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Irekeola AA, Shueb RH, Engku Abd Rahman ENS, Afolabi HA, Wada Y, Elmi AH, Hakami MA, Alghzwani SM, Elnoubi OAE, Alshehri AA. High prevalence of carbapenem-resistant Enterobacterales (CRE) in human samples from Nigeria: A systematic review and meta-analysis. Heliyon 2024; 10:e34926. [PMID: 39144932 PMCID: PMC11320313 DOI: 10.1016/j.heliyon.2024.e34926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 07/18/2024] [Accepted: 07/18/2024] [Indexed: 08/16/2024] Open
Abstract
Objectives The rise in Carbapenem-resistant Enterobacterales (CRE) is perturbing. To curb the menace of CRE, a comprehensive understanding of its prevalence and epidemiology is crucial. As varying reports abound, the true prevalence of CRE in Nigeria remains unknown. Here, we conducted a systematic review and meta-analysis following standard guidelines to assess the situation of CRE in Nigeria. Methods We searched electronic databases including Pubmed, ScienceDirect, Scopus, Web of Science, and Google Scholar for articles providing information on CRE in Nigeria. The data gathered were analyzed using OpenMeta Analyst and Comprehensive Meta-Analysis software. The random-effect model was employed to calculate pooled resistance to carbapenem antibiotics. Results From 321 retrieved records, 57 were finally included. The studies were predominantly from the South-West region (n = 19). Escherichia coli and Klebsiella pneumoniae were the most frequently tested Enterobacterales among the included studies. The pooled prevalence estimate for imipenem resistance among CRE was 11.2 % (95 % CI: 7.9-15.7). Meropenem resistance had an estimate of 13.5 % (95 % CI: 9.1-19.6), whereas ertapenem and doripenem were estimated at 17.0 % (95 % CI: 9.9-27.7) and 37.9 % (95 % CI: 15.0-67.8), respectively. High heterogeneity (I 2 >85 %, p < 0.001) was observed for the estimates. The highest resistance rate to imipenem (28.4 %), meropenem (37.2 %) and ertapenem (46.5 %) were observed for the South-South region. Based on specific CRE genera, Morganella sp. was the most resistant (37.0 %) while Escherichia sp. was the least (9.4 %). Our analyses also revealed a progressive increase in resistance to carbapenem antibiotics over the years. Conclusion This study highlights carbapenem resistance as a concern in Africa's most populous nation, underscoring the need for proactive measures to address and mitigate the threat of CRE.
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Affiliation(s)
- Ahmad Adebayo Irekeola
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Microbiology Unit, Department of Biological Sciences, College of Natural and Applied Sciences, Summit University Offa, Offa, PMB 4412, Kwara State, Nigeria
| | - Rafidah Hanim Shueb
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Institute for Research in Molecular Medicine (INFORMM), Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Engku Nur Syafirah Engku Abd Rahman
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Hafeez Abiola Afolabi
- Department of General Surgery, School of Medical Sciences, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
| | - Yusuf Wada
- Department of Zoology, Faculty of Life Sciences, Ahmadu Bello University, Zaria, 810107, Nigeria
| | - Abdirahman Hussein Elmi
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia
- Department of Medical Laboratory Sciences, Faculty of Medicine and Health Sciences, Jamhuriya University of Science and Technology, Mogadishu, Somalia
| | - Muath Abdu Hakami
- Microbiology Laboratory, Najran Armed Forces Hospital, Najran 108966, Saudi Arabia
| | | | - Osman AE. Elnoubi
- Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Najran University, P.O. Box 1988, Najran, Saudi Arabia
| | - Ahmad A. Alshehri
- Department of Clinical Laboratory Sciences, Faculty of Applied Medical Sciences, Najran University, P.O. Box 1988, Najran, Saudi Arabia
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Venne DM, Hartley DM, Malchione MD, Koch M, Britto AY, Goodman JL. Review and analysis of the overlapping threats of carbapenem and polymyxin resistant E. coli and Klebsiella in Africa. Antimicrob Resist Infect Control 2023; 12:29. [PMID: 37013626 PMCID: PMC10071777 DOI: 10.1186/s13756-023-01220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/18/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacterales are among the most serious antimicrobial resistance (AMR) threats. Emerging resistance to polymyxins raises the specter of untreatable infections. These resistant organisms have spread globally but, as indicated in WHO reports, the surveillance needed to identify and track them is insufficient, particularly in less resourced countries. This study employs comprehensive search strategies with data extraction, meta-analysis and mapping to help address gaps in the understanding of the risks of carbapenem and polymyxin resistance in the nations of Africa. METHODS Three comprehensive Boolean searches were constructed and utilized to query scientific and medical databases as well as grey literature sources through the end of 2019. Search results were screened to exclude irrelevant results and remaining studies were examined for relevant information regarding carbapenem and/or polymyxin(s) susceptibility and/or resistance amongst E. coli and Klebsiella isolates from humans. Such data and study characteristics were extracted and coded, and the resulting data was analyzed and geographically mapped. RESULTS Our analysis yielded 1341 reports documenting carbapenem resistance in 40 of 54 nations. Resistance among E. coli was estimated as high (> 5%) in 3, moderate (1-5%) in 8 and low (< 1%) in 14 nations with at least 100 representative isolates from 2010 to 2019, while present in 9 others with insufficient isolates to support estimates. Carbapenem resistance was generally higher among Klebsiella: high in 10 nations, moderate in 6, low in 6, and present in 11 with insufficient isolates for estimates. While much less information was available concerning polymyxins, we found 341 reports from 33 of 54 nations, documenting resistance in 23. Resistance among E. coli was high in 2 nations, moderate in 1 and low in 6, while present in 10 with insufficient isolates for estimates. Among Klebsiella, resistance was low in 8 nations and present in 8 with insufficient isolates for estimates. The most widespread associated genotypes were, for carbapenems, blaOXA-48, blaNDM-1 and blaOXA-181 and, for polymyxins, mcr-1, mgrB, and phoPQ/pmrAB. Overlapping carbapenem and polymyxin resistance was documented in 23 nations. CONCLUSIONS While numerous data gaps remain, these data show that significant carbapenem resistance is widespread in Africa and polymyxin resistance is also widely distributed, indicating the need to support robust AMR surveillance, antimicrobial stewardship and infection control in a manner that also addresses broader animal and environmental health dimensions.
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Affiliation(s)
- Danielle M Venne
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - David M Hartley
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Marissa D Malchione
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
- Sabin Vaccine Institute, Influenza Vaccine Innovation, 2175 K St NW, Washington, DC, 20037, USA
| | - Michala Koch
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - Anjali Y Britto
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - Jesse L Goodman
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA.
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Peltola H, Roine I, Kallio M, Pelkonen T. Unusual Gram-negative bacteria cause more severe bacterial meningitis than the three classical agents in children. Acta Paediatr 2022; 111:1404-1411. [PMID: 35416317 PMCID: PMC9321881 DOI: 10.1111/apa.16357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/27/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
Aim To compare the characteristics, mortality and sequelae at hospital discharge of childhood bacterial meningitis (BM) caused by the three “classical” agents Neisseria meningitidis, Haemophilus influenzae or Streptococcus pneumoniae versus BM due to other aetiology in Finland, Latin America and Angola. Methods This observational study is a secondary analysis of data from five prospective treatment trials on non‐neonatal BM in Finland, Latin America and Angola in 1984–2017. Results Of the 1568 cases, 1459 (93%) were caused by the classics, 80 (5%) by other Gram‐negative and 29 (2%) by other Gram‐positive bacteria. Nonclassical Gram‐negative disease was encountered especially in Angola (p < 0.0001). Overall, children in the nonclassical group presented later for treatment and were more often underweight and anaemic (p < 0.001). In multivariate analysis, even if the area was strongest predictor of poor outcome, nonclassical Gram‐negative BM increased the odds for death twofold and the odds for death or severe sequelae 2.5‐fold. Conclusion BM of a nonclassical aetiology is a particularly severe disease affecting especially Angolan children poorly armoured to fight infections. Since vaccinations are diminishing the role of classical agents, that of nonclassical agents is growing.
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Affiliation(s)
- Heikki Peltola
- Pediatrics University of Helsinki Helsinki University Hospital Helsinki Finland
| | - Irmeli Roine
- Faculty of Medicine University Diego Portales Santiago Chile
| | - Markku Kallio
- Pediatrics University of Helsinki Helsinki University Hospital Helsinki Finland
| | - Tuula Pelkonen
- Pediatrics University of Helsinki Helsinki University Hospital Helsinki Finland
- Pediatric Research Center New Children’s Hospital Helsinki Finland
- Hospital Pediátrico David Bernardino Luanda Angola
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Valian SK, Mahmoudi S, Pourakbari B, Banar M, Ashtiani MTH, Mamishi S. The Causative Organisms of Bacterial Meningitis and their Antimicrobial Resistance Profiles in Iranian Children in 2011-2016. Infect Disord Drug Targets 2020; 20:229-236. [PMID: 30468130 DOI: 10.2174/1871526519666181123130101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The study aimed to describe the identity and antimicrobial resistance patterns of the causative agents of bacterial meningitis in children referred to Children's Medical Center (CMC) Hospital, Tehran, Iran. METHODS This retrospective study was performed at CMC Hospital during a six-year period from 2011 to 2016. The microbiological information of the patients with a diagnosis of bacterial meningitis was collected and the following data were obtained: patients' age, sex, hospital ward, the results of CSF and blood cultures, and antibiotic susceptibility profiles of isolated organisms. RESULTS A total of 118 patients with bacterial meningitis were admitted to CMC hospital. Sixty-two percent (n=73) of the patients were male. The median age of the patients was ten months (interquartile range [IQR]: 2 months-2 years) and the majority of them (n=92, 80%) were younger than two years of age. The highest number of patients (n=47, 40%) were admitted to the surgery department. Streptococcus epidermidis was the most frequent isolated bacterium (n=27/127, 21%), followed by Klebsiella pneumoniae (n=20/127, 16%), and Staphylococcus aureus (n=16/127, 12.5%). Blood culture was positive in 28% (n=33/118) of patients. Ampicillin-sulbactam and imipenem were the most effective antibiotics against Gram-negative bacteria isolated from CSF cultures. In the case of Gram-positive organisms, ampicillinsulbactam, vancomycin, and linezolid were the best choices. Imipenem was the most active drug against Gram-negative blood pathogens. Also, ampicillin and vancomycin had the best effect on Gram-positive bacteria isolated from blood cultures. CONCLUSION Results of this study provide valuable information about the antibiotic resistance profiles of the etiologic agents of childhood meningitis, which can be used for prescription of more effective empirical therapies.
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Affiliation(s)
| | - Shima Mahmoudi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Pourakbari
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Banar
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Haghi Ashtiani
- Department of Pathology, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Setareh Mamishi
- Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Infectious Diseases, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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A review of bacteriological profile of acute pyogenic meningitis in a tertiary care center in Southwest Nigeria. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.524140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mado S, Aliyu I, Murtala R. Changing Pattern of Childhood Epidemic Cerebrospinal Meningitis in North-Western Nigeria. J Neurosci Rural Pract 2018; 9:203-207. [PMID: 29725170 PMCID: PMC5912025 DOI: 10.4103/jnrp.jnrp_384_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Nigeria lies within the meningitis belt which extends from the Gambia, Senegal through Nigeria to Eritrea; however, outbreaks have been shown to extend further south involving countries such as Angola and Namibia. Epidemic outbreaks are often recorded every 8-12 years averaging in a 10 yearly circle however endemic cases still occurs. Materials and Methods The study was retrospective; all results of cerebrospinal fluid (CSF) samples of children with cases of meningitis from January 2010 to December 2010 were collected from the register of the microbiology laboratory of General Hospital Gusau. Relevant information such as their age, sex, CSF macroscopy/microscopy reports, latex particle agglutination test report, and CSF culture report were retrieved and entered into a pro forma. Results There were 89 (73%) males and 33 (27%) females with male to female ratio of 2.7:1. The age ranged from 2 months to 14 years; the mean was 6.27 ± 4.00 years. Meningitis was mostly recorded from January to April. W135 was the most common serotype identified. Majority of the samples (54) which were nonreactive for any of the tested antigens had clear CSF (36), while among those that reacted; the W135 group had a high proportion of cases that had turbid CSF (44); (Fisher's exact test = 30.650, P = 0.000). Majority of the samples (99) had no cell count; although those of the W135 group had higher cell counts followed by those in the nonreactive group (Fisher's exact test = 11.226, P = 0.181). Conclusion Meningitis was highest between January and April, and W135 was the most common serotype.
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Affiliation(s)
- Sani Mado
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Ibrahim Aliyu
- Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
| | - Rabiu Murtala
- Department of Laboratory, Ahmad Sani Yariman Bakura Specialist Hospital, Gusau, Nigeria
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Jiang H, Su M, Kui L, Huang H, Qiu L, Li L, Ma J, Du T, Fan M, Sun Q, Liu X. Prevalence and antibiotic resistance profiles of cerebrospinal fluid pathogens in children with acute bacterial meningitis in Yunnan province, China, 2012-2015. PLoS One 2017; 12:e0180161. [PMID: 28662145 PMCID: PMC5491142 DOI: 10.1371/journal.pone.0180161] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 06/10/2017] [Indexed: 11/18/2022] Open
Abstract
Acute bacterial meningitis is still considered one of the most dangerous infectious diseases in children. To investigate the prevalence and antibiotic resistance profiles of cerebrospinal fluid (CSF) pathogens in children with acute bacterial meningitis in Southwest China, CSF samples from 179 meningitis patients (3 days to 12 years old) with positive culture results were collected from 2012 to 2015. Isolated pathogens were identified using the Vitek-32 system. Gram stain results were used to guide subcultures and susceptibility testing. The antimicrobial susceptibility of isolates was determined using the disc diffusion method. Of the isolates, 50.8% were Gram-positive bacteria, and 49.2% were Gram-negative bacteria. The most prevalent pathogens were E. coli (28.5%), Streptococcus pneumoniae (17.8%), Staphylococcus epidermidis (10.0%), Haemophilus influenzae type b (9.5%), and group B streptococcus (7.2%). In young infants aged ≤3 months, E. coli was the organism most frequently isolated from CSF (39/76; 51.3%), followed by group B streptococcus (13/76; 17.1%) and Streptococcus pneumoniae (8/76; 10.5%). However, in young infants aged >3 months, the most frequently isolated organism was Streptococcus pneumoniae (24/103; 23.3%), followed by Staphylococcus epidermidis (18/103; 17.5%) and Haemophilus influenzae type b (16/103; 15.5%). Antimicrobial susceptibility tests indicated that for E. coli isolates, the susceptibility rates to aminoglycosides ranged from 56.8% to 100.0%, among them, amikacin was identified as the most effective against E. coli. As for cephalosporins, the susceptibility rates ranged from 29.4% to 78.4%, and cefoxitin was identified as the most effective cephalosporin. In addition, the susceptibility rates of piperacillin/tazobactam and imipenem against E. coli were 86.3% and 100%. Meanwhile, the susceptibility rates of Streptococcus pneumoniae isolates to penicillin G, erythromycin, chloramphenicol, ceftriaxone and tetracycline were 68.8%, 0.0%, 87.5%, 81.3% and 0.0%, respectively. Gentamycin, ofloxacin, linezolid and vancomycin were identified as the most effective antibiotics for Streptococcus pneumoniae, each with susceptibility rates of 100%. It was notable that other emerging pathogens, such as Listeria monocytogenes and group D streptococcus, cannot be underestimated in meningitis.
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Affiliation(s)
- Hongchao Jiang
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China.,Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, P.R. China
| | - Min Su
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Liyue Kui
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Hailin Huang
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Lijuan Qiu
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China.,Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, P.R. China
| | - Li Li
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Jing Ma
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Tingyi Du
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Mao Fan
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
| | - Qiangming Sun
- Institute of Medical Biology, Chinese Academy of Medical Sciences and Peking Union Medical College, Kunming, P.R. China.,Yunnan Key Laboratory of Vaccine Research & Development on Severe Infectious Diseases, Kunming, PR China
| | - Xiaomei Liu
- The Affiliated Children's Hospital of Kunming Medical University, Kunming, P.R. China
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Bari A, Zeeshan F, Zafar A, Ejaz H, Jabeen U, Rathore AW. Acute bacterial meningitis in children presenting to The Children's Hospital Lahore before and after pneumococcal vaccine in Pakistan National Immunization Program; A comparison. Pak J Med Sci 2017; 33:447-451. [PMID: 28523054 PMCID: PMC5432721 DOI: 10.12669/pjms.332.11891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe bacteriological profile, morbidity and mortality of acute bacterial meningitis (ABM) in children and to compare these parameters before and after the introduction of Pneumococcal vaccine in Pakistan National Immunization Program. METHODS The present descriptive study was conducted at the Department of Paediatric Medicine of The Children's Hospital Lahore from January 2012 to December 2015. A total of 503 children one month to five years of age admitted with diagnosis of meningitis were included. Complete blood count, CSF cytology, biochemistry, culture sensitivity and blood culture sensitivity were performed. RESULTS Frequency of meningitis decreased by 50% in 2013-2015 (199 [2012] vs 304 [2013-2015). Most children in both groups were under one year of age. More neurological complications were seen in the group 2, 20% vs 17%. CSF culture positivity decreased from 12% to 6.6%. Streptococcus pneumoniae isolation decreased from 5 (2.5%) in 2012 to 4 (1.3%) in 2013-2015. Refusal to take feed (p=0.002), impaired sensorium (p=<0.001), severe malnutrition (p=0.001), prolonged duration of symptoms (p=<0.001) and incomplete vaccination status (0.005) were associated with mortality. Mortality rate decreased from 20 (10%) in 2012 to 17 (5.6%) in 2013-2015 but more children developed neurological sequelae 2.7% versus 1%. CONCLUSION Acute bacterial meningitis mostly affected children <1 year. Frequency of Streptococcus pneumoniae and mortality of meningitis decreased significantly after PCV but more neurological complications developed in those children who were unvaccinated in 2013-2015 compared to 2012.
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Affiliation(s)
- Attia Bari
- Attia Bari, DCH, MCPS, FCPS. (Paediatric Medicine). Department of Paediatric Medicine, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
| | - Fatima Zeeshan
- Fatima Zeeshan, MRCPCH, FCPS. (Paediatric Medicine). Department of Paediatric Medicine, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
| | - Aizza Zafar
- Aizza Zafar, M. Phil Microbiology. Department of Microbiology, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
| | - Hasan Ejaz
- Hasan Ejaz, M. Phil, PhD Biotechnology. Department of Microbiology, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
| | - Uzma Jabeen
- Uzma Jabeen, FCPS. (Paediatric Medicine). Department of Paediatric Medicine, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
| | - Ahsan Waheed Rathore
- Ahsan Waheed Rathore, MRCPCH, FRCP. Department of Paediatric Medicine, The Children's Hospital & The Institute of Child Health (CHICH), Lahore, Pakistan
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