Trends of Antimicrobial Susceptibility in Clinically Significant Coagulase-Negative Staphylococci Isolated from Cerebrospinal Fluid Cultures in Neurosurgical Adults: a Nine-Year Analysis

Coagulase-negative staphylococci (CoNS) are the main pathogens in health care-associated ventriculitis and meningitis (HCAVM). This study aimed to assess antimicrobial susceptibility. Moreover, the treatment and clinical outcome were described. All neurosurgical adults admitted to one of the largest neurosurgical centers in China with clinically significant CoNS isolated from cerebrospinal fluid cultures in 2012 to 2020 were recruited. One episode was defined as one patient with one bacterial strain. Interpretive categories were applied according to the MICs. The clinical outcomes were dichotomized into poor (Glasgow Outcome Scale 1 to 3) and acceptable (Glasgow Outcome Scale 4 to 5). In total, 534 episodes involving 519 patients and 16 bacteria were analyzed. Over the 9 years, eight antimicrobial agents were used in antimicrobial susceptibility tests, including six in over 80% of CoNS. The range of resistance rates was 0.8% to 84.6%. The vancomycin resistance rate was the lowest, whereas the penicillin resistance rate was the highest. The linezolid (a vancomycin replacement) resistance rate was 3.1%. The rate of oxacillin resistance, representing methicillin-resistant staphylococci, was 70.2%. There were no significant trends of antimicrobial susceptibility over the 9 years for any agents analyzed. However, there were some apparent changes. Notably, vancomycin-resistant CoNS appeared in recent years, while linezolid-resistant CoNS appeared early and disappeared in recent years. Vancomycin (or norvancomycin), the most common treatment agent, was used in 528 (98.9%) episodes. Finally, 527 (98.7%) episodes had acceptable outcomes. It will be safe to use vancomycin to treat CoNS-related HCAVM in the immediate future, although continuous monitoring will be needed. IMPORTANCE Coagulase-negative staphylococci are the main pathogens in health care-associated ventriculitis and meningitis. There are three conclusions from the results of this study. First, according to antimicrobial susceptibility, the rates of resistance to primary antimicrobial agents are high and those to high-level agents, including vancomycin, are low. Second, the trends of resistance rates are acceptable, especially for high-level agents, although long-term and continuous monitoring is necessary. Finally, the clinical outcomes of neurosurgical adults with coagulase-negative staphylococci-related health care-associated ventriculitis and meningitis are acceptable after treatment with vancomycin. Therefore, according to the antimicrobial susceptibility and clinical practice, vancomycin will be safe to treat coagulase-negative staphylococci-related health care-associated ventriculitis and meningitis.

Simultaneous Bilateral Orbital Cellulitis With Meningitis Caused by Methicillin-Resistant Staphylococcus aureus in an Immunocompetent Infant

The authors report a rare case of fulminant bilateral orbital cellulitis caused by methicillin-resistant Staphylococcus aureus associated with meninigitis in a neonate. The clinical, laboratory, photographic, and radiological records are reviewed. A 17-day-old female infant presented with swelling over both upper eyelids and proptosis in both eyes. Computed tomography showed mutli-loculated abscesses within both orbits. Eyelid swelling and proptosis resolved following transcutaneous aspiration of the purulent material. Cerebrospinal fluid examination yielded Gram-positive cocci, which on culture and polymerase chain reaction testing was identified as methicillin-resistant Staphylococcus aureus. The infant received an extended course of antibiotics. At 12 months of follow-up, the infant was systemically normal with normal milestones, complete ocular movements, and no neurological sequelae. This case highlights the need for cerebrospinal fluid analysis in bilateral orbital cellulitis, even in cases not exhibiting central nervous system involvement. Aggressive medical and surgical treatment is needed in bilateral orbital cellulitis. [J Pediatr Ophthalmol Strabismus. 2020;57:e34-e37.].

Positive Culture Samples of Infants with Neonatal Infections in a Tertiary Neonatal Center in Isfahan, Iran

BACKGROUND

The prevalence of microorganisms in the neonatal intensive care unit (NICU) and neonatal internal wards is constantly changing, thus rendering the practice of empiric antibiotic therapy ineffective due to the resistance of these microorganisms. Therefore, the purpose of this study was to determine the relative frequency of positive cultures of Bactec, blood, cerebrospinal fluid (CSF) and urine in infants admitted to the NICU and neonatal internal ward in Al-Zahra hospital in 2011-2017.

METHODS

In this cross-sectional descriptive study, we evaluated 466 positive culture samples from 2853 different cultures (blood, urine, CSF, etc) from infants admitted to the NICU and neonatal internal ward with clinical signs of neonatal infection in Al-Zahra hospital. Isfahan in 2011-2017. The samples were evaluated for type of microorganisms and sensitivity to antibiotics.

RESULTS

Positive cultures among Bactec, blood, CSF and urine culture samples were reported at 15.5% (95% confidence interval [CI]: 12.8-18.1) 9.3% (95% CI: 6.8-11.7), 6.4% (95% CI: 4.3-8) and 28.6% (95% CI: 25.4-31.7), respectively. Staphylococcus epidermidis was the most common species in Bactec (46.7%; 95% CI: 38.7-54.6), blood (53.1%; 95% CI: 39.1-67), and CSF (37.1%; 95% CI: 21-53.1) cultures while Klebsiella pneumoniae was the most frequent species in urine culture (28%; 95% CI: 22.2-33.7).

CONCLUSION

Considering the results of Bactec and blood cultures, it is essential to reduce staphylococcal infections in our settings.

The causes and treatment outcomes of 91 patients with adult nosocomial meningitis

BACKGROUND/AIMS

Frequent pathogens of nosocomial meningitis were investigated and the adequacy of empiric antibiotic therapy was assessed. Outcomes of nosocomial meningitis were also evaluated.

METHODS

Ninety-one patients, who were diagnosed and treated for nosocomial meningitis at a single tertiary hospital in Daegu, Korea for 10 years, were included. Medical record and electronic laboratory data on the causative pathogens, antibiotics used, and outcomes were retrospectively investigated.

RESULTS

Coagulase-negative Staphylococcus (40.9%) was the most common pathogen, followed by Acinetobacter (32.5%). Both were cultured as a single organism in cerebrospinal fluid (CSF). Seventy-eight patients (85.7%) had infections related to external ventricular drains (EVD). The most common empirical antibiotics were extended-spectrum beta-lactam antibiotics plus vancomycin (35/91, 38.6%). Of the 27 patients who had cultured Acinetobacter in CSF, 10 (37%) were given the wrong empirical antibiotic treatment. Seven of the 27 patients (26.9%) with cultured Acinetobacter died, and overall mortality of the 91 patients was 16.5%. In the multivariate analysis, the presence of combined septic shock (p < 0.001) and a persistent EVD state (p = 0.021) were associated with a poor prognosis.

CONCLUSIONS

Acinetobacter is one of the leading pathogens of nosocomial meningitis and may lead to inadequate coverage of empiric antibiotic therapy due to increasing resistance. An EVD should be removed early in cases of suspected nosocomial meningitis, and carbapenem might be required for the poor treatment response.

[A pilot study on the proteome of cerebrospinal fluid of Staphylococcus epidermidis meningitis in children]

OBJECTIVE

Bacterial meningitis is a kind of central nervous system infection with a high incidence, disability and fatality in children. Prompt diagnosis and treatment are associated with an improved prognosis. Low positive rate of bacterial cultures of the cerebrospinal fluid (CSF) makes it difficult to make a definite diagnosis. This experiment aimed to investigate a proteome profile of normal CSF of Chinese children by two-dimensional polyacrydamide gel electrophoresis (2-DE), and to sieve the disease-specific proteins of Staphylococcus epidermidis meningitis (SeM) to provide basis for early diagnosis and treatment of SeM.

METHODS

Four mL CSF samples were obtained respectively from SeM and normal children. The separated proteins with immobile pH gradient (IPG) 2-DE technology and protein spots were visualized by Coomassie Brilliant Blue staining. The stained 2-DE gels were scanned on the Imagescanner and pictures were obtained through Labscan software. The images were analyzed with PDQuest software and the differences of protein spots were compared between the SeM and normal children.

RESULTS

Mean protein spots of the 2-DE gels were 438 and 425 in the SeM and normal groups respectively. Twenty-five protein spots only occurred in normal CSF and 12 spots only occurred in the SeM group. The expression of 6 protein spots showed up-regulation and that of 19 showed down-regulation in the SeM group compared with that in the normal group.

CONCLUSIONS

A 2-DE profile of CSF proteome was successfully established in SeM and normal children through proteomic technique. By the differentiated analysis of these CSF 2-DE gels, the differences of CSF proteome profiles were found between SeM and normal children. Future analysis and identification of these spots will contribute to find out the disease specific proteins of SeM and to provide basis for early diagnosis and therapy of this disorder.

Detection of enterotoxin and toxic shock syndrome toxin 1 genes in Staphylococcus, with emphasis on coagulase-negative staphylococci

The detection of staphylococcal enterotoxins is decisive for the confirmation of an outbreak and for the determination of the enterotoxigenicity of strains. Since the recognition of their antigenicity, a large number of serological methods for the detection of enterotoxins in food and culture media have been proposed. Since immunological methods require detectable amounts of toxin, molecular biology techniques represent important tools in the microbiology laboratory. In the present study, polymerase chain reaction (PCR) was used to identify genes responsible for the production of enterotoxins and toxic shock syndrome toxin 1 (TSST-1) in S. aureus and coagulase-negative staphylococci (CNS) isolated from patients and the results were compared with those obtained by the reverse passive latex agglutination (RPLA) assay. PCR detection of toxin genes revealed a higher percentage of toxigenic S. aureus strains (46.7%) than the RPLA method (38.3%). Analysis of the toxigenic profile of CNS strains showed that 26.7% of the isolates produced some type of toxin, and one or more toxin-specific genes were detected in 40% of the isolates. These results suggests the need for further studies in order to better characterize the pathogenic potential of CNS and indicate that attention should be paid to the toxigenic capacity of this group of microorganisms.

Correlation between the neonatal EEG and the neurological examination in the first year of life in infants with bacterial meningitis

OBJECTIVE

To assess the contribution of neonatal electroencephalogram (EEG) and its correlation with the neurological examination at age of 9 months in newborns with bacterial neonatal meningitis.

METHOD

Twenty seven infants were studied with positive cerebrospinal fluid (CSF) culture for bacteria. We used the worse EEG result during acute phase of meningitis, and performed neurologic follow-up after discharge from hospital. Background cerebral activity was classified as normal or mildly, moderately, or markedly abnormal. Neurologic examination outcomes was classified normal, mild abnormalities, moderate abnormalities and severe abnormalities.

RESULTS

EEG performed in the neonatal period during acute bacterial meningitis predicts adverse outcome early at age of 9 months, and had a significant correlation with cephalic perimeter and active tone alterations.

CONCLUSION

Neonatal EEG is useful for predicting abnormal outcomes, especially cephalic perimeter and active tone abnormalities at 9 months of age in infants with bacterial neonatal meningitis.

Epidemiology of adult staphylococcal meningitis in southern Taiwan: a clinical comparison of Staphylococcus aureus infection and coagulase-negative staphylococcal infection

The clinical and laboratory characteristics of 38 staphylococcal adult bacterial meningitis (ABM) cases (19 Staphylococcus aureus infections and 19 coagulase-negative staphylococcal [CoNS] infections), collected over a period of 6.5 years (July 1999-December 2005; total ABM cases=181) were analyzed. The results were compared with those of our previous study (January 1986-June 1999; total ABM cases=202: monomicrobial infection=180, mixed infection=22, staphylococcal infection=27). The 38 staphylococcal meningitis cases were 21 men and 17 women. Fever and altered consciousness were the leading clinical manifestations. A preceding postneurosurgical state was noted in 12 of the 19 S. aureus infections and all 19 CoNS infections. The ages of onset and mortality rates of S. aureus infection and CoNS infection were 58.21+/-13.05 years and 36.8% (7/19), and 44.16+/-17.57 and 5.3% (1/19), respectively. Eleven of the 19 implicated S. aureus strains and 18 of the 19 implicated CoNS strains were mecA gene-positive and methicillin-resistant; all the strains retained their susceptibility to linezolid. The therapeutic results showed a mortality rate of 21% (8/38). This study revealed an increase of methicillin-resistant, postneurosurgical staphylococcal infection in ABM. Patients with CoNS infection had a younger age at onset and a lower mortality rate.

Linezolid cerebrospinal fluid concentration in central nervous system infection

We report two cases of central nervous system infection due to methicillin-resistant Staphylococcus epidermidis treated with linezolid. The first case was a 72-year old woman with ventriculitis in the presence of intraventricular catheter: therapeutic effectiveness was documented clinically and microbiologically; serum and cerebrospinal fluid levels were measured after the first and fourth doses: trough linezolid concentrations in cerebrospinal fluid were 1.44 and 2.9 mg/L respectively, higher than the minimum inhibitory concentration (MIC). The second case was a 27-year old man with post-traumatic cerebral abscess; during 5 days linezolid was not found in his cerebrospinal fluid despite very high serum level peak, and the drug was not detectable in cerebral tissue surgically removed after 14 days of therapy. Linezolid may not reach therapeutic concentrations in cerebrospinal fluid, and, when possible, we suggest that drug levels be monitored.

Conspicuous endoscopic appearance of ventriculitis caused by coagulase-negative staphylococci

To date, reports about the macroscopic appearance of ventriculitis have been rare, consisting only of a few autopsy cases. A patient in our hospital had ventriculitis caused by coagulase-negative staphylococci, and under neuroendoscopy we obtained clear findings of granular ependymitis. A 44-year-old man was admitted for disturbance of consciousness caused by progressive hydrocephalus. He had experienced subarachnoid hemorrhage (SAH) from a left vertebral dissecting aneurysm, and had subsequently received a ventriculoperitoneal shunt against post-SAH hydrocephalus. After admission, he was found to have retrograde shunt infection from peritonitis caused by cholecystitis. Coagulase-negative staphylococci were detected in cerebrospinal fluid (CSF), and the infection persisted even with intrathecal administration of gentamycin, and intravenous administration of vancomycin and arbekacin. Endoscopic rinsing was performed, and multiple small yellowish microgranulations, less than 1 mm in diameter, were observed in the lateral ventricles and the third ventricle. Rinsing of the CSF after intensive antimicrobial treatment resulted in a cure. Because there have been no reports of endoscopic observations of bacterial ventriculitis, we were unable to be certain about the origin or significance of the microgranulations. However, whether or not the microgranulations were bacterial colonies, infection did not recur during a 2-year follow-up period.

Ruptured Cerebral Artery Aneurysm and Bacterial Meningitis in a Man With Osteogenesis Imperfecta

This report describes a 38-year-old man with osteogenesis imperfecta who died of a ruptured cerebral artery aneurysm and bacterial meningitis. He had multiple long bone fractures in the past, and approximately 4 months before death, he had surgery to relieve symptoms of basilar impression. The surgery was complicated by a postoperative wound infection. For the next 4 months, he had intermittent headaches and vomiting. He was found dead in his bed at home. At autopsy, he had a ruptured anterior communicating artery aneurysm and bacterial meningitis. Cerebrospinal fluid and blood cultures had growth of Staphylococcus aureus. Osteogenesis imperfecta is a disorder of type I collagen. Type I collagen is present in many tissues, including blood vessels. The etiology of cerebral artery aneurysm formation is multifactorial. Some patients with cerebral artery aneurysms have been shown to have abnormalities in type III collagen. There has not been a reported relationship made between abnormalities in type I collagen and aneurysms. Meningitis can also result in cerebral artery aneurysms, but they are usually due to Aspergillus or Mycobacterium species. The case we report is unique; cerebral artery aneurysm formation may have been due to osteogenesis imperfecta and/or bacterial meningitis.

Meningitis Agudas en Córdoba,Colombia 2002 - 2004

OBJECTIVE

Establishing characteristic epidemiologic and microbiologic features of acute meningitis in the Córdoba department.

METHODOLOGY

A descriptive epidemiological study was carried out between June 2002 and June 2004 at the Hospital San Jerónimo in Montería. All suspicious cases of meningitis were included; laboratory tests included cytological smear, biochemistry, latex, Gram stain and culture.

RESULTS

57 (11.3%) and 85 (16.8%) of the 503 samples of cerebrum spinal fluid (CSF) were confirmed by culture as being probable cases. There were 6 cases of polymicrobial infection, making a total of 63 isolates: 17 non-fermenting Gram-negative bacilli (26.9%), 16 Streptococcus pneumoniae (25.4%), 7 Enterobacteriaceae (11%), 5 Criptococcus neoformans (8%) 4 Neisseria meningitidis serotype B (6.3%), 3 S. viridans (4.8%), 2 Streptococcus group B (3.2%), 2 Haemophilus influenzae type B (3.2%), 2 Staphylococcus negative coagulase (3.2%), 2 S. aureus (3.2%), 2 Enterococcus (3.2%) and 1 Candida albicans (1.6%). The S. Pneumoniae serotypes found were: 5 (n=4), 23F (n=3), 14 (n=2), 18C (n=2), 18A (n=l1, 17F (n=l1, 1 (n=1).

CONCLUSIONS

The study led to determining epidemiological and microbiological aspects of acute meningitis in the Códoba department which had been unknown up to now. Streptococcus pneumoniae (25.4% was the main aetiological agent of meningitis; the epidemiologic aspects so established confirmed the need for strengthening and implementing measures for controlling meningitis in C6ódoba and its surveillance there.

[Spinal epidural abscess with persistent increase in cerebrospinal fluid protein: a case study]

A 67-year-old man under hemodialysis treatment developed neck stiffness, fever and conscious disturbances. The patient was infected with Methicilin-resistant Staphylococcus aureus (MRSA) sepsis caused by an infection on a dialysis shunt. On admission, he was diagnosed with bacterial meningoencephalitis and underwent a series of antibiotic chemotherapies. The treatment brought cell count in the cerebrospinal fluid to a subnormal level but his clinical status did not improve. The patient continued to have high level of cerebrospinal fluid protein (898 mg/dl). Cervical MRI demonstrated two abscesses deep in the neck as well as in the epidural region of the cervical spinal cord, from C2 to C5 vertebral levels. Based on these findings, spinal epidural abscess (SEA) was diagnosed. Intensive antibiotic chemotherapy especially targeted for MRSA could eradicate abscesses and improve clinical status. However, persistent high protein level in the cerebrospinal fluid could suggest SEA.

Genetic polymorphism of the accessory gene regulator (agr) locus in Staphylococcus epidermidis and its association with pathogenicity

Staphylococcus epidermidis has become one of the most important causes of nosocomial infections in recent years. The staphylococcal accessory gene regulator (agr) is the most important locus responsible for the regulation of virulence factors, and it has been shown to be polymorphic. The aim of this study was to investigate the agr locus and its genetic polymorphisms in different Chinese S. epidermidis isolates and the relationship between genetic polymorphisms and pathogenicity. Specific PCR was used to amplify the different agr groups. Results were confirmed by restriction enzyme digestion and sequence analysis. agr mutations were detected and three agr groups of S. epidermidis were determined. Of the isolates, 12 % were pathogenic S. epidermidis and 17 % had naturally occurring agr mutations (P > 0.05). Pathogenic S. epidermidis isolates comprised 68.2 % agr group I, 19.3 % group II and 12.5 % group III, while isolates from healthy controls comprised 39 % agr group I, 51 % group II and 10 % group III (P < 0.01). The percentages of agr locus mutants and the three agr groups in different hospitals showed no significant differences (P > 0.05). The percentage of agr group I S. epidermidis isolated from catheters and blood was higher than that isolated from the other clinical specimens. This is the first study to investigate the genetic polymorphism of agr in S. epidermidis in China. The mean percentage of agr locus mutants was 14.9 % (12 % in clinical specimens; 17.7 % in controls). Genetic polymorphism of agr in S. epidermidis was linked to its pathogenicity; group I was associated with pathogenicity, while most isolates from healthy subjects were group II. The mechanism is to be investigated.

Treatment of meningitis due to methicillin-resistant Staphylococcus epidermidis with linezolid

Methicillin-resistant Staphylococcus epidermidis (MRSE) can cause nosocomial meningitis in the presence of prosthetic devices. Vancomycin is the treatment of choice, but its penetration into the cerebrospinal fluid is poor, especially in cases without severe meningeal inflammation. We successfully used linezolid to treat a case of posttraumatic MRSE meningitis with a low-level inflammatory response. Therapeutic effectiveness was documented microbiologically and by the simultaneous measurement of linezolid levels in serum and cerebrospinal fluid.

Prospective study of use of PCR amplification and sequencing of 16S ribosomal DNA from cerebrospinal fluid for diagnosis of bacterial meningitis in a clinical setting

We have evaluated the use of a broad-range PCR aimed at the 16S rRNA gene in detecting bacterial meningitis in a clinical setting. To achieve a uniform DNA extraction procedure for both gram-positive and gram-negative organisms, a combination of physical disruption (bead beating) and a silica-guanidiniumthiocyanate procedure was used for nucleic acid preparation. To diminish the risk of contamination as much as possible, we chose to amplify almost the entire 16S rRNA gene. The analytical sensitivity of the assay was approximately 1 x 10(2) to 2 x 10(2) CFU/ml of cerebrospinal fluid (CSF) for both gram-negative and gram-positive bacteria. In a prospective study of 227 CSF samples, broad-range PCR proved to be superior to conventional methods in detecting bacterial meningitis when antimicrobial therapy had already started. Overall, our assay showed a sensitivity of 86%, a specificity of 97%, a positive predictive value of 80%, and a negative predictive value of 98% compared to culture. We are currently adapting the standard procedures in our laboratory for detecting bacterial meningitis; broad-range 16S ribosomal DNA PCR detection is indicated when antimicrobial therapy has already started at time of lumbar puncture or when cultures remain negative, although the suspicion of bacterial meningitis remains.

Role of the urokinase plasminogen activator system in patients with bacterial meningitis

BACKGROUND

The urokinase plasminogen activator system has the potency to promote leukocyte recruitment and blood-CSF barrier breakdown, and thus may play an important pathophysiologic role in bacterial meningitis.

METHODS

CSF and serum concentrations of urokinase-plasminogen activator (urokinase [uPA]), uPA receptor (uPAR), and PA inhibitor-1 (PAI-1) were quantified by ELISA in 12 patients with bacterial meningitis, control patients (n = 10) with noninflammatory neurologic diseases, and 10 patients with Guillain-Barré syndrome (GBS), a disease in which blood-CSF barrier disruption occurs without CSF pleocytosis. Casein zymography was used to determine PA-dependent plasminogen activation in the CSF.

RESULTS

A marked increase in uPA-dependent plasminogen activation was detected in the CSF of patients with bacterial meningitis vs CSF of patients with GBS and controls. Accordingly, ELISA analysis of CSF revealed intrathecal upregulation of uPA protein in patients with bacterial meningitis. CSF concentrations of uPAR and PAI-1 were also elevated in these patients. The serum of patients with bacterial meningitis showed elevated protein levels of uPA, but not uPAR or PAI-1. Positive correlations were found between blood-CSF barrier breakdown and CSF uPA concentrations, and between CSF pleocytosis and CSF/serum ratios of the potent chemokine uPAR in patients with bacterial meningitis. Furthermore, an adverse clinical outcome in these patients correlated with serum uPA concentrations.

CONCLUSION

In bacterial meningitis, the urokinase plasminogen activator system is involved in leukocyte recruitment and breaching of the blood-CSF barrier, and this may contribute to an unfavorable clinical outcome.

Contrast enhancement of cerebrospinal fluid on delayed MRI in a patient with an epidural abscess and renal failure

Cerebrospinal fluid (CSF) is normally of low signal intensity on T1 weighted MRI. The case of a patient with renal failure who developed an epidural abscess, and in whom the CSF appeared of high signal intensity on delayed T1 weighted MRI is presented. Possible mechanisms for this are discussed.

Molecular identification of Staphylococcus lugdunensis in a patient with meningitis

A 12-year-old child developed meningitis 6 days after a third ventriculostomy by endoscopy. A coagulase-negative Staphylococcus sp. was isolated in pure culture from the cerebrospinal fluid and was definitely identified as Staphylococcus lugdunensis after the 16S ribosomal DNA gene and rpoB gene were sequenced. This report describes the first case of S. lugdunensis meningitis.

Subdural hematoma after cervical epidural steroid injection

STUDY DESIGN

A case report is presented involving a subdural hematoma after cervical epidural steroid injection.

OBJECTIVE

To demonstrate a previously unreported complication of cervical epidural steroid injection.

SUMMARY OF BACKGROUND DATA

Cervical epidural steroid injection is a common procedure performed in the care of patients with spine-related complaints. Reports of complications are rare, and most of these are fairly benign. To the authors' knowledge, subdural hematoma has never been described as a complication of a cervical epidural steroid injection.

METHODS

A patient underwent an uncomplicated cervical epidural steroid injection by an experienced anesthesiologist. She developed acute onset of axial pain followed by progressive quadriparesis within a matter of 8 hours. She was transferred from a local emergency room after a CT scan suggested posterior cord displacement consistent with an anterior spinal hematoma from C3 to C5. She was taken to the operating room for urgent decompression. Exploration revealed an anterior subdural hematoma that was evacuated followed by dural closure with a patch.

RESULTS

After surgery the patient was initially quadriplegic but rapidly gained full function in the left upper and lower extremities. She was making steady progress with motor recovery on the right side when she developed acute meningitis about 8 days after surgery, and then she subsequently went into cardiopulmonary arrest. She was successfully resuscitated but remained critically ill with no evidence of encouraging neurologic function. Six days later she had a second cardiac arrest and could not be resuscitated.

CONCLUSIONS

It is important to acknowledge that spinal hematomas can occur after cervical epidural steroid injection, as prompt recognition and treatment could improve the prognosis for recovery. The sequelae of a cervical subdural hematoma after epidural steroid injection remain potentially devastating.

Treatment of staphylococcal implant infection with rifampicin-ciprofloxacin in stable implants

Infection following total joint replacement remains a problem that has not been solved so far. The treatment options include removal of the implant and a delayed reconstruction or a direct exchange operation. Among patients with stable implants and short duration of infection as well as in patients who for certain reasons are inoperable, antibiotic therapy with a combination of rifampicin-ciprofloxacin may be a reasonable treatment option for curing staphyloccocal infection without removal of the implant. A case study of a Staphylococcus epidermidis (coagulase-negative) infection following delayed revision total knee replacement after septic loosening of a knee arthroplasty and its successful conservative treatment with rifampicin-ciprofloxacin is described. Alternative rifampicin combinations are discussed with respect to recently developed pharmacodynamical and pharmacokinetical findings of biofilm active drugs.

Continuous intrathecal pump infusion of baclofen with antibiotic drugs for treatment of pump-associated meningitis. Case report

Intrathecal baclofen administered by means of an implantable pump is being increasingly used for successful treatment of spasticity. Meningitis following intrathecally administered baclofen is a rare but serious complication that is difficult to treat without removal of the pump. Because success rates with intravenously administered antibiotic drugs for the treatment of meningitis have been low, intrathecal administration of antibiotic agents is often required to eradicate the pathogen. The authors report the case of a patient in whom Staphylococcus epidermidis meningitis developed after insertion of an intrathecal baclofen pump. The patient was successfully treated by intrathecal coadministration of vancomycin and baclofen.

Infectious meningitis mimicking recurrent medulloblastoma on magnetic resonance imaging. Case report

This report and the accompanying review of the literature address the challenges, when using surveillance magnetic resonance (MR) imaging, of establishing the origin of newly detected central nervous system lesions. Routine surveillance MR imaging in a 16-year-old boy, whose medulloblastoma had been successfully treated, demonstrated asymptomatic nodular leptomeningeal enhancement of the brain and spinal cord, which was consistent with recurrent disease. Examination of the cerebrospinal fluid, however, led to the diagnosis of bacterial meningitis. Two weeks after completion of antibiotic therapy, the original MR imaging findings were seen to have resolved. This case illustrates the importance of considering clinical and laboratory data, including results from a complete examination of the cerebrospinal fluid, when interpreting the origin of new lesions revealed by MR imaging.

Identification and medical importance of coagulase-negative staphylococci species

A total of 126 coagulase-negative staphylococci strains (CNS) were isolated from blood samples and from the intravenous catheters and cerebrospinal fluid of 103 patients admitted to the University Hospital of Ribeirão Preto. Staphylococcus epidermidis (68.2%), S. haemolyticus (11.1%) and S. hominis (3.2%) were the most frequent species. The last two CNS showed greater resistance to antimicrobial agents than S. epidermidis. CNS were the agents of infection in 10. 7% of the patients and the agents of intravenous catheter colonization in 18.4% of the cases.

All Wales surveillance of methicillin-resistant Staphylococcus aureus (MRSA): the first year's results

Over the last five years, hospitals in Wales have experienced difficulties with increasing numbers of isolates of methicillin-resistant Staphylococcus aureus (MRSA). Continuous total population surveillance of MRSA was introduced with the objectives of gaining an understanding of the extent and variation in time and place of its occurrence, the burden of disease and possible risk factors associated with its isolation and resistance to other antibiotics. All first isolates of MRSA from both hospital and community settings and all isolates of methicillin-sensitive Staphylococcus aureus (MSSA) associated with bacteraemia and cerebrospinal fluid (CSF) isolates detected in medical microbiology laboratories in Wales were collected via CoSurv, a set of interconnected data-base modules for communicable disease control. A data set was collected on each isolate and the patient associated with that isolate and compiled centrally at CDSC (Wales) for all-Wales analysis of the MRSA situation. Surveillance started in January 1996 and at the end of the first year, 2700 new isolates of MRSA had been reported from hospital and community settings, giving a rate of 92.43/100,000 population. The incidence of MRSA from bacteraemias and CSF was 5.20/100,000 compared with 12.70/100,000 for MSSA. MRSA from bacteraemia and CSF was significantly more commonly associated with male patients than MSSA. MRSA patients were significantly older. For all MRSA isolates, the highest reporting rate was in men aged 75+ (647.21/100,000). The highest incidence of invasive disease was also in men aged 75+ (45.69/100,000). Isolates from post-surgical patients were more likely to be involved in invasive disease (OR = 2.59), P < 0.001) than strains from other sources. The majority of isolates were resistant to at least two antibiotics in addition to methicillin, most frequently erythromycin and the fluoroquinolones. Very little resistance to fusidic acid, mupirocin or rifampicin was reported. Continuous total population surveillance has provided a minimum incidence of MRSA in Wales and has allowed a simple and intelligible picture of the problem to be determined, which has been fed back to hospitals to assist decisions on control.

[Transferability of tazobactam/piperacillin (TAZ/PIPC) to cerebrospinal fluid of rabbit with meningitis caused by Staphylococcus aureus]

The transferability of tazobactam/piperacillin (TAZ/PIPC) to cerebrospinal fluid (CSF) was studied employing rabbits with experimental meningitis caused by Staphylococcus aureus. 125 or 250 mg/kg of TAZ/PIPC was intravenously administered to rabbits with experimental meningitis then concentrations of TAZ and PIPC in CSF and serum were measured. In the group to which 125 mg/kg of TAZ/PIPC was administered, mean concentration of TAZ in CSF was 7.3 and 2.4 micrograms/ml at 30 and 60 min after administration, respectively, and concerning PIPC, it was 10.1 and 3.5 micrograms/ml, respectively. CSF/serum ratio of TAZ was 29.4% and 31.4%, respectively, and that of PIPC was 24.3 and 35.6%, respectively. In the group to which 250 mg/kg of TAZ/PIPC was administered, mean concentration of TAZ in CSF was 16.5 and 12.6% micrograms/ml, respectively, and concerning PIPC, it was 25.6 and 18.2 micrograms/ml, respectively. CSF/serum ratio of TAZ was 22.1 and 56.1%, respectively, and that of PIPC was 12.2 and 51.9%, respectively. Addition of TAZ did not make significant change of transferability of PIPC to CSF. Considering the antibacterial effect of TAZ/PIPC against main causative organism of meningitis, this agent was thought to be effective for the treatment of purulent meningitis.

Detection of staphylococcal genes directly from cerebrospinal and peritoneal fluid samples using a multiplex polymerase chain reaction

A multiplex polymerase chain reaction (PCR) that can simultaneously detect eubacterial isolates and the methicillin-susceptibility of staphylococcal isolates from cerebrospinal and peritoneal fluid samples was compared to conventional microbiological methods. Using conventional methods, bacteria were isolated from 8% (29/350) of the cerebrospinal fluid samples and from 5% (3/60) of the peritoneal fluid samples. All isolates except two Staphylococcus epidermidis isolates were also detected using the multiplex PCR. Coagulase-negative staphylococci and Staphylococcus aureus were correctly identified using both methods. The multiplex PCR can rapidly and simultaneously detect eubacteria, and the methicillin susceptibility of staphylococci from samples containing > or = 10(2) cfu/ml of bacteria.

The diagnostic importance of eosinophil granulocytes in the CSF of children with ventricular-peritoneal shunt systems

We investigated the occurrence of cerebrospinal fluid (CSF) eosinophilia in patients with ventriculo-abdominal shunt systems with regard to possible infection. For this purpose, we examined the CSF of 83 children at the time of shunt obstruction or malfunction. In 32 children (38.6%) we found more than 4% of eosinophil granulocytes in the CSF with a maximum of 76%. In 15 of these 32 children the CSF was sterile, whereas in 17 patients bacterial infection was present. In the CSF of 16 of those 17 children, Staph. epidermidis was cultivated. There was statistically significant correlation between positive Staph. epidermidis culture and the occurrence of CSF eosinophilia (P<0.05). The occurrence of CSF eosinophilia in patients with ventriculo-peritoneal shunts is well known and was mostly attributed to an allergic reaction. Our findings support the theory of an infectious etiology of the eosinophilia and are thus in line with new American and French studies. We believe that CSF eosinophilia indicates a persistent infection of the central nervous system by the contaminated shunt system. As the organism which is the most common cause we cultured Staph. epidermidis.

Cerebrospinal fluid (CSF) pharmacokinetics of intraventricular vancomycin in patients with staphylococcal ventriculitis associated with external CSF drainage

We studied the efficacy and pharmacokinetics of intraventricularly administered vancomycin in three patients with shunt-associated staphylococcal ventriculitis. We instilled 10 mg of the drug intraventricularly every 24 hours. Cerebrospinal fluid (CSF) levels were measured 1 hour after instillation and then every 2 hours. Peak vancomycin levels reached a mean of 292.9 microg/mL. The mean trough levels, measured immediately before readministration of vancomycin, were 7.6 microg/mL; this level has proved to be sufficient for maintaining the necessary steady-state serum concentration of vancomycin. All three patients were cured clinically and bacteriologically, and CSF parameters returned to normal within 5-13 days. No side effects were observed. Our results suggest that intraventricularly administered vancomycin is a valuable therapeutic strategy for treating shunt-associated staphylococcal ventriculitis. In addition, we provide evidence that 10 mg of vancomycin, administered intraventricularly every 24 hours, allows maintenance of therapeutic drug levels in the CSF for at least 24 hours.

[Transferability of cefozopran to cerebrospinal fluid in rabbits with meningitis caused by Staphylococcus aureus]

The transferability of cefozopran (CZOP) to cerebrospinal fluid (CSF) was studied employing rabbits with experimental meningitis caused by Staphylococcus aureus. The mean plasma concentration was 293 +/- 17.6 micrograms/ml at 15 minutes after intravenous administration of CZOP at a dose level of 100 mg/kg. The mean concentration in CSF reached its maximum, 16.5 +/- 2.74 micrograms/ml at 60 minutes after administration. Pharmacokinetic parameters calculated from these values were as follows: Cmax (CSF/plasma) 5.72%, AUC (CSF/plasma) 6.61% between 15 and 60 minutes, 9.38% between 15 and 120 minutes and 11.2% between 15 and 180 minutes, T 1/2 for CZOP in CSF: 138 minutes, T 1/2 (CSF/plasma): 2.81. In comparison to those of beta-lactams that were obtained in the same way, the transferability of CZOP to CSF was moderate but concentration in CSF was high, hence, in consideration of the antimicrobial potency against the main pathogens of meningitis, it appears worthwhile of running clinical trials for CZOP.

Cerebrospinal fluid shunt infections in infants

Infection remains a major cause of morbidity and mortality following CSF shunt procedures. In this study 191 shunt procedures carried out from January 1981 to December 1992 in a series of 81 infants (less than 6 months old) were retrospectively analyzed for possible risk factors. The overall surgical infection rate was 7.8%, with 15 infections occurring in 14 patients (17.2%). No significant difference in the rate of infections was found in relation to sex, birth weight, gestational age, and type of shunt procedure (primary insertion/revision). The occurrence of other infections during the period of shunt surgery did not influence the infection risk either. Intraventricular hemorrhage and central nervous system infections as causes of the hydrocephalus were found to correlate with septic risk. Young age (less than 6 months) seems to represent the main risk factor, and this is related both to the immunologic deficiency and to the particular features of residential bacterial flora in this age group.

[Transferability of biapenem (L-627) to cerebrospinal fluid in rabbits with meningitis caused by Staphylococcus aureus]

The transferability of biapenem (L-627) to cerebrospinal fluid (CSF) was studied employing rabbits with experimental meningitis caused by Staphylococcus aureus. The mean plasma concentration was 192 +/- 12.8 micrograms/ml at 15 minutes after intravenous administration of the drug at a dose level of 100 mg/kg. The mean concentration in CSF was maximum at 45 minutes after administration at 11.4 +/- 2.19 micrograms/ml. Pharmacokinetic parameters calculated from these values were as follows, Cmax (CSF/plasma): 5.96%; AUC (CSF/plasma): 8.15% between 15 and 60 minutes, 12.1% between 15 and 120 minutes and 15.0% between 15 and 180 minutes; T1/2 for L-627 in CSF: 152 minutes; T1/2 (CSF/plasma): 3.34. In comparison with those of other beta-lactam antibiotics that were obtained in the same way, the transferability of L-627 was intermediate, and in consideration of the antimicrobial potency against the main pathogens of meningitis, it appears worthwhile of running clinical trials for this drug.

Changes in cerebrospinal fluid biotinidase activity in Staphylococcus aureus meningitis

An early increase in activity of biotinidase in the cerebrospinal fluid (CSF) during the course of acute Staphylococcus aureus meningitis in a subject with subacute sclerosing panencephalitis (SSPE) is reported. A possible role of CSF biotinidase in the hydrolysis of specific opioid neuropeptides during acute inflammatory processes involving the CSF-central nervous system compartment is suggested.

Staphylococcal meningitis following Synchromed intrathecal pump implant: a case report

Staphylococcal meningitis associated with implantation of an intrathecal drug pump for spasticity was successfully treated by intrathecal vancomycin delivered by the same pump. This produced high CSF antibiotic levels, and the pump and catheter system did not have to be removed. We are unable to identify a similar case reported in the literature to date.

Postoperative cauda syndrome caused by Staphylococcus aureus

Toxic shock syndrome (TSS) is a well-defined clinical syndrome attributed to certain exotoxins produced by Staphylococcus aureus. The acute episode is often characterized by a toxic encephalopathy, possibly caused by direct neurotoxicity of these exotoxins, although this mechanism has never been proven. We describe a patient who developed TSS, meningitis and cauda equina syndrome simultaneously several days after lumbar laminectomy. A space-occupying lesion was excluded. Enterotoxin C-producing S. aureus was cultured from the surgical wound and the cerebrospinal fluid (CSF). The patient recovered from TSS but remained partially paralyzed. Presumably the cauda equina syndrome was caused by neurotoxic effects of the intrathecally produced S. aureus exotoxins. This case provides evidence for the neurotoxic effects of TSS-associated S. aureus exotoxins.

[Transferability of vancomycin to cerebrospinal fluid in rabbits with meningitis caused by Staphylococcus aureus]

The transferability of vancomycin (VCM) to cerebrospinal fluid (CSF) was studied employing rabbits with experimental meningitis caused by Staphylococcus aureus. VCM was administered intravenously for 30 minutes at a dose level of 30 mg/kg. Serum concentration reached a maximum of 75 +/- 3.80 micrograms/ml (mean +/- S.E.) at the completion of administration (i.e., 30 minutes) and CSF concentration reached a maximum of 2.4 +/- 0.39 micrograms/ml at 60 minutes. Pharmacokinetic parameters calculated from this concentration-time curve were as follows: Cmax (CSF/Serum) 3.21%, AUC (CSF/Serum) 2.39% between 15 and 60 minutes, 3.99% between 15 and 120 minutes, and 4.40% between 15 and 150 minutes. T 1/2 for VCM in CSF: 143 minutes, T1/2 (CSF/Serum):2.09. Based on this investigation, VCM appears to be effective in the treatment of meningitis caused by MRSA (Methicillin-resistant S. aureus).

The changing spectrum of neonatal meningitis over a fifteen-year period

One hundred seventy-seven cases of neonatal meningitis treated at the University of Texas Medical Branch at Galveston over a 15-year period (1974-1988) were reviewed. Over this period, the incidence of bacterial meningitis decreased, the incidence of aseptic meningitis remained stable, and the diagnosis of enteroviral meningitis increased in frequency. During 1984-1988, enterovirus was the most common cause of meningitis in neonates older than seven days and accounted for one third of all cases of neonatal meningitis. Half of all neonates with bacterial meningitis had negative blood cultures. We recommend that 1) diagnostic lumbar puncture remain part of the routine assessment of the neonate with suspected sepsis, and 2) CSF be cultured for enterovirus as well as for bacteria when a neonate older than seven days presents with suspected sepsis.

Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts

To determine the significance of cerebrospinal fluid (CSF) eosinophilia, the charts of 106 patients treated with shunt-related procedures during the calendar year 1985 were reviewed. Sixty-nine patients presented for a shunt revision; their charts were retrospectively reviewed from the time of shunt insertion until January, 1988. The remaining 37 patients had a ventriculoperitoneal shunt inserted during the study period and were subsequently followed to January, 1988. A total of 558 shunt-related procedures were performed on these patients during the study period, with a mean follow-up period of 6.9 years. The infection rate was 3.8%. Eosinophilia was diagnosed when eosinophils accounted for 8% or more of the total CSF white blood cell count. Ventricular CSF eosinophilia occurred in 36 patients sometime during their clinical course. These 36 patients required a mean of 8.5 shunt revisions, while the remaining patients required a mean of 2.5 revisions (p less than 0.001). Shunt infections were also more frequent in patients with eosinophilia (p less than 0.01). In no case was peripheral eosinophilia or a parasitic infection present. This study demonstrates that CSF eosinophilia is common in children with shunts. Children with this laboratory finding will experience more shunt failures. In addition, the new appearance of eosinophilia in the CSF of a patient with a shunt in place suggests the possibility of a shunt infection.

[The diagnostic importance of studying metals in the cerebrovascular fluid of patients with bacterial meningoencephalitis]

The author studied the quantitative content of metals in the cerebrospinal fluid of 80 patients depending on the terms and severity of bacterial meningoencephalitis. It was established that examination of the concentration of macro- and microelements in the cerebrospinal fluid reflects the state of mineral homeostasis and may be an objective test in the diagnosis of the disease.

Diagnostic value of lactate dehydrogenase isoenzymes in cerebrospinal fluid

To evaluate the diagnostic value of lactate dehydrogenase (LD) isoenzymes in cerebrospinal fluid (CSF), 93 consecutive CSF specimens were analyzed. These specimens were from patients of four categories: tumors, infections, hemorrhages, and others. It was found that the isoenzyme patterns overlapped among different categories, but they differed within each category and were thus helpful in differential diagnosis. For instance, metastatic tumors showed prominent LD-5, whereas a primary brain tumor demonstrated an increase in all fractions. Viral encephalitis revealed an increase in the first three isoenzymes and bacterial meningitis, the last two. In acquired immune deficiency syndrome (AIDS) cases, however, LD isoenzyme changes were demonstrated in CSF when only cryptococcal meningitis and not when encephalitis was present. Both subdural and subarachnoid hemorrhages showed elevation of all fractions in our study. Elevation of the first three fractions was usually due to brain tissue damage or hemorrhage, as proven by our isoenzyme study of hemolysate mixed with CSF. The prominence of the last two fractions was related to anaerobic metabolism in the central nervous system or to granulocytic infiltration. In conclusion, LD isoenzyme analysis in CSF is helpful in differential diagnosis of various CNS disorders, although its sensitivity awaits further improvement.

Pyogenic meningitis

Fifty cases with pyogenic meningitis, aged 15 to 72 years, with a male:female ratio of 5:1, were studied. The majority of cases (70%) were in the 15 to 25 years age group. The organisms detected in the 29 culture-positive cases included S aureus (12), pneumococci (9) and meningococci (8). Thirteen patients died; the poor prognostic factors included old age, the presence of coma or shock, CSF sugar below 10 mg/dl or protein above 750 mg/dl and the presence of gram negative organisms in the CSF.

Influence of mannitol on the penetration of teicoplanin into infected CSF of experimental Staphylococcus aureus meningitis of rabbits

We investigated the influence to mannitol injections on the teicoplanin penetration into CSF in experimental bacterial meningitis of rabbits. Experimental bacterial meningitis was obtained by intracisternal inoculation of 10(7) cfu of methicillin resistant Staphylococcus aureus. The experimental bacterial meningitis was controlled 18 h later by cisternal puncture. At this time (T0) mannitol (solution for injection 20%) was injected (bolus), at a dosage of 3 ml/kg, into the carotid arteria. Immediately after the previous bolus, teicoplanin was administered through the same line over 5 min, at a dosage of 5 mg/kg. Cerebrospinal fluid was obtained 30 min and 2 h after injection was completed, and serum samples were obtained at the same time. Results were (mg/l) in cerebrospinal fluid: (Table; see text) (* p less than 0.05 comparing the two regimens at T0 + 2 h, and comparing regimen teicoplanin + mannitol infusion at T0 + 30 sec and + 2 h). This is very promising for the treatment of methicillin resistant Staphylococcus aureus bacterial meningitits and should support further investigations.