|Year : 2008 | Volume
| Issue : 2 | Page : 131-133
Pattern and antibiotic susceptibility of bacteria isolated in clinically suspected cases of meningitis in children
Alka E Sonavane, VP Baradkar, M Mathur
Department of Microbiology, L.T.M.M.C and L.T.M.G.H, Sion, Mumbai-400 022, Maharashtra, India
Alka E Sonavane
Department of Microbiology, L.T.M.M.C and L.T.M.G.H, Sion, Mumbai-400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Out of 2000 clinically suspected cases of bacterial meningitis in children admitted between February 2005 and February 2008, bacteria were isolated in 34 (1.7%) cases. Streptococcus pneumoniae was the commonest isolate (12 cases) followed by Acinetobacter sp. (four cases), Escherichia coli, Enterobacter sp., and Enterococcus sp. (three each). Pseudomonas aeruginosa, Group B Salmonella and Hemophilus influenzae were isolated from one case each. Sphingomonas sp. has emerged as newer pathogen. Multidrug resistance was observed in Acinetobacter sp., E. coli, Enterobacter sp., and methicillin resistant Staphylococcus aerues. Five deaths occurred due to multidrug resistant strains.
Keywords: Bacterial meningitis, children, multidrug resistance
|How to cite this article:|
Sonavane AE, Baradkar V P, Mathur M. Pattern and antibiotic susceptibility of bacteria isolated in clinically suspected cases of meningitis in children. J Pediatr Neurosci 2008;3:131-3
| Introduction|| |
Acute bacterial meningitis is one of the most severe diseases of childhood. The global burden of the disease is high. Apart from epidemics, at least 1.2 million cases of meningitis are estimated every year with 1,35,000 deaths. Clinical signs and symptoms of bacterial meningitis vary in pediatrics age group. Most common signs and symptoms of bacterial meningitis in children are lethargy, bulging fontanel, neck stiffness, fever, vomiting, convulsions, unconsciousness, irritability, and Brudzinki's sign. , Though the clinical presentation may give clue to diagnosis cerebrospinal fluid (CSF) culture is gold standard for diagnosis of bacterial meningitis. The percentage of culture proven cases among the children admitted in emergency room ranges 2.43-3.5%. ,, Various bacteria have been isolated from cases of bacterial meningitis in children. These include Streptococcus pneumoniae , Neisseria More Details meningitidis, Hemophilus influenzae , Escherichia More Details coli , Klebsiella pneumoniae , Staphylococcus aureus , Streptococcus pyogens , Stereptococcus agalactiae , Salmonella More Details sp. , Pseudomonas aeruginosa , Enterobacter sp., Acinetobacter sp., other Gram negative bacilli , and Listeria monocytogens. ,,,,, The isolates vary from one study to another. ,,,,, The overall fatality rate and antibiotic susceptibility pattern of the bacterial isolates also differ. ,,,,, Though majority of the cases of bacterial meningitis admitted to a tertiary care hospital are amenable to treat; as mortality differs, the antibiotic susceptibility pattern of the isolates give a clue to the clinicians in the management of cases.
Considering all these facts a retrospective analysis of clinically suspected cases of bacterial meningitis from pediatric age group was carried out to find out isolation rate, presenting signs and symptoms and the bacterial isolates along with their antibiotic susceptibility pattern among the children admitted to our tertiary care hospital.
| Materials and Methods|| |
The study was carried out in the Department of Microbiology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai. This hospital is a tertiary care hospital located in the hearts of the city. Medical records of 2000 children with clinically suspected cases of bacterial meningitis admitted between February 2005 and February 2008 were enrolled in this study. Their medical records were reviewed to find out signs and symptoms. CSF samples were collected under aseptic precautions. The samples were processed for cell counts, Grams staining, culture on blood agar (BA), chocolate agar (CA), and MacConkey agar (MA). The culture plates were incubated at 37°C with 5-10% CO 2 in Candle Jar and with 60-70% humidity for 24-48 hours. All the bacterial isolates were identified by standard laboratory techniques.  Antibiotic susceptibility was performed by Kirby-Bauer disc diffusion method. Susceptibility pattern of all the isolates was studied.
| Results|| |
Out of 2000 clinically suspected cases of bacterial meningitis admitted over a span of 2 years, diagnosis of bacterial meningitis was confirmed by culture in 34 (1.7%) cases. The co-relation between Grams staining and culture was 100%. In all the cases in which bacteria were isolated, CSF cell counts were raised with predominance of neutrophils, CSF proteins were raised.
The commonest manifestations were fever (100%), vomiting (90%), convulsions (75%), neck stiffness (75%), bulging fontanel (50%) while lethargy and irritability were present in 10% cases each. Septicemic signs were present in four cases which were due to multidrug resistant (MDR) E. coli , Acinetobacter sp. , Enterobacter sp., and the patients expired. Space occupying lesion in the form of brain abscess was present in a single case from which methicillin resistant Staphylococcus aureus (MRSA) was isolated The patient presented with fever, convulsions, and expired on the same day of admission. One more patient expired due to Sphingomonas sp.. Rest all patients responded to antibacterial therapy.
Out of 34 culture proven cases of bacterial meningitis 10 (50%) patients were in the age group £12 months. Five cases (25%) were between age group of 1 and 12 years. Rest all patients were between 6 and 12 years of age. All the expired patients were below 1 year. All the expired patients succumbed to death before isolation and antibiotic susceptibility reports were available. The antibiotic susceptibility pattern of the isolates is shown in [Table 1] and [Table 2].
| Discussion|| |
Out of 2000 clinically suspected cases of bacterial meningitis in children, confirmation by culture was obtained in 34 (1.74%) cases. Low bacterial isolation rates were reported in two large studies varying between 2.43% and 3.5%. ,,
Bacterial meningitis is one of the imported causes of morbidity and mortality in pediatric age group. Though culture is the gold standard in the diagnosis, it takes at least 48 hours. A combination model of history of convulsions or being lethargic or unconsciousness, or having neck stiffness is used in World Health Organization (WHO) Integrated Management of childhood Illness (IMCI) has found to be 98% sensitive and 72% specific to predict meningitis.  In the present study history of the patients showed neck stiffness, convulsions in 75% cases while fever (100%), vomiting (90%), and bulging fontanel (50%) were commonest manifestations. Neck stiffness was reported more frequently in children than infants and more frequent in bacterial than viral meningitis.  Convulsions were more commonly reported in our study, which were also recorded frequently in studies from Thailand and Malaysia.  Bulging fontanel can be seen only as long as it is open during first year of life. It has been found previously to be associated more commonly with bacterial than aseptic meningitis. A study from Finland by Valmari et al,  showed that apart from fever (94%), the most common symptoms were irritability (85%), impaired consciousness (70%), vomiting (98.2%), and neck rigidity (78%). They observed that meningitis should be suspected in irritable or lethargic febrile children despite of neck rigidity. Fever and vomiting were the most common reasons for consulting a physician 60% and 31%, respectively. Despite the frequency and alarming character of irritability, impaired consciousness and neck rigidity, their presence led infrequently to consultation (61%, 22%, and 3%, respectively). Parental ignorance of such symptoms may cause treatment delay.
Chotpitayasunodh  in his 11 years review of 618 cases of bacterial meningitis in children showed that the presenting signs and symptoms of meningitis were fever (81.8%), convulsions (45.4%), neck stiffness (22.55), bulging fontanel (33.3%), and they were significantly less than in patients beyond neonatal period.
All the deaths reported by Geisler et al,  in their review of 1316 cases during 1954-1974, occurred within 48 hours of admission as observed in the present study.
Though S. pneumoniae (12 isolates) was the commonest isolate in our study, a variety of other Gram positive and Gram negative bacilli were isolated. These included S. pyogenes (1), Enterococcus sp. (3), MRSA (2), while Gram negative isolates were E. coli (3), Enterobacter sp. (3), Group B Salmonella (1), K. pneumoniae (2), Acinetobacter sp. (4), H. influenzae (1), P. aeruginosa (1), and Sphingomonas sp. (1). Though isolation rate observed in this study was low, all variety of Gram positive and Gram negative pathogens were isolated from CSF. Neisseria meningitidis More Details was not isolated in our study. Akpede et al,  while studying pattern and antibiotic susceptibility of bacteria in cases of pyogenic meningitis in children from Nigeria during a span of 1988-1992 showed that S. pnemoniae , N. meningitides , and H. influenzae together were responsible for 77.3% of the isolates, while 13.4% were Enterobacteriaceae members, 5% isolates were S. auerus , and 4% were untyped alpha hemolytic Streptococci . A study from Gambia  reported H. influenzae (20), N. meningitidis (1), S. pneumoniae (20), Salmonella sp. (2), E. coli (2), and Acromobacter sp. (1). Molyneux et al,  observed commonest isolate as S. pnemoniae (27%) followed by H. influenzae (21%), Salmonella typhimurium (6%), S. agalactiae (23%), and Gram negative bacteria were present in 11.5% cases. In our study also S. pnemoniae was the commonest isolate. We have reported many Gram negative bacteria as important pathogens . P. aeruginosa , Enterobacter sp., Acinetobacte r sp., and K. pneumoniae are emerging pathogens. These are reported by Chotpitayasunodh.  The pathogens reported in neonatal meningitis that study were P. aeruginosa (16.9%), K. pnemoniae (13%), Group B Streptococci (11.7%), E. coli (10.4), Enterobacter sp. (10.4%), while in childhood meningitis H. influenzae was the commonest isolate (42.3%) followed by S. pnemoniae (22.2%) and Salmonella sp. (12.4%). Nalmiri et al,  also reported H. influenzae , N. meningitidis , S. pneumoniae as predominant isolates. Thus, the bacteria which we have isolated in our study are also reported in all other studies stated above except one isolate, i.e. Sphingomonas sp., which is for the first time reported as a pathogen and the patient expired on the day of admission.
Among the Gram positive cocci isolated S. pnemoniae showed 100% susceptibility to penicillin, cefotaxime, cefuroxime, and vancomycin while it showed 50% susceptibility to augmentin and amikacin and 33.33% to ciprofloxacin. All three isolates of Enterococcus sp. were sensitive to vancomycin, two were sensitive to penicillin and cefuroxime while only one isolate was sensitive to augmentin (33%). Both isolates of MRSA were 100% sensitive to vancomycin and linezolid; 50% were sensitive to amikacin and netlimicin. These MRSA isolates were resistant to ciprofloxacin, cefuroxime, and cefotaxime. Among the Gram negative bacteria , two isolates of Acinetbacter sp. were MDR. Two were resistant to higher antibiotic like imipenem. Similarly in Enterobacter sp. and E. coli , one isolate each were MDR and showed resistance to imipenem. Though MDR Gram negative bacteria have not been reported earlier from pediatric cases of bacterial meningitis, this is a significant finding observed in our study. Group B Salmonella and H. influenzae showed good susceptibility to antibiotics used. The newly emerged pathogen, i.e. Sphingomonas sp. was only susceptible to combination of piperacillin and tazobactum.
In conclusion, the present study shows that fever, vomiting, and bulging fontanel were predominant clinical presentation in pediatric age group. There is slightly change of shift of pathogens as S. pneumoniae was the commonest isolate; Gram negative bacilli like P. aeruginosa, Acinetobacter sp., and Enterobacter sp. are emerging pathogens, some of which were MDR strains. Even MDR MRSA was isolated from a fatal case.
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[Table 1], [Table 2]