Epidemiology of Haemophilus influenzae type b, Neisseria meningitidis, and Streptococcus pneumoniae in children in the Valencia Community, Spain. Acute diseases study group

OBJECTIVE: To asses the incidence of Haemophilus influenzae type b (Hib), Neisseria meningitidis and Streptococcus pneumoniae meningitis in children of de Valencian Community (VC), Spain, and to describe the microbiologic characteristics. MATERIAL AND METHODS: Prospective surveillance system with paediatrician and microbiologist participation of all public hospitals of the VC. Cases are children less than 15 with clinical meningitis and with isolation of Hib, N. meningitidis or S. pneumoniae from CSF of blood. RESULTS: From 1st December 1995 to 30th November 1996, 51 cases were declared, 33.3% were Hib, 49.0% N. meningitidis and 17.7% S. pneumoniae. The annual incidence of meningitis was 7.6 cases/100,000 < 15 years, 20.5/100,000 < 5 years and 56.2/100,000 < 1 year. 84.3% of the cases occurred in children younger than 5. S. pneumoniae had the highest mortality. CONCLUSIONS: Hib is a frequent cause of meningitis in spite of that one third of children are vaccinated. 43% of the N. meningitidis isolated in meningitis are serogroup C. S. pneumoniae meningitis are more frequent in children less than one, and has a high mortality rate.     

Bacterial meningitis in the United States in 1995. Active Surveillance Team

BACKGROUND: Before the introduction of the conjugate vaccines, Haemophilus influenzae type b was the major cause of bacterial meningitis in the United States, and meningitis was primarily a disease of infants and young children. We describe the epidemiologic features of bacterial meningitis five years after the H. influenzae type b conjugate vaccines were licensed for routine immunization of infants. METHODS: Data were collected from active, population-based surveillance for culture-confirmed meningitis and other invasive bacterial disease during 1995 in laboratories serving all the acute care hospitals in 22 counties of four states (total population, more than 10 million). The rates were compared with those for 1986 obtained by similar surveillance. RESULTS: On the basis of 248 cases of bacterial meningitis in the surveillance areas, the rates of meningitis (per 100,000) for the major pathogens in 1995 were Streptococcus pneumoniae, 1.1; Neisseria meningitidis, 0.6; group B streptococcus, 0.3; Listeria monocytogenes, 0.2; and H. influenzae, 0.2. Group B streptococcus was the predominant pathogen among newborns, N. meningitidis among children 2 to 18 years old, and S. pneumoniae among adults. Pneumococcal meningitis had the highest case fatality rate (21 percent) and in 36 percent of cases was caused by organisms that were not susceptible to penicillin. From these data, we estimate that 5755 cases of bacterial meningitis were caused by these five pathogens in the United States in 1995, as compared with 12,920 cases in 1986, a reduction of 55 percent. The median age of persons with bacterial meningitis increased greatly, from 15 months in 1986 to 25 years in 1995, largely as a result of a 94 percent reduction in the number of cases of H. influenzae meningitis. CONCLUSIONS: Because of the vaccine-related decline in meningitis due to H. influenzae type b, bacterial meningitis in the United States is now a disease predominantly of adults rather than of infants and young children.     

Pitfalls of hyperfractionation: theoretical considerations of effect of repair time on late radiation damage]

We conducted a 3-year Taiwan-wide hospital-based survey of invasive Haemophilus influenzae infections in children less than 15 years of age. From January 1992 to December 1994, 105 cases (57 boys, 48 girls) were reported. Seventy-three patients (69.5%) had meningitis and 32 patients had other diseases (12 pneumonia, 10 sepsis, 7 cellulitis, 3 arthritis). Fourteen patients (13%) died, all of whom had meningitis or sepsis. Among the 63 patients who survived meningitis, 17 (27%) had neurologic sequelae and eight (47%) had hearing impairment. The number of cases of H. influenzae meningitis (30%) and other H. influenzae diseases (29%) peaked in children between 6 and 12 months of age. Patients with invasive infections (82%) and meningitis (73%) were younger than 24 months of age. Only 12 patients (11%) were older than 5 years of age and four had underlying diseases. The annual incidence of invasive H. influenzae infections in children less than 5 years old was 1.9 per 100,000 per year. During the same period a survey of purulent meningitis in children younger than 15 years of age was also conducted in 20 hospitals. A total of 198 patients, in whom the causative organisms were identified, were included; 94 patients were 2 months of age or under and the most frequent pathogen was group B streptococci (35 cases, 37%). Among the 104 patients who were older than 2 months of age, H. influenzae was the leading cause (38 cases, 37%). In conclusion, invasive H. influenzae type b (Hib) diseases exist in Taiwan but have an incidence lower than in Western countries. Hib meningitis is still the most common cause of purulent meningitis in children in Taiwan and is an important cause of mortality and morbidity. Continuous active surveillance of invasive H. influenzae infections is suggested to determine the best time to introduce an Hib conjugate vaccine in Taiwan.     

Bacterial meningitis in the health sector of Virgen del Rocio, Spain

BACKGROUND: The aim of this study was review the epidemiology of the bacterial meningitis in our area. MATERIAL AND METHODS: A retrospective study was carried out of all the cases of bacterial meningitis in children with ages between two months and fourteen years, admitted in our hospital between 1986 and 1997. The following variables we analyzed: Sex, age of the patient, yearly and monthly incidence, previous antibiotic therapy, length of hospital stay, and analytical data of blood and cerebrospinal fluid. RESULTS: In the 755 cases analyzed, the 50% correspond to bacterial meningitis, the 47.6% to viral or aseptic and 2.3% to tuberculous. In of the bacterial meningitis Neisseria meningitidis was isolated in 55.7% of cases, Haemophilus influenzae in 20.4%, Streptococcus pneumoniae in 5.5%, other bacterias in 3.4%, and in 14.5% was not isolated any bacteria. We are assisting to an increase of Neisseria meningitidis serotype C during the last years. Haemophilus influenzae represents a more percentage of bacterial meningitis that in prior years. In meningitis by Streptococcus pneumoniae we observe a clear association with risk factors in children older than 2 years. CONCLUSION: Neisseria meningitidis is the main etiologic agent in children. The vaccination against Haemophilus influenzae serotype b and Neisseria meningitidis A and C can change the epidemiology in next years.     

The relationship between fatty liver and hyperinsulinemia in obese Japanese children

During 1994, 603 cases of bacterial meningitis were reported in Italy. Seventy-five percent of cases with determined etiology was due to three agents: Neisseria meningitidis (33.4%), Streptococcus pneumoniae (23.4%) and Haemophilus influenzae (18.6%). The majority of cases due to N. meningitidis and H. influenzae occurred in subjects below five years of age (35.7% and 84.8%, respectively) while S. pneumoniae accounted for 52.8% of meningitis cases in subjects older than 44 year of age. The estimated incidence of N. meningitidis on the national population in 1994 was 0.27 per 100,000. Serogroup B accounted for 62.5% of the serotyped isolates, group C for 23.1%, group A for 7.2%, group W135 for 3.6%, group Y for 1.8%. All tested meningococcal strains were susceptible to penicillin as well as to rifampin. Incidence of meningococcal meningitis in 1994 has been low suggesting that its relative importance compared to other bacteria causing meningitis is likely to change in the future. Therefore, extended surveillance on bacterial meningitis by other etiological agents has to be maintained and implemented in order to undertake the appropriate control measures and evaluate their effect.     

Bacterial meningitis in a rural Kenyan hospital

In a prospective study to investigate mortality and antibiotic resistance in meningitis patients, thirty two meningitis cases were seen over a three month period. Mean age was 11.3 years (range one month-60 years). Cerebrospinal fluid cultures were positive in 26 patients (81.3%). S.pneumoniae was responsible for 15 cases (46.9%), followed by H.influenzae in seven (21.9%). Salmonella infection was seen in two patients, and E.coli and N.meningitidis in one each. Twelve patients (37.5%) died during hospitalisation with most of the deaths occurring within 48 hours after admission. No patients presented with atypical signs of meningitis. No significant differences were found between delay and outcome. Malaria parasites were found in blood of thirteen patients (41%), but did not contribute to higher mortality. Three of H.influenzae isolates (42.9%) were resistant to ampicillin and penicillin. Reduced sensitivity to penicillin was found in two (13.3%) of S.pneumoniae isolates.     

Inhibition of peripheral blood mononuclear cell proliferation by cardiac glycosides

We prospectively studied the epidemiologic, clinic signs and outcome of bacterial meningitis in 125 children who were admitted into a PICU (Pediatric Intensive Care Unit) of 11 hospitals of Spain and whose meningitis was diagnosed between May 1994 and April 1995. RESULTS: The median age of the children was 3.55 +/- 3.32 years (range 1 month to 16.5 yrs). Eighty-eight were bacterial meningitis, probably bacterial 30 and aseptic 7. The most frequently isolated organisms were N. meningitidis (52), H. influenza type b (17) and S. pneumoniae (8). Twenty-five percent of N. meningitidis had C serotype. Incidence rate of each germen was depending of age. All patients diagnosed of H. influenza type b meningitis were less than 3 years old. H. influenza type b and meningococcus had similar incidence rate during the first year of life (27% versus 31%). During the first three years of life H. influenza type b produced one third of bacterial meningitis. A mortality rate of 5.6% (seven patients: 3 S. pneumoniae, 1 N. meningitidis, 1 H. influenza type b and 2 unknown germen) was observed. Patients who die had lower Glasgow coma score (p = 0.034) and seizures (p = 0.001) at admission. At discharge of PICU, 9 survivors (7.2%) had sequelae: mental retardation in 7 patients and hearing loss in two. One third of patients needed hemodynamic support and a 15% of them ventilatory support. CONCLUSIONS: Age is an important epidemiological factor in the etiology of pediatric acute meningitis. H. influenza type b and N. meningitidis had similar incidence rate during the first year of life. S. pneumoniae had the highest mortality rate (37.5%). The presence of coma and seizures at admission were associated with mortality.     

Pediatric meningitis in the Western Cape Province of South Africa

During the 9 years 1985-1993 a prospective survey of all cases of meningitis in children < 13 years of age presenting to our hospital in the Western Cape Province of South Africa was carried out. Two-thousand-nine-hundred-and-twenty cases of meningitis were identified. The commonest form of bacterial meningitis was tuberculous meningitis (TBM) diagnosed in 282 children (mean age 2.94 years). N. meningitidis identified in 220 children (mean age 2.87 years), Haemophilus influenzae in 156 children (mean age 1.15 years) and S. pneumoniae in 106 children (mean age 2.14) were the next commonest causes of bacterial meningitis diagnosed. One-hundred-and-eighteen cases of bacterial meningitis were confirmed in infants < 1 month of age and the commonest bacteria identified were group B beta-haemolytic Streptococcus in 27, E. coli in 21, Klebsiella species in 11, and Candida species in 15 neonates. The emergence of TBM as the predominant cause of bacterial meningitis in childhood at our hospital is probably a reflection of the worsening tuberculosis situation in the Western Cape Province of South Africa.     

Prospective study of bacterial meningitis in North East Thames region, 1991-3, during introduction of Haemophilus influenzae vaccine

OBJECTIVE: To describe the epidemiology of primary bacterial meningitis in the North East Thames region over a three year period before and during the introduction of the vaccine for Haemophilus influenzae type b. DESIGN: Analysis of information on cases of primary bacterial meningitis identified by microbiology laboratories in the region, with collection of case data by questionnaire. MAIN OUTCOME MEASURES: Annual incidence rates for types of meningitis according to age and ethnic group. RESULTS: The annual incidence rates for the three major causes of bacterial meningitis in the general population were 1.9/100,000 for Neisseria meningitidis, 1.6/100,000 for Haemophilus influenzae before vaccination, and 1.0/100,000 for Streptococcus pneumoniae. Higher rates of H influenzae meningitis were found in Asians compared with white people (3.6/100,000 v 1.5/100,000, P = 0.01). As a result of the vaccine programme introduced in October 1992 the number of cases of H influenzae meningitis in children under 5 years has fallen by 87%. CONCLUSIONS: Bacterial meningitis is a serious problem especially in preschool children. There are differences in the incidence of some causes of bacterial meningitis in different ethnic groups; with H influenzae type b being significantly more common among black and Asian people than among white people. The immunisation programme for H influenzae type b in the North East Thames region has been successful in reducing the incidence of this type of meningitis in Asian and white populations. The numbers were too small to evaluate in the black population.     

Bacterial meningitis in southwestern Alaska

Between July 1, 1971, and June 30, 1974, thirty-nine cases of bacterial meningitis were diagnosed at the Alaska Native Health Service Hospital at Bethel, Alaska. Thirty-two (82%) occurred in infants less than one year of age. Haemophilus influenzae (H. influenzae) was the predominant causative agent, and was isolated from 23 (72%) of the 32 patients under one year of age. The annual incidence of H. influenzae meningitis in the Bethel area was 63/100,000, and the annual incidence of H. influenzae meningitis in children less than five years of age was 474/100,000 cases.     

Henryk Jordan (1842-1907)--a dedicated Krakow physician, health promotor and welfare worker]

We present 2 cases of Haemophilus influenzae meningitis. The first is a patient with atypical simptomatology: abdominal pain, fever and two days later pain in the back of his legs. Abdominal pathology was not found. The cerebrospinal fluid (CSF) showed polymorphonuclear cells, hyperproteinorachia and lowered glucose. CSF culture revealed Haemophilus influenzae, blood culture was sterile. The second had suffered surgery at maxilar and ethmoid sinuses four years before, and unknown germ meningitis 6 months before. Haemophilus influenzae was isolated from CSF cultures and CSF rhinorrhea was detected by isotopic cisternography.     

Meningococcal disease: recognition, treatment, and prevention

Meningococcal disease is an infection caused by Neisseria meningitidis, a gram-negative diplococcus that is the leading cause of bacterial meningitis in children and young adults in the United States, with an estimated 2,600 cases reported each year. N. meningitidis infection rates are highest in children 3 to 12 months of age. Four distinct clinical situations are associated with meningococcal infection. The most common is asymptomatic nasopharyngeal colonization. Benign bacteremia is discovered in the absence of classical clinical findings of meningococcemia, but blood cultures are positive for N. meningitidis. Meningitis, the most common pathologic presentation, is associated with fever, headache, and nuchal rigidity. The mortality rate is about 5% in children and 10% to 15% in adults. Meningococcemia, the most severe form of infection, may involve petechial rash, hypotension, and disseminated intravascular coagulation. It is a fulminant condition that can, if untreated, progress from initial symptoms to coma and death in 12 to 48 hours. Spread of these endemic cases can be controlled by administering prophylactic antibiotics to close contacts of patients.     

Where''s the cash?

This study was done to analyze the epidemiology of invasive Haemophilus influenzae disease in Bochum city area. Forty-eight children with invasive Haemophilus influenzae infections were treated at the University Children's Hospital in Bochum during the study period from January 1971 to June 1992. Clinical manifestations included meningitis (n = 34), epiglottitis (n = 8), pneumonia (n = 2), bacteremia (n = 2), cellulitis (n = 1) and osteomyelitis (n = 1). The overall yearly incidence rate for all invasive Haemophilus influenzae infections was 13 per 100,000 children younger than five years of age, with a marked increase in the last six years. Haemophilus influenzae meningitis showed no significant change during the study period with an overall yearly incidence of 9 per 100,000 children younger than five years. Twenty-eight cases (58%) of all invasive Haemophilus influenzae infections occurred in patients under two years of age and five cases (10%) were younger than six months. Invasive Haemophilus influenzae disease showed no seasonal prevalence. All isolates were susceptible to ampicillin. No deaths occurred, but severe bilateral deafness resulted in one patient with meningitis. Prospective epidemiologic studies are needed to estimate clinical efficacy of the Haemophilus influenzae type b immunization program in Germany.     

Central venous access: low internal jugular vein approach using imaging guidance

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniae and Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.     

Dexamethasone therapy for bacterial meningitis in children: 2- versus 4-day regimen

Four-day dexamethasone therapy has been used to treat bacterial meningitis. This prospective, randomized study compared the effect of a 2-day versus a 4-day regimen. Children (n = 118, ages 2.5 months to 15 years) were evaluated; 50% of the cases were due to Neisseria meningitidis and 40% to Haemophilus influenzae type b. Patients were treated intravenously (iv) mainly with conventional antimicrobial therapy and were randomly assigned to receive dexamethasone, 0.15 mg/kg iv every 6 h for 2 or 4 days. The clinical response was similar for both dexamethasone regimens. The meningococcal meningitis patients survived without neurologic or audiologic sequelae. On long-term follow-up, neurologic sequelae or moderate or more severe unilateral or bilateral hearing impairment (or both) were found in 1.8% and 3.8% of patients treated with dexamethasone for 2 and 4 days, respectively. The 2-day regimen appears appropriate for the treatment of H. influenzae and meningococcal meningitis.     

Trend of bacterial meningitis in children over a 14 year period (1981 through 1994) in Japan--an analysis based on studies in 27 institutions]

We observed 266 children with purulent meningitis in 27 institutions in Japan during the 14 years from 1981 on dividing these years into 3 periods, 1981-1985, 1986-1990 and 1991-1994, and studied the trend of causative organisms identified in 254 among the 266 patients. Their ages were less than 3 months after birth in 50 children and 3 months or older in 216: there were 141 boys and 125 girls. The causative organisms were H. influenzae in 134 patients and S. pneumoniae in 50, most of them being aged 3 months or older. Next to the above bacteria ranked S. agalactiae in 29 and E. coli in 12, many of the patients were aged less than 3 months. Staphylococcus spp. was found in 7 patients and about 70% of them were aged 3 months or older. L. monocytogenes was found in 4 patients and N. meningitidis in 3 and they were aged 3 months or older in both patient groups. S. pyogenes, Enterococcus spp., Peptostreptococcus spp., P. Mirabilis and Enterobacter spp. were detected each in 1 patient. The causative organism was unknown in 21 patients and there was no double infection. H. influenzae were detected in 18 patients in 1981-1985 period (36.7%), in 56 in 1986-1990 (54.9%) and in 60 in 1991-1994 (63.8%) showing an increasing tendency, but S. pneumoniae exhibited neither an increasing nor decreasing tendency. There was a decreasing tendency with S. agalactiae and E. coli, but the details were not clear because there were few patients aged less than 3 months. Although the period of coexistence of 4 main bacterial species was not made clear in this study. Listeria is considered to develop mainly in the early childhood, and we believe that the conventional way of using a cephem preparation and ampicillin combined for patients under 6 years need not be altered. However, panipenem (phonetic) is likely to be effective for insensible S. pneumoniae for the time being.     

Outbreak of meningococcal disease in a family

An outbreak of three cases of meningococcal disease occurring in a family of 14 is presented. Three of the children, between the ages of 10 months to 10 years, were hospitalized. Two of them showed positive signs of meningitis, and one had evidence of bacteremia. Neisseria meningitidis was isolated from a blood sample of one patient and a CSF sample of another. The organism was also recovered from the nasopharyngeal secretion of four other adult members of the family. All three hospitalized children were treated with parenteral penicillin and responded well to therapy. The rest of the family was treated with oral rifampin, and subsequent cultures of the nasopharynx were negative.     

Systemic Haemophilus influenzae infection in childhood

Forty-nine children who had systemic Haemophilus infection and were treated at the Westmead Centre, Sydney, over a two-year period are described. The majority (29 of 49 children) were aged two years or less. Epiglottis and meningitis accounted for 77% of these infections. All H. influenzae isolates associated with clinical disease were of the capsular type b. Eight per cent (four of 50) of H. influenzae infections were caused by beta-lactamase producing strains. There was no geographic clustering or seasonal variation. There was no mortality. Major morbidity included two patients who had epiglottis and required tracheostomy, and two patients who had meningitis developed bilateral profound sensorineural deafness. No secondary cases were detected in household contacts of 21 patients with H. influenzae meningitis during the study period. Epiglottis frequently occurs in very young children. The rapid response to antibiotic treatment suggests that early cases of epiglottis may be undiagnosed, but treated with antibiotic agents in the community.     

Pattern and antibiotic susceptibility of bacteria in pyogenic meningitis in a children's emergency room population in Maiduguri, Nigeria, 1988-1992

From January 1988 to November 1992, 107 (3.5%) of 3074 postneonatal children admitted to the Children's Emergency Room, University of Maiduguri Teaching Hospital, Nigeria, had sporadic pyogenic meningitis; 66 (61.7%) were aged < or = 12 months. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae together were responsible for 77.3% (58) of 75 culture-proven cases, 13.4% (10) had Enterobacteriaceae, 5.3% (4) had Staphylococcus aureus and 4% (3) untyped alpha-haemolytic streptococci. Fifty percent of 62 bacteria were resistant to ampicillin, 47.2% of 36 to penicillin and 10.7% of 56 to chloramphenicol; none of 21 bacteria was simultaneously resistant to all three antibiotics. Up until 1992, we have encountered treatment failure with a regimen containing chloramphenicol in only 2 of 53 patients; the 2 patients had coliform meningitis. Non-meningococcal bacteria are an important cause of sporadic pyogenic meningitis in sub-Saharan Nigeria and chloramphenicol is the most appropriate initial drug of choice at the present time for the management of sporadic meningitis.     

Chronic neutrophilic meningitis caused by Candida albicans

Meningitis caused by Candida albicans is a very infrequent entity. We present 3 intravenous drug users with chronic neutrophilic meningitis caused by Candida albicans. The clinical, microbiological and radiological features of the 3 patients are reviewed. The interval between the onset of the disease and the diagnosis was long (from 4 to 12 months). Candida albicans was cultured from cerebrospinal fluid (CSF) in the 3 patients. All of them developed hydrocephalus, meanwhile arachnoiditis was disclosed in two. The therapy with amphotericyn, 5-flucytosine and fluconazole produced clinical improvement and the sterilisation of the CSF in all the 3 cases. Clinicians should be aware of this entity because of diagnosis may be delayed in several months.