Phenotype, molecular characterisation and risk factors for postoperative meningitis caused by ESBL-producing-Enterobacteriaceae: a six years multi-Centre comparative cohort study.

BACKGROUND: To determine the phenotype, molecular characterisation and risk factors of postoperative meningitis induced by Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae (EPE) in China. METHODS: We performed a multi-centre comparative cohort study of postoperative meningitis patients infected with Enterobacteriaceae in 4 neurosurgical centres in China from January 2014 to December 2019. Phenotype and molecular characteristics of the isolates were reviewed and tested, and independent risk factors of the EPE meningitis were evaluated by binary logistic regression. RESULTS: In total, 220 Enterobacteriaceae include 78 EPE were available in this study. 85.6% (67/78) ESBL-related genes were tested, and blaSHV (14.9%) and blaSHV + blaTEM + blaCTX-M-9 (20.9%) were found to be the most frequent mono and combined ESBL-related genes harboured by Enterobacteriaceae. On binary logistic analysis, craniotomy (OR. 2.583, 95% C.I. 1.274-5.235, P = 0.008) and malignancy (OR. 2.406, 95% C.I. 1.299-4.456, P = 0.005) were the associated independent risk factors to meningitis induced by EPE. CONCLUSIONS: To the best of our knowledge, this is the largest series focusing on risk factors of EPE meningitis which has been conducted in China. Craniotomy and malignancy were independent risk factors for EPE meningitis. The risk factors identified may be further utilized in clinical practice and research to avoid and reduce the mortality in future.

Two Cases of Cronobacter Sakazakii Meningitis in Infants: The Importance Of Early Advanced Brain Imaging and Public Health Reporting.

We report 2 infants hospitalized with Cronobacter sakazakii meningitis. Each infant had exposure to powdered infant formula at home. Both infants survived, but 1 infant had a subdural empyema drained and developed left sensorineural hearing loss. Early advanced brain imaging is recommended in infants with C. sakazakii meningitis. Reporting to state and federal public health officials may help identify outbreaks.

Nosocomial enterobacter meningitis: risk factors, management, and treatment outcomes.

Enterobacter species are increasingly a cause of nosocomial meningitis among neurosurgery patients, but risk factors for these infections are not well defined. A review of all adult patients hospitalized at the University of California-Los Angeles (UCLA) Medical Center during an 8-year period identified 15 postneurosurgical cases of Enterobacter meningitis (EM). Cure was achieved in 14 cases (93%), and efficacy was similar for carbapenem- and cephalosporin-based treatment. A matched case-control study comparing 26 controls with 13 case patients hospitalized exclusively at the UCLA Medical Center found that external cerebrospinal fluid (CSF) drainage devices (odds ratio [OR], 21.8; P=.001), isolation of Enterobacter species from a non-CSF culture (OR, 24.6; P=.002), and prolonged administration of antimicrobial drugs before the diagnosis of meningitis that were inactive in vitro against Enterobacter species (OR, 13.3; P=.008) were independent risk factors for EM. Despite favorable treatment outcomes, EM is a serious infection associated with Enterobacter species colonization or infection at other surgical sites, with selective antimicrobial pressure, and with invasive CNS devices.

Neonatal meningitis caused by Citrobacter koseri.

Three cases of neonatal meningitis, two of which were fatal, occurred in a premature baby unit during a period of one week. A fourth case occurred in the same unit six months later. Citrobacter koseri was isolated from the cerebrospinal fluid of all four cases. Detailed biochemical and serological examination of the organisms showed that two distinct bioserotypes were involved.

Enterobacter cloacae ventriculitis successfully treated with cefepime and gentamicin: case report and review of the literature.

A 55-year-old woman was found unresponsive and subsequently was diagnosed with a subarachnoid hemorrhage secondary to a right posterior communicating artery aneurysm. The development of hydrocephalus and decreased mental status necessitated placement of an intraventricular catheter; 18 days later she was diagnosed with Enterobacter cloacae ventriculitis. After treatment was begun with intravenous cefepime 2 g every 8 hours and intraventricular gentamicin 5 mg every 24 hours, the catheter was replaced. Cerebrospinal fluid (CSF) and plasma cefepime concentrations and a CSF trough gentamicin concentration were obtained. Intraventricular gentamicin was administered for 6 days and cefepime for 21 days; both clinical and microbiologic resolution of the ventriculitis occurred. The literature reports limited clinical experience with cefepime for the treatment of central nervous system infections in humans. This case report provides clinical evidence to support administration of intravenous cefepime in critically ill adult patients with Enterobacter ventriculitis. Because CSF is easily obtained from patients with intraventricular catheters, strong consideration should be given to monitoring CSF cefepime concentrations in concert with the minimum inhibitory concentration of the offending pathogen to help assure the efficacy of this approach to therapy.

Intracerebral sepsis due to intestinal perforation by ventriculo-peritoneal shunts: two cases.

Two cases of ventriculo-peritoneal (V-P) shunt infection attributable to intestinal perforation are reported. One patient developed a brain abscess, the other ventriculitis. Microbiology consisted of faecal flora and the peritoneal catheter was found to be faecally stained in both cases. There were no abdominal symptoms or signs. It is likely that infection developed via the ascending route.

[Treatment with a cefotaxime-fosfomycin combination of staphylococcal or enterobacterial meningitis in adults]. / Traitement par l'association céfotaxime-fosfomycine des méningites de l'adulte à staphylocoques ou à entérobactéries.

Thirty-two patients were included in this trial: 22 with staphylococcal meningitis (including 5 methicillin-resistant) and 10 with enterobacterial meningitis. Mean duration of treatment was 14.5 and 15.9 days respectively. The combination was synergistic in vitro against 10 of the 12 strains of Staphylococcus and 5 of the 6 strains of Enterobacteriaceae studied. Bacteriological sterilization occurred in all cases which could be evaluated, and clinical recovery was obtained in 95.2% of patients with staphylococcal meningitis (4 unrelated deaths) and 100% of patients with enterobacterial meningitis (2 deaths). Bactericidal power of the cerebro-spinal fluid, often less than 1/8, was not correlated with effectiveness against Staphylococci. Mean CSF concentrations of cefotaxime, desacetylcefotaxime and fosfomycin on the 2nd and 15th days of treatment were 4, 3.5 and 39.8 mg/l and 2.2, 2.1 and 28.0 mg/l, respectively. Clinical and biological acceptability was satisfactory. There were three cases of superinfection or colonization, by Pseudomonas and Enterobacter.

Citrobacter sedlakii meningitis and brain abscess in a premature infant.

Citrobacter sedlakii was isolated from blood and cerebrospinal fluid cultures of a 5-day-old premature infant with sepsis, meningitis, and brain abscess. This newly described organism was difficult to identify due to discrepancies between the Vitek and API 20E identification systems. To our knowledge, this is the first report of the isolation of C. sedlakii from cerebrospinal fluid.

Moxalactam (LY127935) in treatment of meningitis due to gram-negative bacilli.

Moxalactam (LY127935; 6059S), a new broad-spectrum beta-lactam antibiotic, was used successfully with an aminoglycoside in a patient with Serratia marcescens meningitis complicating a neurosurgical procedure. With a bioassay method, peak and trough serum and cerebrospinal; fluid concentrations of moxalactam were determined during therapy. Mean peak and trough serum levels were 100.6 and 35.5 micrograms/ml, respectively. Corresponding mean peak and trough cerebrospinal fluid levels were 12.4 and 10.38 micrograms/ml. Cerebrospinal fluid levels of moxalactam exceeded the minimal bactericidal concentration for the infecting organism by more than 30-fold throughout therapy. No untoward effects of moxalactam were observed. Moxalactam may be a useful agent in the treatment of meningitis due to susceptible gram-negative bacilli.

Penetration of parenterally administered gentamicin into the cerebrospinal fluid in experimental meningitis.

The penetration of parenterally administered gentamicin into the CSF was examined in dogs. The experiments were carried out in three stages: (1) in healthy dogs, (2) in dogs with meningitis, and (3) during recovery from the acute inflammation. Gentamicin was found to penetrate poorly into the CSF, reaching mean peak levels of 0.7 mug/ml in healthy dogs. During the height of the meningeal inflammation the mean peak gentamicin level in the CSF was 0.9 mug/ml. The ratio of mean maximum CSF to mean maximum serum levels of gentamicin was 5.8% in healthy dogs, and 11.3% in dogs with meningitis. Thus, inflammation increases the penetration of parenterally administered gentamicin into the CSF, but therapeutically adequate levels for gram-negative bacillary meningitis are not achieved.

Increased endotoxin and interleukin-1 beta concentrations in cerebrospinal fluid of infants with coliform meningitis and ventriculitis associated with intraventricular gentamicin therapy.

Intraventricular gentamicin therapy in infants with gram-negative enteric bacillary meningitis and ventriculitis is associated with increased mortality. Therefore, endotoxin, interleukin-1 beta, and cachectin (tumor necrosis factor) concentrations in ventricular cerebrospinal fluid from 21 infants (11 received intravenous antibiotics alone and 10 received intraventricular gentamicin also) were determined and correlated with outcome and other ventricular cerebrospinal fluid indexes of inflammation. Mean interleukin-1 beta concentrations in ventricular cerebrospinal fluid correlated significantly with adverse outcome and with mean concentrations of endotoxin, white blood cells, and protein and inversely with glucose concentrations. Mean and peak endotoxin and interleukin-1 beta concentrations were significantly higher in infants who received intraventricular gentamicin and intravenous antibiotics than in infants given intravenous antibiotics alone. Intraventricular gentamicin may have caused release of endotoxin from gram-negative bacilli in ventricular cerebrospinal fluid, resulting in increased interleukin-1 beta concentrations and inflammation, which could have contributed to the poor outcome in these patients.

Use of ciprofloxacin in an infant with ventriculitis.

Ciprofloxacin was used successfully in a neonate with ventriculitis caused by a multiply resistant strain of Enterobacter cloacae. Limited pharmacokinetic data indicated that adequate concentrations of drug could be attained in cerebrospinal fluid.

Cerebrospinal fluid lactate and lactate dehydrogenase activity in the rapid diagnosis of bacterial meningitis.

The value of cerebrospinal fluid (CSF) lactate and lactate dehydrogenase (LD) activity in the rapid diagnosis of meningitis was investigated in three groups of patients--a 'no meningitis', an aseptic meningitis and a bacterial meningitis group. The sensitivity achieved in the detection of bacterial meningitis by CSF lactate values of 2.85 mmol/l (93.8%) and 3.9 mmol/l (89.6%) was greater than that reached by conventional chemical investigations using a CSF protein value of 1 g/l (81.5%) or a CSF glucose value of 2.2 mmol/l (68.8%) as the indicator. The sensitivity of an absolute CSF LD value of 40 U/l (86.3%) in the detection of bacterial meningitis was slightly lower than that of a CSF protein value of 1 g/l (87%) and better than the sensitivity of either a CSF/serum LD ratio of 0.1:1.0 (83.9%) or a CSF glucose level of 2.2 mmol/l (76.3%). As with conventional CSF chemistry, both investigations may give normal values in the presence of bacterial meningitis.

Gram-negative enteric bacillary meningitis: a twenty-one-year experience.

We reviewed our experience with gram-negative enteric bacillary meningitis in neonates and infants from 1969 through 1989. Ninety-eight patients were identified. Their ages were from 1 day to 2 years with a median of 10 days. In 25 patients (26%), predisposing factors were identified, the most common of which were neural tube defects and urinary tract anomalies. The causative agents were Escherichia coli (53%), Klebsiella-Enterobacter species (16%), Citrobacter diversus (9%), Salmonella species (9%), Proteus mirabilis (4%), Serratia marcescens (3%), Bacteroides fragilis (3%), and Aeromonas species (2%). At the time of diagnosis, Gram-stained smears of cerebrospinal fluid revealed gram-negative bacilli in 61% of patients. The causative organism was cultured from blood obtained from 55% of patients, and 21% had positive urine culture results. The cerebrospinal fluid leukocyte counts ranged from 0 to 80,600 cells/mm3, and the cerebrospinal fluid/serum glucose concentration ratio was less than 0.5 in 72% of patients. Antimicrobial regimens varied greatly. After initiation of antibiotic therapy, an average of 3 days was needed for eradication of bacteria from cerebrospinal fluid. The case-fatality rate was 17%, and 61% of survivors had long-term sequelae that included seizure disorders, hydrocephalus, physical disability, developmental delay, and hearing loss.