Posts filed under ‘Infecciones del SNC’

Emergence of Ceftriaxone Resistance during a Case of Pneumococcal Meningitis with Fatal Evolution

Antimicrob. Agents Chemother. March 2020 V.64 N.3

We report a case of a 62-year-old man treated for Streptococcus pneumoniae meningitis by ceftriaxone and dexamethasone. After neurological improvement, neurological degradation by vasculitis occurred, despite effective concentrations of ceftriaxone in the serum and cerebrospinal fluid (CSF). S. pneumoniae with increased MICs to third-generation-cephalosporins (3GC) was isolated from the ventricular fluid 10 days after the isolation of the first strain. Isolate analysis showed that a mutation in the penicillin-binding protein 2X (PBP2X) has occurred under treatment.

This Journal section presents a real, challenging case involving a multidrug-resistant organism. The case authors present the rationale for their therapeutic strategy and discuss the impact of mechanisms of resistance on clinical outcome. An expert clinician then provides a commentary on the case.





Antimicrob. Agents Chemother. March 2020 V.64 N.3

Case Commentary: Delayed Cerebral Vasculitis Associated with the Development of Ceftriaxone-Resistant Pneumococcal Meningitis

Mizrahi and colleagues present a well-described case of the emergence of drug resistance in Streptococcus pneumoniae meningitis during therapy with ceftriaxone monotherapy with a low bactericidal concentration in the cerebrospinal fluid. Adherence to international guidelines could possibly have prevented the emergence of this resistant isolate and the adverse outcome.




February 25, 2020 at 10:41 am

Perspective – Eastern Equine Encephalitis Virus — Another Emergent Arbovirus in the United States

NEJM November 21, 219 V.381 P.1989-1992

David M. Morens, M.D., Gregory K. Folkers, M.S., M.P.H., and Anthony S. Fauci, M.D.

Humans have always lived in intimate association with arthropods that transmit pathogens between humans or from animals to humans. About 700,000 deaths due to vectorborne diseases occur globally each year, according to World Health Organization estimates. In the summer and fall of 2019, nine U.S. states have reported 36 human cases (14 of them fatal) of one of the deadliest of these diseases: eastern equine encephalitis (EEE), an arthropod-borne viral (arboviral) disease transmitted by mosquitoes. In recent years, the Americas have witnessed a steady stream of other emerging or reemerging arboviruses, such as dengue, West Nile, chikungunya, Zika, and Powassan, as well as increasing numbers of travel-related cases of various other arboviral infections. This year’s EEE outbreaks may thus be a harbinger of a new era of arboviral emergences……



November 21, 2019 at 8:06 am

Listeriosis in Spain based on hospitalisation records, 1997 to 2015: need for greater awareness


Listeriosis is an infectious disease caused by bacteria of the genus Listeria spp. L. monocytogenes is the major pathogenic species in both animals and humans. L. monocytogenes is a Gram-positive, rod-shaped organism that can grow in aerobic and anaerobic conditions [1], is widely distributed in the environment and is able to contaminate a wide variety of foods or beverages (soft cheese, deli meats, unpasteurised milk, refrigerated smoked seafood, etc.) [2]. The bacteria can multiply at refrigerator temperatures [3]; therefore, contaminated products are often kept for several days or even weeks, e.g. in the household/restaurants, and may be eaten on multiple occasions, which can complicate the identification of the incriminated food source [4].

The clinical syndromes of listeriosis include: febrile gastroenteritis, sepsis, central nervous system (CNS) involvement in the form of encephalitis, meningoencephalitis and focal infections such as pneumonia myo-endocarditis and septic arthritis, etc [5]. Invasive listeriosis most commonly affects pregnant women, neonates, elderly people and people with chronic conditions or weakened immune response [6]. Listeriosis has one of the highest case fatality rates among all food-borne infections; when it affects the CNS, the mortality rate is above 50% and neurological sequelae are present in more than 60% of survivors [2]. Listeriosis is also associated with fetal and neonatal death.

Worldwide, listeriosis is an emerging infection of public health concern [7]. In Europe, human listeriosis peaked in incidence during the 1980s, showed a general decline during the 1990s and stabilised in the 2000s [8]. More recent data show an increasing trend since 2008 [9]. This increase seems to be related to the ageing of the population and the increase in life expectancy of immunocompromised patients, but also to changes in the ways food is produced, stored, distributed and consumed around the world [10]. Although listeriosis is often a sporadic disease [11], large food-borne outbreaks have occurred during the last decade in Europe and the United States (US) [12]. In South Africa, an outbreak with more than 1,024 laboratory-confirmed listeriosis cases, as at 2 May 2018, has been ongoing since the start of 2017, with a 28.6% case fatality rate [13].

In Spain, food safety criteria (FSC) for L. monocytogenes follow European Commission (EC) regulations [14,15]. Before 2015, when it was added to the list of mandatory notifiable diseases, regions could voluntarily report listeriosis to the Microbiological Information System (Sistema de Información Microbiológica, SIM) [16]. Using the centralised hospital discharge database (Conjunto Mínimo Básico de Datos, CMBD), we aimed to describe the epidemiology of listeriosis in Spain from 1997–2015.



June 21, 2019 at 7:49 am

Meningococcal Disease Among College-Aged Young Adults: 2014–2016

Pediatrics January 2019  V.143  N.1


Freshman college students living in residence halls have previously been identified as being at an increased risk for meningococcal disease. In this evaluation, we assess the incidence and characteristics of meningococcal disease in college-aged young adults in the United States.


The incidence and relative risk (RR) of meningococcal disease among college students compared with noncollege students aged 18 to 24 years during 2014–2016 were calculated by using data from the National Notifiable Diseases Surveillance System and enhanced meningococcal disease surveillance. Differences in demographic characteristics and clinical features of meningococcal disease cases were assessed. Available meningococcal isolates were characterized by using slide agglutination, polymerase chain reaction, and whole genome sequencing.


From 2014 to 2016, 166 cases of meningococcal disease occurred in persons aged 18 to 24 years, with an average annual incidence of 0.17 cases per 100 000 population. Six serogroup B outbreaks were identified on college campuses, accounting for 30% of serogroup B cases in college students during this period. The RR of serogroup B meningococcal (MenB) disease in college students versus noncollege students was 3.54 (95% confidence interval: 2.21–5.41), and the RR of serogroups C, W, and Y combined was 0.56 (95% confidence interval: 0.27–1.14). The most common serogroup B clonal complexes identified were CC32/ET-5 and CC41/44 lineage 3.


Although the incidence is low, among 18- to 24-year-olds, college students are at an increased risk for sporadic and outbreak-associated MenB disease. Providers, college students, and parents should be aware of the availability of MenB vaccines.



June 17, 2019 at 6:59 pm

REVISION – Difusión de los antibióticos en el sistema nervioso central

Revista Española de Quimioterapia Febrero 2018 V.31 N.1 P.1–12.

José María Cabrera-Maqueda,corresponding author1 Luna Fuentes Rumí,1 Gabriel Valero López,1 Ana Esther Baidez Guerrero,1 Estefanía García Molina,1 José Díaz Pérez,1 and Elisa García-Vázquez2


Las infecciones del SNC causadas por patógenos mutiresistentes suponen un reto terapéutico. El paso de fluidos y de solutos al SNC está estrechamente regulado a través de la BHE.La penetración de cualquier fármaco, inclusive los ATB, en el LCR depende del tamaño molecular, la lipofilicidad, la unión a proteínas plasmáticas y su afinidad por transportadores de la BHE. La relación entre el área bajo la curva en el LCR y el suero AUCCSF (Area Bajo la Curva en LCR)/AUCS (Area Bajo la Curva en suero) de una sustancia es el parámetro más preciso para determinar su capacidad de difusión.

Linezolid, algunas quinolonas y metronidazol consiguen altas concentraciones en LCR y son útiles para tratar microorganismos sensibles. Algunos ATB cuya permeabilidad a través de la BHE es baja pueden ser administrados directamente en el ventrículo a la vez que se realiza infusión IV. El ATB ideal para tratar una infección del SNC es pequeño, no tiene alta tasa de unión a proteínas plasmáticas, es moderadamente lipofílico y no es un ligando de alta afinidad a bombas de expulsión de la BHE.

Conocer la farmacocinética de los ATB y su interacción con la BHE permitirá mejorar el tratamiento de los pacientes con infecciones del SNC. En este artículo se exponen las propiedades físico-químicas de los principales grupos de ATB para evaluar cuáles son más prometedores en el tratamiento de las infecciones del SNC y cómo usarlos en la práctica clínica habitual.


May 19, 2019 at 7:13 pm

Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis

Journal of Clinical Microbiology June 1998 V.36 N.6 P.1617-1620

Dunbar SA et al

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 pneumoniaeand 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.

Bacterial meningitis is a life-threatening infection. Although patients typically present with fever, headache, stiff neck, and altered mental status, these symptoms may be subtle in elderly or immunocompromised persons (1, 6, 7,18). Early implementation of appropriate antimicrobial therapy requires prompt identification of the infecting pathogen. Although culture is considered to be the definitive diagnostic test, microscopic examination of a Gram-stained specimen of cerebrospinal fluid (CSF) may provide immediate information about the causative microorganism. Previous studies have suggested that the sensitivity of this technique ranges from 60 to 90% and the specificity approaches 100% (1, 5,6, 8, 12, 18). Scheld concludes that the overall sensitivity is only 75% (14). It is often unclear whether earlier studies have stratified patients based upon their having received prior antimicrobial therapy. Further, the role of semiquantitative assessment of leukocytes (WBC) by microscopic examination as an indicator of infection (8, 12) is uncertain. The value of using broth culture in various populations is also questionable (9, 10,17). In the present study, we reviewed the results of microscopic examination and routine culture of 2,635 CSF specimens to establish the predictive value of the cytocentrifuged Gram stain and the usefulness of broth culture in a veteran population.



April 2, 2019 at 6:15 pm

Predictive Value of Cerebrospinal Fluid (CSF) Lactate Level vs CSF-Blood Glucose Ratio for the Diagnosis of Bacterial Meningitis Following Neurosurgery

Clinical Infectious Diseases July 1999 V.29 N.1 P.69-74

Stephen L. Leib; Remy Boscacci; Othmar Gratzl; Werner Zimmerli

The value of cerebrospinal fluid (CSF) lactate level and CSF/blood glucose ratio for the identification of bacterial meningitis following neurosurgery was assessed in a retrospective study. During a 3-year period, 73 patients fulfilled the inclusion criteria and could be grouped by preset criteria in one of three categories: proven bacterial meningitis (n = 12), presumed bacterial meningitis (n = 14), and nonbacterial meningeal syndrome (n = 47). Of 73 patients analyzed, 45% were treated with antibiotics and 33% with steroids at the time of first lumbar puncture. CSF lactate values (cutoff, 4 mmol/L), in comparison with CSF/blood glucose ratios (cutoff, 0.4), were associated with higher sensitivity (0.88 vs. 0.77), specificity (0.98 vs. 0.87), and positive (0.96 vs. 0.77) and negative (0.94 vs. 0.87) predictive values. In conclusion, determination of the CSF lactate value is a quick, sensitive, and specific test to identify patients with bacterial meningitis after neurosurgery.



April 2, 2019 at 6:13 pm

Characterization of Chemical Meningitis after Neurological Surgery

Clinical Infectious Diseases January 2001 V.32 N.2 P.179-185

Pierre Forgacs; Carl A. Geyer; Stephen R. Freidberg

We reviewed the records of 70 consecutive adult patients with meningitis after a neurosurgical procedure, to determine the characteristics that might help to distinguish a sterile postoperative chemical meningitis from bacterial infection. The spinal fluid profiles in bacterial and chemical meningitis are similar. The exceptions are that a spinal fluid white blood cell count >7500/µL (7500 × 106/L) and a glucose level of <10 mg/dL were not found in any case of chemical meningitis. The clinical setting and clinical manifestations were distinct enough that no antibiotic was administered after lumbar puncture to 30 (43%) of the 70 patients with postoperative meningitis. Chemical meningitis was infrequent after surgery involving the spine and sinuses. Patients with chemical meningitis did not have purulent wound drainage or significant wound erythema or tenderness, coma, new focal neurological findings, or onset of a new seizure disorder. They rarely had temperatures >39.4°C or cerebrospinal fluid rhinorrhea or otorrhea.



April 2, 2019 at 6:10 pm

Meningitis postquirúrgica. Características diferenciales de la meningitis aséptica post-quirúrgica

Neurocirugía ABRIL 2009 V.20 N.2

Ramos-Martínez; T. de las Heras-Carballo; C. Fernández-Mateos*; L. de Reina*; T. Álvarez de Espejo-Montiel; N. Escamilla-Fernández; I. Sánchez-Romero** e I. Millán***

Servicios de Medicina Interna (Unidad de Infecciosas) Neurocirugía* y Microbiología**. Sección de Bioestadística***. Hospital Universitario Puerta de Hierro. Madrid.


La meningitis postquirúrgica es una complicación infrecuente que se acompaña de un incremento de la estancia hospitalaria y de una elevada mortalidad. Algunos de estos casos no son debidos a una verdadera infección sino a una inflamación aséptica de las meninges denominada meningitis aséptica post-quirúrgica (MAPQ). La adecuada identificación de estos casos permitiría una mejor utilización de los fármacos antimicrobianos.

Material y métodos

Estudio retrospectivo de los pacientes con meningitis postquirúrgica en un hospital terciario durante 14 años comparando las características clínicas de los pacientes con meningitis bacteriana postquirúrgica (MBP) frente a las de pacientes con MAPQ


Durante el período analizado se identificaron 35 pacientes (71%) con MBP y 14 pacientes (29%) con MAPQ. La edad media de los pacientes con MBP fue similar a la de los pacientes con MAPQ. Hubo predominio de varones en el grupo de MBP (71%) en relación con los pacientes con MAPQ (36%, p=0,020). La proporción de pacientes con hemorragia intracraneal tendió a ser más frecuente en pacientes que posteriormente desarrollaron MAPQ (9 pacientes, 64 %) que en los pacientes con MBP (12 casos, 34%, p=0,055). Los pacientes sometidos a craneotomía posterior (p=0,092) y los que recibían tratamiento esteroideo (p=0,051) mostraron una mayor tendencia a padecer MAPQ. Siete pacientes MBP (20%) presentaron un recuento celular superior a 5000 células/mm3 en el LCR, cifra no encontrada en ningún caso de MAPQ. No se detectaron diferencias en la glucorraquia y proteinorraquia entre ambos grupos. La bacterias más frecuentemente aisladas fueron Staphylococcus coagulasa negativa y S. aureus. En 5 pacientes (14%) se aislaron bacilos gramnegativos no fermentadores (Pseudomonas aeruginosa y Acinetobacter spp). No hubo ningún fallecimiento atribuido a meningitis postquirúrgica.


Los pacientes sometidos a neurocirugía que fueron ingresados por hemorragia cerebral, intervenidos de la fosa posterior o tratados con esteroides presentan una mayor tendencia a presentar MAPQ. Los recuentos celulares en LCR elevados (superiores a 5000 células /mm3) sugieren la existencia de MBP.


April 2, 2019 at 6:08 pm

Management of post-neurosurgical meningitis: narrative review.

Clinical Microbiology and Infection September 2017 V.23 N.9 P.621-628.

Hussein K1, Bitterman R2, Shofty B3, Paul M1, Neuberger A4.



Infections complicating neurosurgery pose unacceptable mortality and morbidity.


To summarize what is known about the epidemiology, diagnosis and treatment of post-neurosurgical meningitis (PNM).


PubMed, references of identified studies and reviews, and personal experience when evidence was lacking.


The incidence and pathogen distribution of PNM is highly variable. A shift towards Gram-negative bacteria has been observed with use of antibiotic prophylaxis and antibiotic-coated devices directed mainly against Gram-positive bacteria. However, knowledge of the local epidemiology is necessary to treat PNM. The diagnosis of PNM is difficult because, unlike community-acquired meningitis, symptoms are less specific; patients are ill at baseline and many neurosurgical conditions mimic meningitis and cause cerebrospinal fluid (CSF) abnormalities. Pivotal CSF findings for diagnosis of PNM are the CSF glucose, CSF lactate and Gram stain. CSF leucocyte counts are not specific in PNM. Current diagnostic capabilities leave a non-negligible category of patients with microbiologically negative, uncertain diagnosis of PNM. There is no high-quality evidence on several cardinal issues in PNM management, including the effectiveness of intraventricular or intrathecal (IV/IT) antibiotics, effectiveness of dual antibiotic therapy for multidrug-resistant Gram-negative bacteria; clinical benefit of routine therapeutic drug monitoring; and safest timing of shunt replacement. Some data point to a potential benefit of IV/IT antibiotic treatment, mainly for PNM caused by carbapenem-resistant Gram-negative bacteria. Carbapenem-colistin combination therapy is suggested for PNM caused by carbapenem-resistant Gram-negative bacteria with a carbapenem MIC ≤8 mg/L.


Guiding the optimal management of PNM will necessitate collaborative multicentre efforts and unique study designs.



April 1, 2019 at 6:34 pm

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