Neutrophil-to-lymphocyte ratio is associated with increased cerebral blood flow velocity in acute bacterial meningitis.

In community-acquired bacterial meningitis (CABM) intracranial vascular alterations are devastating complications which are triggered by neuroinflammation and result in worse clinical outcome. The Neutrophil-to-Lymphocyte ratio (NLR) represents a reliable parameter of the inflammatory response. In this study we analyzed the association between NLR and elevated cerebral blood flow velocity (CBFv) in CABM-patients. This study included all (CABM)-patients admitted to a German tertiary center between 2006 and 2016. Patients' demographics, in-hospital measures, neuroradiological data and clinical outcome were retrieved from institutional databases. CBFv was assessed by transcranial doppler (TCD). Patients', radiological and laboratory characteristics were compared between patients with/without elevated CBFv. Multivariate-analysis investigated parameters independently associated with elevated CBFv. Receiver operating characteristic(ROC-)curve analysis was undertaken to identify the best cut-off for NLR to discriminate between increased CBFv. 108 patients with CABM were identified. 27.8% (30/108) showed elevated CBFv. Patients with elevated CBFv and normal CBFv, respectively had a worse clinical status on admission (Glasgow Coma Scale: 12 [9-14] vs. 14 [11-15]; p = 0.005) and required more often intensive care (30/30 [100.0%] vs. 63/78 [80.8%]; p = 0.01).The causative pathogen was S. pneumoniae in 70%. Patients with elevated CBFv developed more often cerebrovascular complications with delayed cerebral ischemia (DCI) within hospital stay (p = 0.031). A significantly higher admission-NLR was observed in patients with elevated CBFv (median [IQR]: elevated CBFv:24.0 [20.4-30.2] vs. normal CBFv:13.5 [8.4-19.5]; p < 0.001). Multivariate analysis, revealed NLR to be significantly associated with increased CBFv (Odds ratio [95%CI] 1.042 [1.003-1.084]; p = 0.036). ROC-analysis identified a NLR of 20.9 as best cut-off value to discriminate between elevated CBFv (AUC = 0.713, p < 0.0001, Youden's Index = 0.441;elevated CBFv: NLR ≥ 20.9 19/30[63.5%] vs. normal CBFv: NLR > 20.9 15/78[19.2%]; p < 0.001). Intracranial vascular complications are common among CABM-patients and are a risk factor for unfavorable outcome at discharge. Elevated NLR is independently associated with high CBFv and may be useful in predicting patients' prognosis.

Bacterial Meningitis in the Absence of Pleocytosis in Children: A Systematic Review.

One of the main features of bacterial meningitis is pleocytosis. However, when children with meningitis present within hours of onset of symptoms, there is the possibility that the meninges are not yet sufficiently inflamed to lead to a raised cerebrospinal fluid (CSF) white blood cell count. A systematic search was done to identify published studies reporting children with culture- or polymerase chain reaction-proven bacterial meningitis in the absence of pleocytosis. We identified 26 studies describing 62 children (18 neonates). In those in whom fever duration was specified, 32 (80%) of 40 had a fever for less than or equal to 24 hours before lumbar puncture (LP). In those in whom the glucose level was reported, it was normal in 14 (82%) of 17 neonates and 33 (80%) of 41 older infants and children. The protein level was normal in 8 (44%) of 17 neonates and 32 (80%) of 40 older infants and children. Twelve of the 62 children had a Gram stain of their CSF and this was positive in 2 (17%). Simultaneous blood cultures were positive in 5 (28%) of 18 neonates and 21 (68%) of 31 older infants and children. There was no association between the absence of pleocytosis and particular bacteria. All of the 10 children who had a second LP had an abnormal CSF including pleocytosis. These findings indicate that the absence of pleocytosis does not exclude bacterial meningitis reliably and should be interpreted in the context of the duration of illness. CSF samples, particularly those from cases with relatively short symptom duration, should be cultured even when the cell count and biochemistry are normal. A second LP can be helpful when bacterial meningitis is suspected despite a normal initial CSF.

Individual responsiveness of macrophage migration inhibitory factor predicts long-term cognitive impairment after bacterial meningitis.

BACKGROUND: Patients with pneumococcal meningitis are at risk for death and neurological sequelae including cognitive impairment. Functional genetic polymorphisms of macrophage migration inhibitory factor (MIF) alleles have shown to predict mortality of pneumococcal meningitis. METHODS: We investigated whether MIF concentrations during the acute phase of disease were predictive for death in a nationwide prospective cohort study. Subsequently, we studied whether individual ex vivo MIF response years after meningitis was associated with the development of cognitive impairment. RESULTS: We found that in the acute illness of pneumococcal meningitis, higher plasma MIF concentrations were predictive for mortality (p = 0.009). Cognitive impairment, examined 1-5 years after meningitis, was present in 11 of 79 patients after pneumococcal meningitis (14%), as compared to 1 of 63 (2%) in controls, and was consistently associated with individual variability in MIF production by peripheral blood mononuclear cells after ex vivo stimulation with various infectious stimuli. CONCLUSIONS: Our study confirms the role of MIF in poor disease outcome of pneumococcal meningitis. Inter-individual differences in MIF production were associated with long-term cognitive impairment years after pneumococcal meningitis. The present study provides evidence that MIF mediates long-term cognitive impairment in bacterial meningitis survivors and suggests a potential role for MIF as a target of immune-modulating adjunctive therapy.

Leuconostoc lactis- A Rare Cause of Bacterial Meningitis in an Immunocompromised Host.

Leuconostoc lactis, often found in fermented dairy products, although considered to have a low pathogenic potential, can cause life-threatening infections in immunocompromised hosts. We herein report a 62-year-old man with a history of alcoholic liver cirrhosis, hepatocellular carcinoma, and diabetes mellitus who developed a very rare case of bacterial meningitis caused by this organism. After we administered antibiotics including ampicillin, he recovered completely within two weeks. This gram-positive coccus (GPC) is sensitive to ampicillin but naturally resistant to vancomycin, while its susceptibility to ceftriaxone has not yet been established. In acute GPC meningitis in immunocompromised hosts, Leuconostoc lactis should therefore be considered as a possible pathogen.

Sequential intraventricular injection of tigecycline and polymyxin B in the treatment of intracranial Acinetobacter baumannii infection after trauma: a case report and review of the literature.

BACKGROUND: Intracranial infection after craniotomy is one of the most serious postoperative complications, especially multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacterial meningitis, and strongly affects the prognosis of patients. Current treatment experience regarding these infections is scarce. CASE PRESENTATION: We report a case of severe intracranial infection of XDR Acinetobacter baumannii (A. baumannii) that was treated by intravenous (IV) injection, sequential intraventricular (IVT) injection of tigecycline and polymyxin B, and other anti-infective drugs. Good results were obtained, and the patient was eventually discharged from the hospital. This case is characterized by intracranial infection. CONCLUSIONS: The polymyxin B IV + IVT pathway is an ideal treatment strategy for XDR A. baumannii. The tigecycline IVT pathway is also a safe treatment option.

TRIM32 Drives Pathogenesis in Streptococcal Toxic Shock-Like Syndrome and Streptococcus suis Meningitis by Regulating Innate Immune Responses.

Streptococcus suis is an emerging zoonotic agent that causes streptococcal toxic shock-like syndrome (STSLS) and meningitis in humans, with high mortality and morbidity. The pathogenesis of both STSLS and central nervous system (CNS) infections caused by S. suis is not well understood. TRIM32, a member of the tripartite motif (TRIM) protein family, has been reported to regulate host inflammatory responses. In this study, we showed that TRIM32 deficiency significantly reduced the level of bacteremia and the production of proinflammatory cytokines following severe S. suis infection, protecting infected mice from STSLS. The influence of TRIM32 gene deletion on a range of processes known to be involved in S. suis meningitis was also examined. Both levels of bacterial loads and indications of brain hemorrhage were reduced in infected Trim32-/- mice compared with infected wild-type (WT) controls. We also found that TRIM32 deficiency increased the permeability of the blood-brain barrier (BBB) and the recruitment of inflammatory monocytes during the early course of S. suis infection, potentially limiting the development of S. suis meningitis. Our results suggest that TRIM32 sensitizes S. suis-induced infection via innate immune response regulation.

MeningiSSS: A New Predictive Score to Support Decision on Invasive Procedures to Monitor or Manage the Intracerebral Pressure in Children with Bacterial Meningitis.

BACKGROUND: Knowing the individual child's risk is highly useful when deciding on treatment strategies, especially when deciding on invasive procedures. In this study, we aimed to develop a new predictive score for children with bacterial meningitis and compare this with existing predictive scores and individual risk factors. METHODS: We developed the Meningitis Swedish Survival Score (MeningiSSS) based on a previous systematic review of risk factors. From this, we selected risk factors identified in moderate-to-high-quality studies that could be assessed at admission to the hospital. Using data acquired from medical records of 101 children with bacterial meningitis, we tested the overall capabilities of the MeningiSSS compared with four existing predictive scores using a receiver operating characteristic curve (ROC) analysis to assert the area under the curve (AUC). Finally, we tested all predictive scores at their cut-off levels using a Chi-square test. As outcome, we used a small number of predefined outcomes; in-hospital mortality, 30-day mortality, occurrence of neurological disabilities at discharge defined as Pediatric Cerebral Performance Category Scale category two to five, any type of complications occurring during the hospital stay, use of intensive care, and use of invasive procedures to monitor or manage the intracerebral pressure. RESULTS: For identifying children later undergoing invasive procedures to monitor or manage the intracerebral pressure, the MeningiSSS excelled in the ROC-analysis (AUC = 0.90) and also was the only predictive score able to identify all cases at its cut-off level (25 vs 0%, p < 0.01). For intensive care, the MeningiSSS (AUC = 0.79) and the Simple Luanda Scale (AUC = 0.75) had the best results in the ROC-analysis, whereas others performed less well (AUC ≤ 0.65). Finally, while none of the scores' results were significantly associated with complications, an elevated score on the MeningiSSS (AUC = 0.70), Niklasson Scale (AUC = 0.72), and the Herson-Todd Scale (AUC = 0.79) was all associated with death. CONCLUSIONS: The MeningiSSS outperformed existing predictive scores at identifying children later having to undergo invasive procedures to monitor or manage the intracerebral pressure in children with bacterial meningitis. Our results need further external validation before use in clinical practice. Thus, the MeningiSSS could potentially be helpful when making difficult decisions concerning intracerebral pressure management.

Investigating Bacterial Penetration of the Blood-Brain Barrier for the Pathogenesis, Prevention, and Therapy of Bacterial Meningitis.

The most distressing aspect of bacterial meningitis is limited improvement in the mortality and morbidity despite attributable advances in antimicrobial chemotherapy and supportive care. A major contributing factor to such mortality and morbidity is our incomplete understanding of the pathogenesis of this disease. Microbial penetration of the blood-brain barrier, a prerequisite for the development of bacterial meningitis, exploits specific host and bacterial factors as well as host cell signaling molecules. Determination and characterization of such host and bacterial factors have been instrumental for developing our current knowledge on the pathogenesis of bacterial meningitis. In addition, counteracting such host and microbial factors has been shown to be efficacious in the prevention of bacterial meningitis. Antimicrobial therapy alone has limited efficacy in improving the outcome of bacterial meningitis. Recent studies suggest that counteracting targets contributing to bacterial penetration of the blood-brain barrier are a beneficial therapeutic adjunct to antimicrobial therapy in improving the outcome of bacterial meningitis. Taken together, these findings indicate that the elucidation of host and bacterial factors contributing to microbial penetration of the blood-brain barrier provides a novel strategy for investigating the pathogenesis, prevention, and therapy of bacterial meningitis.

Chronic alcohol abuse affects the clinical course and outcome of community-acquired bacterial meningitis.

The aim of the study was to determine the effect of chronic alcohol abuse on the course and outcome of bacterial meningitis (BM). We analyzed records of patients with BM who were hospitalized between January 2010 and December 2017 in the largest neuroinfection center in Poland. Out of 340 analyzed patients, 45 (13.2%) were alcoholics. Compared with non-alcoholics, alcoholics were more likely to present with seizures (p < 0.001), scored higher on the Sequential Organ Failure Assessment (SOFA) (p = 0.002) and lower on the Glasgow Coma Scale (GCS) (p < 0.001), and had worse outcome as measured by the Glasgow Outcome Score (GOS) (p < 0.001). Furthermore, alcoholics were less likely to complain of headache (p < 0.001) and nausea/vomiting (p = 0.005) and had lower concentration of glucose in cerebrospinal fluid (CSF) (p = 0.025). In the multiple logistic regression analysis, alcoholism was associated with lower GCS (p = 0.036), presence of seizures (p = 0.041), male gender (p = 0.042), and absence of nausea/vomiting (p = 0.040). Furthermore, alcoholism (p = 0.031), lower GCS score (p = 0.001), and higher blood urea concentration (p = 0.018) were independently associated with worse outcome measured by GOS. Compared with non-alcoholics, chronic alcohol abusers are more likely to present with seizures, altered mental status, and higher SOFA score and have an increased risk of unfavorable outcome. In multivariate analysis, seizures and low GCS were independently associated with alcoholism, while alcoholism was independently associated with worse outcome.

[Cranial computed tomography, lumbar puncture and clinical deterioration in bacterial meningitis: a nationwide cohort study]. / CT-hersenen, lumbaalpunctie en klinische achteruitgang bij bacteriële meningitis.

BACKGROUND: Investigate how often cerebral herniation occurs following lumbar puncture (LP) in patients with bacterial meningitis, and whether cranial computed tomography (CT) can be used to identify patients at a higher risk of cerebral herniation. STUDY DESIGN: Prospective, nationwide cohort study covering the period March 2006 - November 2014. METHOD: We identified patients with community-acquired bacterial meningitis who showed signs of clinical deterioration, possibly caused by LP. For systematic evaluation of contraindications for LP on cranial CT, the included patients were matched to bacterial meningitis patients without deterioration. Four experts, blinded for patient outcome, scored cranial CT scan imaging for the cases as well as control patients in relation to contraindications for LP. Inter-assessor reliability was determined with Fleiss' generalized κ. RESULTS: Of the 1533 bacterial meningitis patients included, 47 (3.1%) exhibited clinical deterioration possibly caused by LP. Two patients deteriorated within 1 hour after LP (0.1%). In 43 of 47 patients that showed signs of clinical deterioration, cranial CT was performed prior to LP. The inter-rater reliability of assessment of contraindications for LP on cranial CT was moderate (Fleiss' generalized κ = 0.47). A contraindication for LP was reported by all four raters in 6 patients with clinical deterioration (14%) and in 5 patients without clinical deterioration (11%). CONCLUSION: LP can be performed safely in the large majority of patients with bacterial meningitis, as it only very rarely results in cerebral herniation. Cranial CT can be considered a screening method to identify patients who are at a higher risk of cerebral herniation, but the inter-rater reliability of the CT scan assessment for contraindications of LP is moderate.

Subarachnoid Mirage: A Case of Pseudosubarachnoid Hemorrhage.

A 22-year-old man with a history of intravenous methamphetamine use presented with severe headache for 5 days, was afebrile, and had nuchal rigidity. Computed tomography and magnetic resonance imaging results were interpreted as revealing acute subarachnoid hemorrhage. Twenty-four hours later, he developed acute neurologic deterioration. A lumbar puncture was performed, revealing the presence of Staphylococcus aureus. The false-positive image mimicking blood was potentially a result of an extremely high protein concentration present in the cerebrospinal fluid, provoked by an intense inflammatory reaction leading to disruption of the blood-brain barrier. Pyogenic meningitis is one of the causes of pseudosubarachnoid hemorrhage, or a false diagnosis of subarachnoid hemorrhage, when one does not actually exist.

Brain imaging can predict neurodevelopmental outcome of Group B streptococcal meningitis in neonates.

AIM: The association between cranial ultrasound (CUS) or magnetic resonance imaging (MRI) lesions and neonatal Group B streptococcal (GBS) meningitis outcome has not been studied in detail. METHODS: This retrospective study assessed CUS, cranial MRI and neurodevelopmental outcome in 50 neonates with GBS meningitis admitted to three neonatal intensive care units in the Netherlands between 1992 and 2014. Death, cognitive outcome and motor outcome below -1 SD were considered as adverse outcomes. RESULTS: CUS was available in all and MRIs in 31 infants (62%) with 28 CUS (56%) and 27 MRIs (87%) being abnormal. MRI lesions were multifocal (n = 10, 37%), bilateral (n = 22; 82%) and extensive (n = 11; 41%). A total of 10 died in the neonatal period. Median age at assessment was 24 months. Among survivors, abnormal cognitive outcome and motor outcome were seen in 23 and 20 patients, respectively. Abnormal CUS [odds ratio (OR) 5.3, p = 0.017], extensive bilateral deep grey lesions (OR 6.7, p = 0.035) and white matter lesions (OR 14.0, p = 0.039) correlated with abnormal motor outcome. Extensive bilateral deep grey matter lesions correlated with abnormal cognitive outcome (OR 8.1, p = 0.029). CONCLUSION: Abnormal CUS and the most severely affected MRIs were associated with poor neurodevelopmental outcome in neonatal GBS meningitis.

A Diagnostic Formula for Discrimination of Tuberculous and Bacterial Meningitis Using Clinical and Laboratory Features.

Background: The discrimination of tuberculous meningitis and bacterial meningitis remains difficult at present, even with the introduction of advanced diagnostic tools. This study aims to differentiate these two kinds of meningitis by using the rule of clinical and laboratory features. Methods: A prospective observational study was conducted to collect the clinical and laboratory parameters of patients with tuberculous meningitis or bacterial meningitis. Logistic regression was used to define the diagnostic formula for the discrimination of tuberculous meningitis and bacterial meningitis. A receiver operator characteristic curve was established to determine the best cutoff point for the diagnostic formula. Results: Five parameters (duration of illness, coughing for two or more weeks, meningeal signs, blood sodium, and percentage of neutrophils in cerebrospinal fluid) were predictive of tuberculous meningitis. The diagnostic formula developed from these parameters was 98% sensitive and 82% specific, while these were 95% sensitive and 91% specific when prospectively applied to another 70 patients. Conclusion: The diagnostic formula developed in the present study can help physicians to differentiate tuberculous meningitis from bacterial meningitis in high-tuberculosis-incidence-areas, particularly in settings with limited microbiological and radiological resources.

Prognostic factors among critically ill patients with community-acquired acute bacterial meningitis and acute kidney injury. / Fatores prognósticos em pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda.

OBJECTIVE: To investigate prognostic factors among critically ill patients with community-acquired bacterial meningitis and acute kidney injury. METHODS: A retrospective study including patients admitted to a tertiary infectious disease hospital in Fortaleza, Brazil diagnosed with community-acquired bacterial meningitis complicated with acute kidney injury. Factors associated with death, mechanical ventilation and use of vasopressors were investigated. RESULTS: Forty-one patients were included, with a mean age of 41.6 ± 15.5 years; 56% were males. Mean time between intensive care unit admission and acute kidney injury diagnosis was 5.8 ± 10.6 days. Overall mortality was 53.7%. According to KDIGO criteria, 10 patients were classified as stage 1 (24.4%), 18 as stage 2 (43.9%) and 13 as stage 3 (31.7%). KDIGO 3 significantly increased mortality (OR = 6.67; 95%CI = 1.23 - 36.23; p = 0.028). Thrombocytopenia was not associated with higher mortality, but it was a risk factor for KDIGO 3 (OR = 5.67; 95%CI = 1.25 - 25.61; p = 0.024) and for mechanical ventilation (OR = 6.25; 95%CI = 1.33 - 29.37; p = 0.02). Patients who needed mechanical ventilation by 48 hours from acute kidney injury diagnosis had higher urea (44.6 versus 74mg/dL, p = 0.039) and sodium (138.6 versus 144.1mEq/L; p = 0.036). CONCLUSION: Mortality among critically ill patients with community-acquired bacterial meningitis and acute kidney injury is high. Acute kidney injury severity was associated with even higher mortality. Thrombocytopenia was associated with severer acute kidney injury. Higher urea was an earlier predictor of severer acute kidney injury than was creatinine.

OBJETIVO: Investigar os fatores prognósticos em pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda. MÉTODOS: Estudo retrospectivo com inclusão de pacientes em um hospital terciário dedicado a doenças infecciosas localizado em Fortaleza (CE), com diagnóstico de meningite bacteriana adquirida na comunidade complicada por lesão renal aguda. Investigaram-se os fatores associados a óbito, ventilação mecânica e uso de vasopressores. RESULTADOS: Incluíram-se 41 pacientes, com média de idade de 41,6 ± 15,5 anos, 56% dos quais do sexo masculino. O tempo médio entre a admissão à unidade de terapia intensiva e o diagnóstico de lesão renal aguda foi de 5,8 ± 10,6 dias. A mortalidade global foi de 53,7%. Segundo os critérios KDIGO, 10 pacientes foram classificados como estágio 1 (24,4%), 18 como estágio 2 (43,9%) e 13 como estágio 3 (31,7%). A classificação em estágio KDIGO 3 aumentou de forma significante a mortalidade (OR = 6,67; IC95% = 1,23 - 36,23; p = 0,028). A presença de trombocitopenia não se associou com aumento da mortalidade, porém foi um fator de risco para a ocorrência da classificação KDIGO 3 (OR = 5,67; IC95% = 1,25 - 25,61; p = 0,024) e para necessidade de utilizar ventilação mecânica (OR = 6,25; IC95% = 1,33 - 29,37; p = 0,02). Os pacientes que necessitaram de ventilação mecânica 48 horas após o diagnóstico de lesão renal aguda tiveram níveis mais elevados de ureia (44,6 versus 74mg/dL; p = 0,039) e sódio (138,6 versus 144,1mEq/L; p = 0,036). CONCLUSÃO: A mortalidade de pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda é alta. A severidade da lesão renal aguda se associou com mortalidade ainda mais elevada. A presença de trombocitopenia se associou com lesão renal aguda mais grave. Níveis mais elevados de ureia podem prever mais precocemente a ocorrência de lesão renal aguda de maior gravidade.

Fatores prognósticos em pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda / Prognostic factors among critically ill patients with community-acquired acute bacterial meningitis and acute kidney injury

RESUMO Objetivo: Investigar os fatores prognósticos em pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda. Métodos: Estudo retrospectivo com inclusão de pacientes em um hospital terciário dedicado a doenças infecciosas localizado em Fortaleza (CE), com diagnóstico de meningite bacteriana adquirida na comunidade complicada por lesão renal aguda. Investigaram-se os fatores associados a óbito, ventilação mecânica e uso de vasopressores. Resultados: Incluíram-se 41 pacientes, com média de idade de 41,6 ± 15,5 anos, 56% dos quais do sexo masculino. O tempo médio entre a admissão à unidade de terapia intensiva e o diagnóstico de lesão renal aguda foi de 5,8 ± 10,6 dias. A mortalidade global foi de 53,7%. Segundo os critérios KDIGO, 10 pacientes foram classificados como estágio 1 (24,4%), 18 como estágio 2 (43,9%) e 13 como estágio 3 (31,7%). A classificação em estágio KDIGO 3 aumentou de forma significante a mortalidade (OR = 6,67; IC95% = 1,23 - 36,23; p = 0,028). A presença de trombocitopenia não se associou com aumento da mortalidade, porém foi um fator de risco para a ocorrência da classificação KDIGO 3 (OR = 5,67; IC95% = 1,25 - 25,61; p = 0,024) e para necessidade de utilizar ventilação mecânica (OR = 6,25; IC95% = 1,33 - 29,37; p = 0,02). Os pacientes que necessitaram de ventilação mecânica 48 horas após o diagnóstico de lesão renal aguda tiveram níveis mais elevados de ureia (44,6 versus 74mg/dL; p = 0,039) e sódio (138,6 versus 144,1mEq/L; p = 0,036). Conclusão: A mortalidade de pacientes graves com meningite bacteriana adquirida na comunidade e lesão renal aguda é alta. A severidade da lesão renal aguda se associou com mortalidade ainda mais elevada. A presença de trombocitopenia se associou com lesão renal aguda mais grave. Níveis mais elevados de ureia podem prever mais precocemente a ocorrência de lesão renal aguda de maior gravidade.

ABSTRACT Objective: To investigate prognostic factors among critically ill patients with community-acquired bacterial meningitis and acute kidney injury. Methods: A retrospective study including patients admitted to a tertiary infectious disease hospital in Fortaleza, Brazil diagnosed with community-acquired bacterial meningitis complicated with acute kidney injury. Factors associated with death, mechanical ventilation and use of vasopressors were investigated. Results: Forty-one patients were included, with a mean age of 41.6 ± 15.5 years; 56% were males. Mean time between intensive care unit admission and acute kidney injury diagnosis was 5.8 ± 10.6 days. Overall mortality was 53.7%. According to KDIGO criteria, 10 patients were classified as stage 1 (24.4%), 18 as stage 2 (43.9%) and 13 as stage 3 (31.7%). KDIGO 3 significantly increased mortality (OR = 6.67; 95%CI = 1.23 - 36.23; p = 0.028). Thrombocytopenia was not associated with higher mortality, but it was a risk factor for KDIGO 3 (OR = 5.67; 95%CI = 1.25 - 25.61; p = 0.024) and for mechanical ventilation (OR = 6.25; 95%CI = 1.33 - 29.37; p = 0.02). Patients who needed mechanical ventilation by 48 hours from acute kidney injury diagnosis had higher urea (44.6 versus 74mg/dL, p = 0.039) and sodium (138.6 versus 144.1mEq/L; p = 0.036). Conclusion: Mortality among critically ill patients with community-acquired bacterial meningitis and acute kidney injury is high. Acute kidney injury severity was associated with even higher mortality. Thrombocytopenia was associated with severer acute kidney injury. Higher urea was an earlier predictor of severer acute kidney injury than was creatinine.

Streptococcus gallolyticus subsp. pasteurianus meningitis complicated by venous sinus thrombosis: A case report.

A case of Streptococcus gallolyticus subsp. pasteurianus meningitis, unusually occurring in a splenectomized patient and complicated by cerebral venous thrombosis, is described. Following presentation with meningism and diagnosis and management of S. gallolyticus meningitis, the patient presented again with a further 4days of fevers and subsequently developed left-sided paresthesias. Cerebral imaging revealed a venous thrombus in the right frontal cortical veins and left sigmoid sinus. The patient recovered following 4 weeks of intravenous ceftriaxone and anticoagulation with enoxaparin and then warfarin. Apart from the splenectomy, no underlying cause was found. The patient was commenced on life-long prophylactic amoxicillin, given appropriate vaccinations, and anticoagulated with warfarin. After initial difficulties, identification of the causative organism to the subspecies level was confirmed by analysis of short-read whole genome sequencing data. This case demonstrates two features that have not previously been reported for S. gallolyticus subsp. pasteurianus infections: splenectomy as a potential risk factor and that infection may be complicated by cerebral venous thrombosis. The resolution provided by whole genome sequencing was valuable in accurately identifying the bacterial subspecies.

The first case report of Enterococcus gallinarum meningitis in neonate: A literature review.

RATIONALE: Enterococcus gallinarum meningitis (EGM) is rarely found in normal adults and even rarer in children. To our knowledge, EGM in neonate has not been reported previously. PATIENTS CONCERNS: Here we reported the first case of EGM in neonate. Prolonged fever was the only manifestation for the case after admission. DIAGNOSES: Cerebrospinal fluid cultures showed that the isolate was Enterococcus gallinarum and sensitive to linezolid. INTERVENTIONS: Ceftriaxone, beta lactam type, and vancomycin were used respectively, but not effective. OUTCOMES: The temperature went down to normal after linezolid was used and the baby was discharged in good condition in the end. LESSONS: This case indicated that EGM could also occur in neonate and fever could be the only obvious manifestation. Thus, the effective antibiotics and adequate duration are very important and linezolid is a potential good choice, especially for vancomycin-resistant patients.