Epidemiology of bacterial meningitis in children admitted to Gondar University Hospital in the post pneumococcal vaccine era

CARD8 polymorphisms among bacterial meningitis patients in North-West Ethiopia

BACKGROUND

The severity of infectious disease outcomes is dependent on the virulence factors of the pathogen and the host immune response. CARD8 is a major regulator of the innate immune proinflammatory response and has been suggested to modulate the host response to common inflammatory diseases. In the present study, the C10X genetic polymorphism in the CARD8 gene was investigated in relation to bacterial meningitis.

METHODS

A total of 400 clinically suspected meningitis patients hospitalized at the University of Gondar Hospital were enrolled in the study. Cerebrospinal fluid (CSF) and blood samples were collected for laboratory investigations. The collected CSF was cultured, and all the results obtained from the culture were confirmed using direct RT‒PCR. Genotyping of whole-blood samples was performed using a TaqMan assay. The results were compared with apparently healthy controls and with PCR-negative meningitis suspected patients.

RESULTS

Of the included patients, 57% were men and the most common clinical signs and symptoms were fever (81%), headache (80%), neck stiffness (76%), nausea (68%), and vomiting (67%). Microbiology culture identified 7 patients with bacterial meningitis caused by Neisseria meningitidis (n = 4) and Streptococcus pneumoniae (n = 3). The RT-PCR revealed 39 positive samples for N. meningitidis (n = 10) and S. pneumoniae (n = 29). A total of 332 whole-blood samples were genotyped with the following results: 151 (45.5%) C10X heterozygotes, 59 (17.7%) C10X homozygotes and 122 (36.7%) wild genotypes. The polymorphic gene carriers among laboratory confirmed, clinically diagnosed meningitis and healthy controls were 23(46%), 246(40%), and 1526(39%), respectively with OR = 1.27 (0.7-2.3) and OR = 1.34 (0.76-2.4). The presence of the C10X polymorphism in the CARD8 gene was more prevalent in suspected meningitis patients than in healthy controls (OR 1.2; 1.00-1.5). Homozygote C10X polymorphic gene carriers were more susceptible to infectious disease. The presence of viable or active bacterial infection was found to be associated with the presence of heterozygous C10X carriers.

CONCLUSIONS

A greater proportion of C10X in the CARD8 gene in confirmed bacterial meningitis patients and clinically diagnosed meningitis patients than in healthy controls. Homozygote C10X polymorphic gene carriers were more susceptible to infectious disease than heterozygote gene carriers and healthy controls.

Global Case Fatality of Bacterial Meningitis During an 80-Year Period: A Systematic Review and Meta-Analysis

Importance

The impact of vaccination, antibiotics, and anti-inflammatory treatment on pathogen distribution and outcome of bacterial meningitis over the past century is uncertain.

Objective

To describe worldwide pathogen distribution and case fatality ratios of community-acquired bacterial meningitis.

Data Sources

Google Scholar and MEDLINE were searched in January 2022 using the search terms bacterial meningitis and mortality.

Study Selection

Included studies reported at least 10 patients with bacterial meningitis and survival status. Studies that selected participants by a specific risk factor, had a mean observation period before 1940, or had more than 10% of patients with health care-associated meningitis, tuberculous meningitis, or missing outcome were excluded.

Data Extraction and Synthesis

Data were extracted by 1 author and verified by a second author. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Random-effects models stratified by age (ie, neonates, children, adults), Human Development Index (ie, low-income or high-income countries), and decade and meta-regression using the study period's year as an estimator variable were used.

Main Outcome and Measure

Case fatality ratios of bacterial meningitis.

Results

This review included 371 studies performed in 108 countries from January 1, 1935, to December 31, 2019, describing 157 656 episodes. Of the 33 295 episodes for which the patients' sex was reported, 13 452 (40%) occurred in females. Causative pathogens were reported in 104 598 episodes with Neisseria meningitidis in 26 344 (25%) episodes, Streptococcus pneumoniae in 26 035 (25%) episodes, Haemophilus influenzae in 22 722 (22%), other bacteria in 19 161 (18%) episodes, and unidentified pathogen in 10 336 (10%) episodes. The overall case fatality ratio was 18% (95% CI, 16%-19%), decreasing from 32% (95% CI, 24%-40%) before 1961 to 15% (95% CI, 12%-19%) after 2010. It was highest in meningitis caused by Listeria monocytogenes at 27% (95% CI, 24%-31%) and pneumococci at 24% (95% CI, 22%-26%), compared with meningitis caused by meningococci at 9% (95% CI, 8%-10%) or H influenzae at 11% (95% CI, 10%-13%). Meta-regression showed decreasing case fatality ratios overall and stratified by S pneumoniae, Escherichia coli, or Streptococcus agalactiae (P < .001).

Conclusions and Relevance

In this meta-analysis with meta-regression, declining case fatality ratios of community-acquired bacterial meningitis throughout the last century were observed, but a high burden of disease remained.

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

Determinants of mortality among pediatric patients admitted to Wolaita Sodo University Comprehensive Specialized Hospital with acute bacterial meningitis, Southern Ethiopia: an unmatched case-control study

BACKGROUND

People of all ages suffer from acute bacterial meningitis, but children are the most vulnerable, accounting for over 50% of all cases and deaths in children under the age of five. It is the leading cause of morbidity, mortality, and long-term suffering worldwide. Children are at great risk of disease and mortality due to a lack of specific immunity associated with their young age. As a result, determinants of death were found among pediatric patients treated with acute bacterial meningitis at Wolaita Sodo University Comprehensive Specialized Hospital in Southern Ethiopia.

METHODS

A facility-based unmatched case-control study was conducted on pediatric patients admitted with acute bacterial meningitis at Wolaita Sodo University Comprehensive Specialized Hospital from July 1, 2019, to June 30, 2022. A total of 355 (71 cases and 284 controls) pediatric medical charts were used for data extraction using a preestablished checklist. Data were checked for completeness and consistency, entered into Epi-Data version 4.6 software, and transported to SPSS version 25 for analysis. Multivariable logistic regression analysis was performed to identify the independent determinants of acute bacterial meningitis mortality at a P value of < 0.05 along with a 95% confidence interval (CI).

RESULTS

Age between 2 months and 5 years (adjusted odds ratio (AOR) = 3.19, 95% CI = 1.15-8.88), admission in the summer season (AOR = 0.27, 95% CI = 0.15-0.49), and family size greater than or equal to six (AOR = 3.13, 95% CI = 1.76-5.56), initial antibiotic change (AOR = 10.81, 95% CI = 2.10-55.7), clinical features at presentation such as loss of consciousness (AOR = 16.90, 95% CI = 4.70-60.4), abnormal body movements (seizures) (AOR = 6.51, 95% CI = 1.82-23.4), increased intracranial pressure (AOR = 3.63, 95% CI = 1.78-7.4), malnutrition (AOR = 2.98, 95% CI = 1.34-6.59) and presence of more than one comorbidity (AOR = 3.03, 95% CI = 1.03-9.03) were found to be determinants of acute bacterial meningitis mortality.

CONCLUSIONS

In summary, children aged 2 months to 5 years from large families ( > = 6) with a history of initial antibiotic change, malnutrition, more than one comorbidity, and worse clinical characteristics were related to greater death due to acute bacterial mortality in this study.

Bacterial meningitis in Africa

Bacterial meningitis differs globally, and the incidence and case fatality rates vary by region, country, pathogen, and age group; being a life-threatening disease with a high case fatality rate and long-term complications in low-income countries. Africa has the most significant prevalence of bacterial meningitis illness, and the outbreaks typically vary with the season and the geographic location, with a high incidence in the meningitis belt of the sub-Saharan area from Senegal to Ethiopia. Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus) are the main etiological agents of bacterial meningitis in adults and children above the age of one. Streptococcus agalactiae (group B Streptococcus), Escherichia coli, and Staphylococcus aureus are neonatal meningitis's most common causal agents. Despite efforts to vaccinate against the most common causes of bacterial neuro-infections, bacterial meningitis remains a significant cause of mortality and morbidity in Africa, with children below 5 years bearing the heaviest disease burden. The factors attributed to this continued high disease burden include poor infrastructure, continued war, instability, and difficulty in diagnosis of bacterial neuro-infections leading to delay in treatment and hence high morbidity. Despite having the highest disease burden, there is a paucity of African data on bacterial meningitis. In this article, we discuss the common etiologies of bacterial neuroinfectious diseases, diagnosis and the interplay between microorganisms and the immune system, and the value of neuroimmune changes in diagnostics and therapeutics.

Investigation of the Etiological Causes of Central Nervous System Infection in Children with Multiplex PCR

Objective The aim of this study is to investigate the causative agents of central nervous system (CNS) infection in hospitalized pediatric patients by multiplex polymerase chain reaction.

Methods We retrospectively reviewed the medical records of children who underwent lumbar puncture with suspected CNS infection between September 2019 and September 2021. The cerebrospinal fluid (CSF) samples were evaluated by the BioFire FilmArray Meningitis/Encephalitis (ME) Panel.

Results The etiology of the infection was established in 13,02% (n = 25) cases. Human herpesvirus (HHV) type 6 was the most commonly identified pathogen 60% (n = 15), followed by enterovirus 20% (n = 5), Streptococcus pneumoniae 8% (n = 2), Streptococcus agalactiae 4% (n = 1), HHV type 1 4% (n = 1), and Listeria monocytogenes 4% (n = 1). The statistical analysis showed that the age of the group with enterovirus was younger than the age of the group with other causative microorganisms and the group with HHV-6 (respectively p: 0.032; p: 0.011). The hospitalization periods of the group with enterovirus and HHV-6 were shorter than the hospitalization periods of the other causative microorganisms (respectively p: 0.016; p: 0.000) and the absolute neutrophil count values of the group with HHV-6 were lower than the group of other causative microorganisms (p: 0.015).

Conclusion Our study identified HHV-6 as the main cause of CNS infection in Istanbul during coronavirus disease 2019 pandemic when isolation measures were taken. The duration of hospital stay was found to be shorter in CNS infection caused by viral agents. Revealing the causative agent in the CSF is a fast and effective method that prevents unnecessary antibiotic treatment and shortens the hospitalization period of patients.

Evaluation of Multiplex Real-time PCR and WHO Criteria for Diagnosing Childhood Bacterial Meningitis in a Tertiary Referral Hospital in Iran

Background: Childhood bacterial meningitis (BM) requires prompt and precise diagnosis to provide proper treatment and decline mortality and morbidity. Objectives: We aimed to evaluate the World Health Organization (WHO) criteria and polymerase chain reaction (PCR) for diagnosing BM in children admitted to a tertiary referral hospital in Shiraz, southern Iran. Materials: We included all 492 children aged one month to 17 years suspected of meningitis who had cerebrospinal fluid (CSF) leukocytosis admitted to Nemazi Hospital from August 2016 to September 2017. The CSF specimens were examined for routine analysis, Gram staining, and culture. A multiplex real-time PCR was used to identify Streptococcus pneumoniae, Haemophilus influenzae type b (Hib), and Neisseria meningitidis in the CSF samples. Seven viruses were also investigated using real-time PCR. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the WHO criteria and the multiplex real-time PCR results. Results: Seventy-four CSF samples had leukocytosis. Nineteen (22.9%) patients had BM caused by S. pneumoniae (n = 14), Hib (n = 2), Salmonella enterica (n = 2), and N. meningitidis (n = 1). The PCR test detected all cases, except for two with Salmonella meningitis (sensitivity 89.4%, specificity 100%, PPV 100%, and NPV 96%). The WHO criteria detected all cases, except three who received antibiotics at least four days before performing lumbar puncture (sensitivity 84.2%, specificity 98.2%, PPV 94.1%, and NPV 94.7%). Enterovirus was the most common viral etiology (6.75%). Conclusions: The WHO criteria and the multiplex real-time PCR had high accuracy in our setting, and their use could decrease the antibiotic over-prescription in febrile children suspected of meningitis.

Treatment Outcomes and Associated Factors among Children Hospitalized with Acute Bacterial Meningitis in Eastern Ethiopia: A Cross-Sectional Study

Background

Bacterial meningitis is a common central nervous system infection that is associated with high morbidity and mortality in pediatrics. In Ethiopia, little is known about treatment outcomes of acute bacterial meningitis and associated factors among hospitalized children.

Objective

To assess treatment outcomes of acute bacterial meningitis and associated factors among hospitalized children with acute bacterial meningitis in the Hiwot Fana Specialized University Hospital pediatric ward.

Methods

A retrospective cross-sectional study was conducted at the pediatric ward of Hiwot Fana Specialized University Hospital, eastern Ethiopia. Relevant data were collected using a structured data-collection tool from patients' medical charts. Bivariate and multivariate logistic regression analyses were done to identify predictors of treatment outcomes. OR with 95% CI and P≤0.05 was used for statistical significance.

Results

A total of 200 children with acute bacterial meningitis were included in the study, of which 92% were aged ≥2 months and the majority (128, 64%) had delayed (≥72 hours) presentation to the hospital. At admission, 181 (90.5%) were febrile, 92 (46%) had depressed level of consciousness, and 40 (20%) had had seizures. Most (126, 63%) had documented medical comorbidities. The antibiotic combination of ampicillin and gentamycin had been frequently administered in children aged <2 months while ceftriaxone was commonly prescribed for those aged >2 months. Of the total study participants, 154 (77%) showed successful treatment outcomes, while 46 (23%) experienced poor treatment outcomes (died or "self"-discharged). Level of consciousness (AOR 3.25, 95% CI 1.21-8.75), duration of illness before admission (AOR 3.74, 95% CI 1.76-7.98), and antibiotic-regimen change (AOR 4.7, 95% CI 2.4-10) were predictors of treatment outcomes.

Conclusion

The majority of study participants experienced good treatment outcomes. Unconsciousness, antibiotic-regimen change, and duration of illness before hospitalization were significantly associated with treatment outcomes. Early treatment, linkage of primary-health facilities to tertiary health-care centers, and availability of diagnostics should be promoted to improve patient outcomes.

Bacterial Isolates from CSF Samples and Their Antimicrobial Resistance Patterns Among Children Under Five Suspected to Have Meningitis in Dilla University Referral Hospital

INTRODUCTION

Bacterial meningitis is a medical emergency that requires immediate medical attention. It causes an estimated 288,649 deaths worldwide per year, of which 94,883 death occur among children under 5 years old. Up to 24% of survivors suffer from long-term sequelae such as epilepsy, mental disability, or sensorineural deafness, especially when the disease is contracted during early childhood.

OBJECTIVE

This study aimed to assess bacterial isolates of cerebrospinal fluid (CSF) samples and their antimicrobial resistance patterns among children under 5 years old in Dilla University Referral Hospital.

MATERIAL AND METHODS

Hospital-based cross-sectional study design was used to collect clinical data and CSF sample from children under 5 years old who were suspected for meningitis. Sediment of CSF samples was inoculated to blood agar plate, chocolate agar plate, and MacConkey agar for bacterial isolation and identification. Chemical analysis and cytological analysis were also conducted based on standard operating procedures.

RESULTS

From a total of 287 CSF samples cultured, causative bacteria were detected in 38 (13.2%). From culture positive cases, the most frequent isolate was Streptococcus pneumoniae (13 (34.2%)) followed by Staphylococcus aureas (7 (18.4%)), Neisseria meningitidis (6 (16%)) and Escherichia coli (6 (16%)). Haemophilus influenzae type b was isolated in 4 (10.5%) children with meningitis. Another cause of meningitis was Streptococcus agalactiae which accounted for 10.5%. Cryptococcus neoformans was detected in 4 (1.9%) cases of meningitis. Of all bacterial isolates, about 42.1% (16/38) were multi-drug resistant. About 38.5% of S. pneumoniae had multi-drug resistance, while about 33.3% of N. meningitidis, 50% of H. influenzae, 57.1% of S. aureas and 40% of E. coli showed multi-drug resistance.

CONCLUSION

A high prevalence of bacterial meningitis and high rate of drug resistance were observed. Streptococcus pneumoniae was the leading cause of bacterial meningitis among children under 5 years old.