La meningitis por Streptococcus pneumoniae provoca frecuentemente elevada morbimortalidad. El objetivo del presente estudio fue identificar las características epidemiológicas y clínicas, la susceptibilidad antibiótica y la evolución de los niños con meningitis por neumococo antes de la introducción de la vacuna en Argentina. Métodos. Se incluyeron pacientes menores de 18 años internados en el Hospital J. P. Garrahan entre 1999 y 2010. Se revisaron los registros del laboratorio de microbiología y las historias clínicas de los niños. Resultados. Se identificaron 111 niños con meningitis por S. pneumoniae. En el período 1999-2002, hubo 40 casos, 35 en 2003-2006 y 36 en 2007-2010. La media de edad fue 7 meses (r: 1-191). Eran inmunocompetentes 104 pacientes (94%). Solo 20 pacientes (18%) tenían enfermedad de base. La presentación clínica más frecuente fue el compromiso neurológico en 80 pacientes (75%) y la sepsis en 59 pacientes (53%). Requirieron admisión en terapia intensiva 49 pacientes (44%). Otro foco clínico de infección estuvo presente en 24 pacientes (22%); en la mitad de ellos, neumonía. El cultivo de líquido cefalorraquídeo fue positivo en 103 pacientes (93%) y los hemocultivos en 88 pacientes (79%). Se identificó resistencia a la penicilina en 15% de los casos y en el 5% resistencia a cefotaxima. La resistencia antibiótica disminuyó a lo largo de los años. Presentaron complicaciones 56 pacientes (50%), y 11 pacientes (10%) fallecieron por la infección. Conclusión. La resistencia de S. pneumoniae a los antimicrobianos disminuyó a lo largo de los años. Es importante mantener la vigilancia epidemiológica para evaluar el impacto de la vacunación en Argentina

Introduction. Pneumococcal meningitis is caused by Streptococcus pneumoniae and has high morbidity and mortality rates. The objective of this study was to identify the epidemiological and clinical characteristics, antibiotic sensitivity and evolution of pneumococcal meningitis in children prior to the introduction of the vaccine in Argentina. Methods. Patients younger than 18 years old hospitalized at Hospital J. P. Garrahan between 1999 and 2010 were included. Children's microbiology lab records and case records were reviewed. Results. One hundred and eleven children with S. pneumoniae meningitis were identified. Forty cases were found in the 1999-2002 period, 35 in the 2003-2006 period, and 36 in the 2007- 2010 period. The mean age was 7 months old (range: 1-191). One hundred and four patients were immunocompetent (94%). Only 20 patients (18%) had an underlying disease. The most commonly observed clinical presentation was neurological involvement in 80 patients (75%), and sepsis in 59 (53%). Forty-nine patients (44%) had to be admitted to the ICU. A second clinical source of infection was identified in 24 patients (22%); half of these cases corresponded to pneumonia. Positive findings were observed in the cerebrospinal fluid culture of 103 patients (93%) and in the blood culture of 88 (79%). Resistance to penicillin was identified in 15% of cases, while 5% showed resistance to cefotaxime. Antibiotic resistance was reduced over the years. Complications occurred in 56 patients (50%), and 11 (10%) died because of the infection. Conclusion. Antimicrobial resistance by S. pneumoniae was reduced over time. It is important to maintain epidemiological surveillance to assess the impact of immunization in Argentina.

Pathophysiology of acute meningitis caused by Streptococcus pneumoniae and adjunctive therapy approaches / Fisiopatologia da meningite ocasionada pelo Streptococcus pneumoniae e novas possibilidades terapêuticas adjuvantes

Pneumococcal meningitis is a life-threatening disease characterized by an acute purulent infection affecting piamater, arachnoid and the subarachnoid space. The intense inflammatory host's response is potentially fatal and contributes to the neurological sequelae. Streptococcus pneumoniae colonizes the nasopharynx, followed by bacteremia, microbial invasion and blood-brain barrier traversal. S. pneumoniae is recognized by antigen-presenting cells through the binding of Toll-like receptors inducing the activation of factor nuclear kappa B or mitogen-activated protein kinase pathways and subsequent up-regulation of lymphocyte populations and expression of numerous proteins involved in inflammation and immune response. Many brain cells can produce cytokines, chemokines and others pro-inflammatory molecules in response to bacteria stimuli, as consequence, polymorphonuclear are attracted, activated and released in large amounts of superoxide anion and nitric oxide, leading to the peroxynitrite formation, generating oxidative stress. This cascade leads to lipid peroxidation, mitochondrial damage, blood-brain barrier breakdown contributing to cell injury during pneumococcal meningitis.

A meningite pneumocócica é doença potencialmente fatal caracterizada por infecção aguda purulenta que afeta a pia-máter, a aracnoide e o espaço subaracnoide. A resposta inflamatória do hospedeiro é potencialmente fatal e contribui para as sequelas neurológicas. O processo inicia-se com a colonização da nasofaringe pelo Streptococcus pneumoniae, seguida de invasão, bacteremia e passagem através da barreira hematoencefálica. O S. pneumoniae é reconhecido por células apresentadoras de antígenos através da ligação aos receptores Toll-like. Isto induz a ativação do fator nuclear kappa B ou proteína quinase ativada por mitógenos. Muitas células cerebrais também podem produzir citocinas, quimiocinas e outras moléculas pró-inflamatórias em resposta aos estímulos bacterianos. Como consequência, são atraídos polimorfonucleares, ocorrendo a liberação de grandes quantidades de ânion superóxido e óxido nítrico, o que leva à formação de peroxinitrito e ocasiona o estresse oxidativo. Esta cascata pró-inflamatória leva à peroxidação lipídica, a danos mitocondriais e à ruptura da barreira hematoencefálica, contribuindo para o dano celular em meningite pneumocócica.

Acute bacterial meningitis caused by Streptococcus pneumoniae resistant to the antimicrobian agents and their serotypes / Meningite bacteriana aguda por Streptococcus pneumoniae resistente aos antimicrobianos e seus sorotipos

The main objectives of this study are to evaluate the resistance rates of Streptococcus pneumonia to penicillin G, ceftriaxone and vancomycin in patients with meningitis; to analyze possible risk factors to the antimicrobian resistance; to describe the serotypes detected and to suggest an initial empirical treatment for meningitis. The sensitiveness and serotypes of all isolated S. pneumoniae of patients with acute bacterial meningitis received by the Paraná State Central Laboratory from April 2001 to august 2002 have been evaluated. One hundred S. pneumoniae have been isolated, of which 15 percent were resistant to penicillin, 1 percent to cephalosporin and 0 percent to vancomycin. The serotypes most found were 14 (19 percent), 3 and 23F (10 percent each). When only the resistant serotypes were analyzed, the most prevalent was the 14 with 44 percent. The risk factors found in relation to the S. pneumoniae resistance were: age under one year old (p=0.01) and previous use of antibiotic (p=0.046). The resistance rates found, which were moderate to penicillin, low to cephalosporin and neutral to vancomycin, suggest the isolated use of a 3rd generation cephalosporin as an initial empirical therapy for the treatment of acute bacterial meningitis with a communitarian background.

Este estudo teve como objetivo avaliar as taxas de resistência de Streptococcus pneumoniae, isolados de pacientes com meningite, à penicilina G, ceftriaxona e vancomicina; avaliar possíveis fatores de risco para resistência antimicrobiana; descrever os sorotipos encontrados e sugerir a terapêutica empírica inicial para meningite. Foram isoladas 100 amostras de S. pneumoniae, encontrando-se 15 por cento de resistência à penicilina, 1 por cento à cefalosporina e 0 por cento à vancomicina. Os sorotipos mais encontrados foram 14 (19 por cento), 3 e 23F (10 por cento cada). Analisando-se os resistentes, o sorotipo 14 (44 por cento) também foi o mais freqüente. Os fatores de risco para resistência de S. pneumoniae encontrados foram: idade menor que um ano (p=0,01) e o uso prévio de antibiótico (p=0,046). As taxas de resistência encontradas, moderada a penicilina, baixa para cefalosporina e nula para vancomicina, sugerem como terapêutica empírica inicial para tratamento da meningite bacteriana aguda de origem comunitária, a cefalosporina de terceira geração isoladamente.

Evaluating the costs of pneumococcal disease in selected Latin American countries

OBJECTIVES: To estimate the costs of pneumococcal disease in Brazil, Chile and Uruguay, to describe how these costs vary between different patient groups, and to discuss factors that affect these cost variations. METHODS: The cost of pneumococcal disease was estimated from the health care perspective. For each country, baseline cost estimates were primarily developed using health resources information from patient-level data and facility-specific cost data. A regression model was constructed separately for four types of pneumococcal diseases. The skewness-kurtosis test and the Cook-Weisberg test were performed to test the normality of the residuals and the heteroscedasticity, respectively. RESULTS: The treatment of pneumococcal meningitis generated up to US$ 5 435 per child. The treatment costs of pneumococcal pneumonia were lower, ranging from US$ 372 per child to US$ 3 483 per child. Treatment of acute otitis media cost between US$ 20 per child and US$ 217 per child. The main source of treatment costs variations was level of service provided and country in which costs were incurred. However, the tendency of costs to change with these variables was not statistically significant at the 5 percent level for most pneumococcal disease models. CONCLUSIONS: Pneumococcal disease resulted in significant economic burden to selected health care systems in Latin America. The patterns of treatment cost of pneumococcal disease showed a great deal of variation.

OBJETIVOS: Estimar los costos de la enfermedad neumocócica en Brasil, Chile y Uruguay, describir cómo varían estos costos entre diferentes grupos de pacientes y discutir los factores que influyen en las variaciones de estos costos. MÉTODOS: El costo de la enfermedad neumocócica se estimó desde la perspectiva de la atención sanitaria. Inicialmente se establecieron estimados de referencia de los costos para cada país a partir de la información de los recursos sanitarios empleados, según los datos de cada paciente y los costos específicos de cada institución. Se construyeron modelos de regresión por separado para cuatro tipos de enfermedad neumocócica. Se realizaron las pruebas de asimetría-curtosis y de Cook-Weisberg para comprobar la normalidad de los residuos y la heterocedasticidad, respectivamente. RESULTADOS: El costo del tratamiento de la meningitis neumocócica fue de US$ 5 435 por cada niño, mientras el de la neumonía neumocócica fue menor, entre US$ 372 y US$ 3 483 por niño. El costo del tratamiento de la otitis media aguda fue de US$ 20 a US$ 217 por niño. La principal fuente de variación en los costos de tratamiento fue el nivel de servicio brindado y el país en que se generaron los costos. No obstante, la tendencia de los costos a variar no fue estadísticamente significativa (P > 0,05) en la mayoría de los modelos de la enfermedad neumocócica. CONCLUSIONES: La enfermedad neumocócica constituye una notable carga económica para los sistemas de salud seleccionados de América Latina. Los patrones del costo de tratamiento de la enfermedad neumocócica mostraron una gran variación.

Streptococcus pneumoniae: estudo das cepas isoladas de liquor / Streptococcus pneumoniae: a study of strains isolated from cerebrospinal fluid

OBJETIVO: Determinar a freqüência dos sorotipos capsulares e a susceptibilidade antimicrobiana de cepas de Streptococcus pneumoniae, assim como dar suporte à indicação de vacinas disponíveis e ao uso de antimicrobianos. MÉTODOS: Neste estudo retrospectivo, foram adotadas metodologias padronizadas para identificar, sorotipar e determinar a susceptibilidade à penicilina, cefotaxima e vancomicina. O estudo foi realizado com cepas de pneumococo isoladas de liquor em pacientes atendidos nos hospitais públicos e em três hospitais particulares do Distrito Federal no período de janeiro de 1995 a dezembro de 2004. A identificação e a determinação de susceptibilidade a antimicrobianos foi realizada no Laboratório Central de Saúde Pública no Distrito Federal. A sorotipagem foi realizada no Instituto Adolfo Lutz. RESULTADOS: Foram isoladas 232 cepas de pneumococo, compreendendo 126 cepas (54,31 por cento) de pacientes do sexo masculino. A idade dos pacientes variou de 0 a 62 anos, sendo agrupados em faixas etárias de 0 a 5, 6 a 17, 18 a 50 e acima de 50 anos. Identificaram-se 36 sorotipos distintos. Desses destacaram-se oito: 14, 6B, 18C, 5, 19F, 23F, 9V e 6A. O teste de oxacilina caracterizou 67 cepas resistentes à penicilina; dessas, 47 foram confirmadas pelo E teste com resistência de nível intermediário. Nenhuma cepa apresentou resistência de alto nível. CONCLUSÃO: A resistência do pneumococo à penicilina apresentou um aumento gradativo nos últimos 10 anos no Distrito Federal. Os sorotipos mais isolados na faixa etária de 0 a 5 anos foram também os mais envolvidos na resistência à penicilina, e estão incluídos na vacina 7-valente.

OBJECTIVE: To determine the frequency of capsular serotypes and the antimicrobial susceptibility of strains of Streptococcus pneumoniae, as well as to provide recommendations on the use of available vaccines and antimicrobial drugs. METHODS: In this retrospective study, standard procedures were followed to identify, serotype, and determine bacterial susceptibility to penicillin, cefotaxime, and vancomycin. Pneumococcal strains were isolated from the cerebrospinal fluid (CSF) of patients admitted to nine public and three private hospitals in Distrito Federal, Brazil, between January 1995 and December 2004. Identification and antimicrobial susceptibility tests were carried out at the Central Laboratory of Public Health (Laboratório Central de Saúde Pública). Serotyping was performed at Instituto Adolfo Lutz. RESULTS: A total of 232 pneumococcal strains were isolated, including 126 (54.31 percent) strains from male patients. Patients had an age range of 0 to 62 years and were distributed into four age groups: 0 to 5, 6 to 17, 18 to 50, and above 50. From the 36 distinct serotypes identified, eight were more prevalent: 14, 6B, 18C, 5, 19F, 23F, 9V, and 6A. The oxacillin test identified 67 penicillin-resistant strains, out of which 47 were confirmed by the E test as having intermediate level of resistance. None of the strains exhibited high-level resistance. CONCLUSIONS: Pneumococcal resistance to penicillin has gradually increased over the last 10 years in Distrito Federal. Serotypes more frequently isolated in the 0 to 5 years age group were the same involved in penicillin-resistance, all of which are covered by the 7-valent vaccine.

Meningitis neonatal por Streptococcus pneumoniae atípico: Reporte de un caso y revisión / Neonatal meningitis caused by atypical Streptococcus pneumoniae: Case report and review

Streptococcus pneumoniae is a rarely recognized cause of neonatal sepsis and/or meningitis, but it is associated with substantial morbidity and mortality. Traditionally, S. pneumoniae is identified in the laboratory by demonstrating susceptibility to optochin. However, the emergence of optochin-resistant organisms makes definite identification difficult when only phenotypic tests are taken as markers. We present the case of a severe early-onset neonatal meningitis due to an atypical strain of S. pneumoniae. Laboratory methods utilized to certify this species diagnosis are discussed.

Streptococcus pneumoniae es una causa infrecuente de infección en el recién nacido y se caracteriza por gran capacidad invasora (sepsis, meningitis) y alta mortalidad. Tradicionalmente, esta bacteria se diagnostica en base a su susceptibilidad a optoquina. Sin embargo, la emergencia de cepas de S. pneumoniae resistentes a optoquina (atípicas) dificulta el diagnóstico sin utilizar varias pruebas diagnósticas, incluyendo las de biología molecular. Se describe el caso de una neonata con infección invasora causada por una cepa de S. pneumoniae atípico y se discuten los métodos empleados para certificar el diagnóstico de esta especie.

Antibiotic resistance of streptococcus pneumoniae from meningitis children in Damascus

Beta-Iactam resistance by Streptococcus pneumoniae is becoming a significant threat to the public health worldwide. However, data concerning antibiotic susceptibility patterns in Syria have not been published. Therefore, we isolated between September 2003 and May 2004, 25 strains of Streptococcus pneumoniae recovered from the cerebrospinal fluid [CSF] of children with pneumococcal meningitis reported to the Children's hospital in Damascus.The susceptibility of the strains were tested against 10 antibiotics using disk diffusion method and against 6 antibiotics using broth macrodilution method and breakpoints from the National Committee for Clinical Laboratory Standards [NCCLS] were used. 64% of the strains were resistant to penicillin whereas 0% resistant to ceftriaxone, cefotaxime and amoxicillin-clavulanate. Resistant to erythromycin and tetracycline was detected in 16%, and 48% of the strains were resistant to sulfamethoxazole-trimethoprim, 0% resistant to vancomycin and imipenem and 4% resistant to ticarcillin. Multi-drug resistant S. pneumoniae was 24% and was much higher in penicillin-resistant strains than in penicillin-susceptible strains. We recommend performing susceptibility tests to all S. pneumoniae isolates to set a susceptibility pattern and choose the optimal antibacterial agent for treatment

Therapeutic Efficacy of Meropenem for Treatment of Experimental Penicillin-Resistant Pneumococcal Meningitis

With the widespread emergence of antimicrobial resistance, combination regimens of ceftriaxone and vancomycin (C+V) or ceftriaxone and rifampin (C+R) are recommended for empirical treatment of pneumococcal meningitis. To evaluate the therapeutic efficacy of meropenem (M), we compared various treatment regimens in arabbit model of meningitis caused by penicillin-resistant Streptococcus pneumoniae (PRSP). Therapeutic efficacy was also evaluated by the final bacterial concentration in the cerebrospinal fluid (CSF) at 24 hr. Each group consisted of six rabbits. C+V cleared the CSF at 10 hr, but regrowth was noted in 3 rabbits at 24 hr. Meropenem monotherapy resulted in sterilization at 10 hr, but regrowth was observed in all 6 rabbits at 24 hr. M+V also resulted in sterilization at 10 hr, but regrowth was observed in 2 rabbits at 24 hr. M+V was superior to the meropenem monotherapy at 24 hr (reduction of 4.8 vs. 1.8 log10 cfu/mL, respectively; p=0.003). The therapeutic efficacy of M+V was comparable to that of C+V (reduction of 4.8 vs. 4.0 log10 cfu/mL, respectively; p=0.054). The meropenem monotherapy may not be a suitable choice for PRSP meningitis, while combination of meropenem and vancomycin could be a possible alternative in the treatment of PRSP meningitis.

Manejo hospitalario de la meningoencefalitis bacteriana por S. Neumoniae / Hospital management of bacterial meningoencephalitis due to S. pneumoniae

La actitud terapéutica ante la meningitis bacteriana (MEB) es uno de los retos más importantes a los que se enfrenta el pediatra, pues de su oportuno y adecuado manejo depende el pronóstico. Los cambios en la epidemiología de los síndromes neurológicos infecciosos bacterianos observados en Cuba a partir del año 2000, promovieron la implementación de modificaciones al régimen terapéutico antibiótico convencional. En este artículo, sin olvidar que el tratamiento ideal es el preventivo, se expone una revisión actualizada del manejo hospitalario de las MEB por S.pneumoniae, que incluye: adopción de medidas generales, instauración temprana de acciones dirigidas a atenuar los efectos perjudiciales de la respuesta inflamatoria sistémica, conducta específica contra el agente (antibioticoterapia) y finalmente la identificación precoz e inicio de la rehabilitación de secuelas. Se hace énfasis en las modificaciones al esquema antibiótico adoptadas recientemente por la Comisión Nacional de SNI. Se exponen consideraciones sobre la introducción de la vancomicina en esquema antimicrobiano de las MEB por S.pneumoniae.

Infecciones invasoras por streptococcus pneumoniae: impacto de la resistencia / Invasive streptococcus pneumoniae infections: impact of resistance

Streptococcus pneumoniae constituye un problema epidemiológico mundial por el aumento de su incidencia y aparición de cepas resistentes a los antimicrobianos considerados útiles en su manejo, como son penicilina y cefalosporinas de espectro expandido. Se presenta la revisión de 141 casos de infecciones invasoras por S. pneumoniae en un hospital pediátrico de la Región Metropolitana de Santiago, ocurridos en un período de 7 años. Destacan como formas de presentación más frecuentes meningitis (39 por ciento) y neumonía (36,9 por ciento), con una letalidad global de 6,4 por ciento. De las cepas identificadas, 23,4 por ciento presentaban resistencia a penicilina y 6,7 por ciento a cefotaxima, habiendo sido aisladas de todas las localizaciones. Se discute el tratamiento antibiótico a usar en las infecciones por cepas resistentes, siendo necesario diferenciar infección meníngea de otras infecciones sistémicas, pues el enfrentamiento terapéutico es distinto. Esto pone en evidencia la necesidad de mantener estricta vigilancia de la sensibilidad de S. pneumoniae, con el objeto de decidir el tratamiento más adecuado en cada caso

Características clínico-microbiológicas de la meningitis por Streptococcus pneumoniae resistente a la penicilina / Streptococcus pneumoniae meningitis resistant to penicillin clinical and microbiological characteristics

Objetivo. Evaluar la susceptibilidad antimicrobiana de Streptococcus pneumoniae aislado del líquido cefalorraquídeo de niños con meningitis, así como describir y comparar las características clínicas y microbiológicas, el tratamiento y la evolución del padecimiento entre niños infectados con cepas sensibles y resistentes a la penicilina y la cefalosporina. Material y métodos. Treinta y ocho niños con meningitis neumocóica, durante el lapso 1994-1998. Los datos clínicos y de laboratorio se colectaron de cada expediente. Resultados. Del total de niños, 63 por ciento era menor de dos años de edad, 28.9 por ciento mostró cepas insensible a la penicilina, 18.4 por ciento tenía resistencia intermedia, y 10.5 por ciento tenía resistencia elevada. El 2.6 por ciento mostró también resistencia a la cefotaxima. La única característica (por la prueba exacta de Fisher) asociada con la resistencia fue: enfermedad de base previa al procesos (p< 0.001), y condiciones de gravedad al ingreso como convulsiones, choque tóxico y coma (p< 0.07). El curso de la enfermedad y la evolución clínica fue similar para los niños infectados con cepas sensibles a la penicilina o a la cefotaxima vs. las cepas no susceptibles. Conclusiones. El perfil actual de resistencia del S. pneumoniae a la penicilina y la cefalosporina no se encontró asociado con un aumento en la mortalidad de niños con meningitis neumocóica

Bacterial meningitidis of penicillin and cephalosporin resistant streptococcus pneumoniae

The authors report a case of bacterial meningitis with pneumococcus resisting to penicillin. It concerns an 8 years old child, who presented since the age of 9 months with recurrent meningitis due to a malformation in the internal ear [Mondini malformation]. The pneumococcus responsible of this is a serotype 23 which is resistant to penicillin, the oxacillin and to the cephalosporins of 3rd generation [CMI=2ug/ml]. The improvement was obtained with great doses of vancomycin. In Morocco, the resistance of the pneumococcus to penicillin is close to 10% and it is especially made of an intermediary level of resistance

Rising incidence of beta-lactam resistance among pneumococci in Kuwait: Failure of cefotaxime therapy in pneumococcal meningitis

Pneumococcal resistance to antimicrobial agents has become a global problem. This study was done to evaluate the resistance of Streptococcus pneumoniae [pneumococci] to penicillin G in Kuwait, and to assess the efficacy of other -lactam agents [cefotaxime or ceftriaxone] in the management of invasive pneumococcal infections. Surveillance studies were done in a general teaching hospital in Kuwait for penicillin G resistance [intermediate or high level resistance] of pneumococci isolated from clinical specimens by agar diffusion method using oxacillin [1 micro g] disc. In cases of pneumococcal meningitis, minimum inhibitory concentrations [MICs] of penicillin and cefotaxime were determined by agar dilution method, to differentiate intermediate resistance and high level resistance. An increase in the incidence of penicillin G-resistant pneumococci from 20.6% [94 out of 457 isolates] for the period 1985-1988 to 28.5% [40 out of 140 isolates] during 1992-1994 and 38.3% [43 out of 112 isolates] during 1995/96 was observed. During the period 1992-1994, 40-45% [7 out of 16 isolates] blood culture isolates of pneumococci were intermediate or highly resistant to penicillin. Therapy with cefotaxime or ceftriaxone produced a positive outcome in 6 of the 7 patients. However, failure of cefotaxime therapy to achieve a cure was noted in 1 patient who had systemic lupus erythematosus and intermediate resistant [penicillin MIC 0.5 mg/l; cefotaxime MIC 1 mg/l] pneumococcal septicaemia complicated with meningitis. A cure was however achieved with the addition of chloramphenicol to the regimen. Resistance of pneumococci to penicillin G and other -lactam agents is increasing in Kuwait. Penicillin-resistant pneumococcal bacteraemia in an immunosuppressed setting, if managed with cefotaxime or ceftriaxone, should be given high doses [cefotaxime 12 g/day or ceftriaxone 4 g/day] from the beginning. Cases of pneumococcal meningitis with cefotaxime-intermediate resistant strains [MIC 0.5-1 mg/l] on monotherapy consisting of cefotaxime or ceftriaxone should be viewed with caution. Chloramphenicol or vancomycin with rifampicin should be added to the regimen if therapeutic failure is suspected

Traitement des meningites purulentes comenunautaires [Meningite neo-natale exclues]

The Moroccan Society of Infectious Pathology, in collaboration with the Direction of Epidemiology and Disease Prevention of the Public Health Ministry, organized its second conference on consensus over anti-infectious therapeutic: between the 30th of may and the 2nd of June 1996. This second conference of consensus held in Morocco, treats a subject of common medical practice in infectious Pathology: Treatment of community Purulent Meningitis [Excluding neo-natal meningitis] The Organization and the holding of this conference were inspired from the Methodology advocated by the National Agency for the Development of the French medical evaluation. The conclusion and the recommendations given in this document were written independently by the conference jury