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Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.

Background and Objectives: After neurosurgery, intracranial infection is a common complication with high rates of clinical impairment and death. Traditional diagnostic approaches are time-consuming. Early and correct diagnosis improves infection control, treatment success, and survival. Novel markers are used to diagnose and classify post-neurosurgical meningitis (PNM) to overcome the difficulties of diagnosing postoperative intracranial infections and avoid the drawbacks of existing diagnostic measures. The objective was to investigate the diagnostic value of β-2 transferrin (β-2TF) and transferrin (TF) in the cerebrospinal fluid (CSF) for the identification of intracranial infection after neurosurgery., Methods: Owing to their symptoms and laboratory results, 168 patients with suspected intracranial infection after neurosurgery were divided into 3 groups: post-neurosurgical bacterial meningitis (PNBM; n = 61), post-neurosurgical aseptic meningitis (PNAM; n = 45), and non-PNM (n = 62). We measured lactate (LA), β-2TF, and TF levels in the CSF., Results: CSF LA levels were significantly higher in the PNM, PNBM, and PNAM groups compared with the non-PNM group ( P < .05). The CSF β-2TF level in PNM, PNBM, and PNAM were statistically higher than those in non-PNMs ( P < .05). CSF TF levels in the PNBM group were statistically higher than those in the PNAM and non-PNM groups ( P < .05). The PNBM and non-PNM receiver operating curve (ROC) analysis indicates that the cutoff values for the combination (LA, β-2TF, TF) was 0.349, and the area under the curve (AUC) was 0.945 ( P < .0001), with 92.86% sensitivity and 92.98% specificity. The PNAM and non-PNM ROC analysis indicates that the cutoff values for the combination (LA, β-2TF, TF) was 0.346, and the AUC was 0.962 ( P < .0001), with 89.29% sensitivity and 90.24% specificity. The PNM and non-PNM ROC analysis indicates that the cutoff values for the combination (LA, β-2TF, TF) was 0.609, and the AUC was 0.941 ( P < .0001), with 96.36% sensitivity and 82.83% specificity. A Glasgow Coma Scale score ≤8, LA, β-2TF/TF ratio, length of hospital stay, intensive care unit admission, poor surgical wound, and craniotomy were associated with poor outcomes ( P < .05). LA and β-2TF were independent risk factors for intracranial infection., Conclusion: Postoperative cerebral infections can be identified using CSF β-2TF as a particular marker protein. CSF TF helps distinguish PNBM from PNAM. Combining CSF LA with them improves diagnostic speed, sensitivity, and accuracy. LA and β-2TF were independent risk factors for cerebral infection., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objective: To understand the characteristics of bacterial meningitis after pediatric neurosurgical procedures. Methods: This was a retrospective observational study. From January 2016 to December 2022, 64 children diagnosed with post-neurosurgical bacterial meningitis based on positive cerebrospinal fluid (CSF) culture in Department of Neurosurgery of Shanghai Children's Medical Center were selected as the study population. The clinical characteristics, onset time, routine biochemical indexes of cerebrospinal fluid before anti infection treatment, bacteriology characteristics and sensitivity to antibiotics of bacteria cultured from cerebrospinal fluid were analyzed. Based on the CSF culture results, the patients were divided into the Gram-positive bacteria infection group and the Gram-negative bacteria infection group. The clinical characteristics of the two groups were compared using t -tests or Wilcoxon rank-sum tests, and chi-square tests. Results: There were 64 children,42 boys and 22 girls, with onset age of 0.83 (0.50, 1.75) years. Seventy cases of post-neurosurgical bacterial meningitis occurred in the 64 children, of which 15 cases (21%) in spring, 23 cases (33%) in summer, 19 cases (27%) in autumn, and 13 cases (19%) in winter. The time of onset was 3.5 (1.0, 10.0) months after surgery; 15 cases (21%) occurred within the first month after the surgery, and 55 cases (79%) occurred after the first month. There were 38 cases (59%) showing obvious abnormal clinical manifestations, fever 36 cases (56%), vomiting 11 cases (17%). Forty-eight cases (69%) were caused by Gram-positive bacteria, with Staphylococcus epidermidis 24 cases; 22 cases (31%) were caused by Gram-negative bacteria, with Acinetobacter baumannii the prominent pathogen 7 cases. The Gram-positive bacterial infection was more common in summer than the Gram-negative bacterial infection (20 cases (42%) vs. 3 cases (14%), χ 2 =5.37, P= 0.020), while the Gram-negative bacterial infection was more in autumn and within the first month after surgery than the Gram-positive bacterial infection (11 cases (50%) vs . 8 cases (17%), 15 cases (67%) vs. 5 cases (33%), χ 2 = 8.48, 9.02; P= 0.004, 0.003). Gram-positive bacteria resistant to vancomycin and Acinetobacter baumannii resistant to polymyxin were not found. However, Acinetobacter baumannii showed only 45% (10/22) susceptibility to carbapenem antibiotics. Conclusions: The clinical presentation of post-neurosurgical bacterial meningitis in children is atypical. Gram-positive bacteria are the main pathogens causing post-neurosurgical bacterial meningitis; Gram-negative bacterial meningitis are more likely to occur in autumn and within the first month after surgery. Acinetobacter baumannii has a high resistance rate to carbapenem antibiotics, which should be taken seriously.

Bacterial meningitis after percutaneous radiofrequency trigeminal ganglion is a rare but severe complication. In this article, we report a case of meningitis due to Streptococcus parasanguinis and review the related literature. A 62-year-old male patient with uremia and severe trigeminal neuralgia presented to another hospital and was offered to undergo radiofrequency treatment for a trigeminal ganglion lesion (2022.08.05). The next day (2022.08.06), he presented with a headache and right shoulder and back pain. The pain continued to worsen, so he came to our hospital (The First Affiliated Hospital of Wannan Medical College) and received a diagnosis of bacterial meningitis, which was confirmed by a lumbar puncture. The patient was treated with appropriate antibiotics, and subsequently recovered before being discharged. Although this complication is relatively rare, its progression is rapid. Meningitis must be suspected when a patient presents with headache, fever, and other symptoms associated with meningitis within days after undergoing radiofrequency treatment for a trigeminal ganglion lesion, especially if the patient has an underlying disease that causes a decline in immunity. We discuss this case in terms of clinical presentation, time of onset, treatment, prognosis, past history, and sex. Although early detection of this complication is beneficial, it is better to effectively prevent its occurrence.

Bacterial meningitis is a rare but severe infectious complication after hematopoietic stem cell transplantation. However, its clinical features were previously not clear. We reviewed the cases of 7 patients diagnosed with bacterial meningitis with a positive cerebrospinal fluid culture among 1147 patients who underwent cord blood transplantation (CBT) at our institution between September 2007 and September 2020. The diagnosis was made on day + 5- + 45, and 5 patients developed bacterial meningitis before neutrophil engraftment. The causative organisms were all Gram-positive cocci: Enterococcus faecium and Enterococcus gallinarum (2 patients each), and Staphylococcus haemolyticus, Streptococcus mitis/oralis, and Rothia mucilaginosa (1 patient each). Six patients developed bacterial meningitis secondary to prior or concomitant bacteremia caused by the same bacterium. Five patients had received anti-MRSA agents at onset: vancomycin in 3, teicoplanin in 1, and daptomycin in 1. After diagnosis of bacterial meningitis, linezolid was eventually used for 6 patients. Two patients with E. gallinarum were alive at day + 1380 and + 157 after CBT, respectively, whereas 5 patients died 17-53 (median 43) days after the onset of bacterial meningitis. Breakthrough meningitis in CBT can occur even during the use of anti-MRSA drugs, and intensive antibiotic treatment is necessary., (© 2022. Japanese Society of Hematology.)

Objectives: To investigate the incidence, risk factors, and management of meningitis in cochlear implant (CI)users., Methods: A systematic review was carried out using PubMed, Scopus, Web of Science, and Cochrane Central Register. Articles were considered relevant if reported any data on incidence, clinical presentations, the role of vaccination, management, and outcomes of meningitis after CI., Results: A total of 32 studies including 27358 patients were included, and meningitis was reported in only 202 cases. Meningitis occurred in the period ranging from 1 day to 72 months after CI. A total of 55 patients received the pneumococcal vaccine, while 20 patients received the Haemophilus influenzae type B vaccine. A large number of participants (n=47) had associated anatomical malformations, while 62 had otitis media before meningitis. A total of 24 cases required revision surgery along with medical treatment. Full recovery was the outcome reported by the included studies in 19 patients., Conclusion: Cochlear implant users seem to be at possible risk of bacterial meningitis at any time after implantation, especially in the presence of risk factors, such as otitis media and anatomical malformations of the cochlea., (Copyright: © Saudi Medical Journal.)

Objectives: Recurrent bacterial meningitis (RBM) is a rare but life-threatening disease. This study aims to analyze the clinical features, potential causes, and therapeutic outcomes of RBM in children., Methods: This article retrospectively reviews the clinical characteristics, etiologies, and treatments in children with RBM hospitalized in Hebei children's hospital from 2012 to 2020., Results: A total of 10 children with RBM, five males and five females, were included in this study. The age of RBM in children spans from the neonatal stage to the childhood stage. The underlying illnesses were identified and classified as cerebrospinal fluid rhinorrhea (1 case), humoral immunodeficiency with Mondini dysplasia (1 case), common cavity deformity with cerebrospinal fluid ear leakage (1 case), Mondini malformations (2 cases), incomplete cochlear separation type I with a vestibular enlargement (2 cases), local inflammation of the sphenoid bone caused by cellulitis (1 case), congenital skull base defects (1 case), and congenital dermal sinus with intraspinal abscess (1 case). 6 patients chose targeted therapy for potential reasons., Conclusions: Congenital abnormalities or acquired injuries lead to intracranial communication with the outside world, which can quickly become a portal for bacterial invasion of the central nervous system, resulting in repeated infections., Competing Interests: All the authors declare that they have no conflict of interest., (Copyright © 2022 Xin Li et al.)

Due to heightened awareness and advanced genetic tools, inborn errors of immunity (IEI) are increasingly recognized in children. However, diagnosing of IEI in premature infants is challenging and, subsequently, reports of IEI in premature infants remain rare. This review focuses on how common disorders of prematurity, such as sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia, can clinically overlap with presenting signs of IEI. We present four recent cases from a single neonatal intensive care unit that highlight diagnostic dilemmas facing neonatologists and clinical immunologists when considering IEI in preterm infants. Finally, we present a conceptual framework for when to consider IEI in premature infants and a guide to initial workup of premature infants suspected of having IEI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gordon and O’Connell.)

Encephalitis and meningitis (EM) are severe infections of the central nervous system associated with high morbidity and mortality. The etiology of EM in Kazakhstan is not clearly defined, so from February 1, 2017 to January 31, 2018 we conducted hospital-based syndromic surveillance for EM at the Shymkent City Hospital, in the South Kazakhstan region. All consenting inpatients meeting a standard case definition were enrolled. Blood and cerebrospinal fluid (CSF) samples were collected for bacterial culture, and CSF samples were additionally tested by PCR for four bacterial species and three viruses using a cascading algorithm. We enrolled 556 patients. Of these, 494 were of viral etiology (including 4 probable rabies cases), 37 were of bacterial etiology, 19 were of unknown etiology and 6 were not tested. The most commonly identified pathogens included enterovirus (73%, n = 406 cases), herpes simplex virus (12.8%, n = 71), and Neisseria meningitidis (3.8%, n = 21). The incidence rates (IRs) for enteroviral and meningococcal EM were found to be 14.5 and 0.7 per 100,000 persons, respectively. The IR for bacterial EM using both PCR and culture results was 3-5 times higher compared to culture-only results. Antibacterial medicines were used to treat 97.2% (480/494) of virus-associated EM. Incorporation of PCR into routine laboratory diagnostics of EM improves diagnosis, pathogen identification, ensures IRs are not underestimated, and can help avoid unnecessary antibacterial treatment., Competing Interests: The authors have declared that no competing interests exist.

A 47-year-old man who was previously hospitalized three times due to bacterial meningitis experienced a headache and posterior neck pain in May. He was admitted to our hospital because of a fever 3 h later. He was fully conscious and febrile, with a headache and signs of meningeal irritation. A cerebrospinal fluid examination showed an increased number of cells with polynuclear cell predominance and decreased glucose levels, leading to the diagnosis of bacterial meningitis. Steroid and antibiotic treatment was initiated, at which time, large amounts of nasal discharge were observed. Cisternal scintigraphy was performed, and cerebrospinal fluid was detected in the nasal discharge. The cause was idiopathic, and endoscopic repair was performed. The nasal fluid leakage was suggested to be the cause of the recurrent bacterial meningitis in this case.

Bacterial meningitis is a neurological emergency with high morbidity and mortality. We herein investigated clinical features, etiology, antimicrobial susceptibility profiles, and prognosis of bacterial meningitis in adults from a single tertiary center. We retrospectively reviewed medical records of patients with laboratory-confirmed bacterial meningitis from 2007 to 2016. Patients with recent neurosurgery, head trauma, or indwelling neurosurgical devices were classified as having healthcare-related meningitis. Causative microorganisms were identified by analyzing cerebrospinal fluid (CSF) and blood cultures, and antimicrobial susceptibility profiles were evaluated. We performed multiple logistic regression analysis to identify factors associated with unfavorable outcomes. We identified 161 cases (age, 55.9 ± 15.5 years; male, 50.9%), of which 43 had community-acquired and 118 had healthcare-related meningitis. CSF and blood culture positivity rates were 91.3% and 30.4%, respectively. In community-acquired meningitis patients, Klebsiella pneumoniae (25.6%) was the most common isolate, followed by Streptococcus pneumoniae (18.6%) and Listeria monocytogenes (11.6%). The susceptibility rates of K. pneumoniae to ceftriaxone, cefepime, and meropenem were 85.7%, 81.3%, and 100%, respectively. Among healthcare-related meningitis patients, the most common bacterial isolates were coagulase-negative staphylococci (28.0%), followed by Staphylococcus aureus (16.1%) and Enterobacter spp. (13.6%). Neurological complications occurred in 39.1% of the patients and the 3-month mortality rate was 14.8%. After adjusting for covariates, unfavorable outcome was significantly associated with old age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.06), neurological complications (OR 4.53, 95% CI 1.57-13.05), and initial Glasgow coma scale ≤ 8 (OR 19.71, 95% CI 4.35-89.40). Understanding bacterial pathogens and their antibiotic susceptibility may help optimize antimicrobial therapy in adult bacterial meningitis.

Bacterial meningitis (BM) is an acute infectious central nervous system (CNS) disease worldwide, occurring with 50% of the survivors left with a long-term serious sequela. Acute bacterial meningitis is more prevalent in resource-poor than resource-rich areas. The pathogenesis of BM involves complex mechanisms that are related to bacterial survival and multiplication in the bloodstream, increased permeability of blood-brain barrier (BBB), oxidative stress, and excessive inflammatory response in CNS. Considering drug-resistant bacteria increases the difficulty of meningitis treatment and the vaccine also has been limited to several serotypes, and the morbidity rate of BM still is very high. With recent development in neurology, there is promising progress for drug supplements of effectively preventing and treating BM. Several in vivo and in vitro studies have elaborated on understanding the significant mechanism of melatonin on BM. Melatonin is mainly secreted in the pineal gland and can cross the BBB. Melatonin and its metabolite have been reported as effective antioxidants and anti-inflammation, which are potentially useful as prevention and treatment therapy of BM. In bacterial meningitis, melatonin can play multiple protection effects in BM through various mechanisms, including immune response, antibacterial ability, the protection of BBB integrity, free radical scavenging, anti-inflammation, signaling pathways, and gut microbiome. This manuscript summarizes the major neuroprotective mechanisms of melatonin and explores the potential prevention and treatment approaches aimed at reducing morbidity and alleviating nerve injury of BM.

Cochleocele is an extrusion or herniation of the endosteum, through an incomplete stapes footplate, into the middle ear. The cochleocele may rupture resulting in a cerebrospinal fluid leak into the middle ear space causing a risk of menigitis. We report six cases of Incomplete Partition Type I with cochleocele which have all been successfully treated using a Totally Endoscopic Ear Surgery approach even during infancy. As the first two cases developed post-operative pseudomonas meningitis, preventative strategies are recommended., (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

Stress-induced changes in pharmacokinetics can significantly alter the plasma levels of some drugs such as clozapine. This report describes the case of a middle-aged man with schizoaffective disorder, bipolar type who showed sustained elevation in clozapine levels 3 days after discontinuation. Before the clozapine levels were drawn, he had developed acute bacterial pneumonia and signs of acute bacterial meningitis followed by neuroleptic malignant syndrome after he received multiple doses of intravenous haloperidol for worsening psychosis and aggressive behavior. Existing literature on this topic is also reviewed to investigate potential reasons for sustained clozapine levels during acute inflammatory stress and neuroleptic malignant syndrome., (© Copyright 2020 Physicians Postgraduate Press, Inc.)

Spinal adhesive arachnoiditis (SAA) with cyst formation secondary to infectious meningitis is a rare clinical entity. These cysts can compress the spinal cord and cause neurologic decline. We present a case of a patient who underwent resection for an intradural schwannoma which was complicated post-operatively by bacterial meningitis and development of several recurrent thoracic arachnoid cysts. After two separate thoracic decompressions with lysis of intradural adhesions, a permanent ventriculoperitoneal shunt (VPS) was eventually placed with complete recovery of his symptoms. Our review of the literature showed that CSF shunts have previously been successfully used to treat spinal fluid collections. Although there are many factors to consider when treating these patients, CSF diversion may be beneficial for similar SAA presentations in order to simultaneously treat and prevent recurrence of symptoms., (Copyright © 2020 Elsevier B.V. All rights reserved.)

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Clinical characteristics of disseminated strongyloidiasis, the severest form of strongyloidiasis, are not well described. We conducted a retrospective, consecutive chart review of patients with disseminated strongyloidiasis admitted to Okinawa Chubu Hospital in Okinawa, Japan, during January 1975-December 2017. The 70 patients were classified into 3 clinical phenotypes: dissemination (32 patients [45.7%]), occult dissemination with meningitis caused by enteric organisms (12 patients [17.1%]), and occult dissemination with culture-negative suppurative meningitis (26 patients [37.1%]). Associated mortality rates were 56.3%, 16.7%, and 11.5%, respectively, and sepsis occurred in 40.6%, 58.3%, and 11.5% of cases, respectively. Common symptoms included fever (52.9% of patients), headache (32.9%), and altered mental status (24.3%). Patients were treated with thiabendazole (before 2003) or ivermectin (after 2003). Our findings show that disseminated strongyloidiasis has clinical phenotypes in terms of severity and that identification of occult dissemination, a mild form with prominent neurologic manifestations, is lifesaving.

Background: Invasive infections caused by Capnocytophaga canimorsus are rare. Immunocompromised patients, who report being bitten by or having a close contact with an animal, represent a high-risk group for this infection. There are only few dozens of infections by this bacteria manifesting as purulent meningitis reported worldwide. The reported case is a first reported case of purulent meningitis caused by by Capnocytophaga canimorsus in Czech Republic with only a limited risk factor history., Case Presentation: The patient, a 74 years old man, was referred to the infectious diseases department of a teaching hospital with clear signs of developing purulent meningitis. His anamnestic data did not show any unusual findings. He was treated for compensated diabetes mellitus type II. The blood cultures were negative and the etiological agent did not grow from the cerebrospinal fluid (CSF) on common media. Eventually, it was identified by detecting pan-bacterial DNA and DNA sequencing. Subsequently, the pathogen was confirmed by anaerobic cultivation from CSF. Only after then the patient recalled being bitten by his German shepherd puppy during play. The patient was successfully treated intravenously by ceftriaxone., Conclusions: Purulent meningitis caused by Capnocytophaga spp. is a rare disease, but it needs to be considered in patients at risk with pre-existing conditions, who report close contact with or being bitten by an animal. It is important to test for this microbe in cases with negative microbiological results for the more common agents.

Objective: To evaluate the diagnostic accuracy of cerebrospinal fluid (CSF)-based routine clinical examinations for post-neurosurgical bacterial meningitis (PNBM) in multicenter post-neurosurgical patients., Methods: The diagnostic accuracies of routine examinations to distinguish between PNBM and post-neurosurgical aseptic meningitis (PNAM) were evaluated by determining the values of the area under the curve (AUC) of the receiver operating characteristic curve in a retrospective analysis of post-neurosurgical patients in four centers., Results: An algorithm was constructed using the logistic analysis as a classical method to maximize the capacity for differentiating the two classes by integrating the measurements of five variables. The AUC value of this algorithm was 0.907, which was significantly higher than those of individual routine blood/CSF examinations. The predicted value from 70 PNBM patients was greater than the cutoff value, and the diagnostic accuracy rate was 75.3%. The results of 181 patients with PNAM showed that 172 patients could be correctly identified with specificity of 95.3%, while the overall correctness rate of the algorithm was 88.6%., Conclusions: Routine biomarkers such as CSF/blood glucose ratio (C/B-Glu), CSF lactate (C-Lac), CSF glucose concentration (C-Glu), CSF leukocyte count (C-Leu), and blood glucose concentration (B-Glu) can be used for auxiliary diagnosis of PNBM. The multicenter retrospective research revealed that the combination of the five abovementioned biomarkers can effectively improve the efficacy of the PNBM diagnosis., (© 2019 The Authors. Journal of Clinical Laboratory Analysis published by Wiley Periodicals, Inc.)

Aim: To measure cytokine and lactate levels in the cerebrospinal fluid (CSF) of patients with suspected post-neurosurgical meningitis., Material and Methods: Interleukin (IL)-8,-12, and -13, interferon (IFN) gamma, and lactate concentrations were determined in the CSF of patients diagnosed with meningitis, who were undergoing follow-up after neurosurgical procedures at the Neurosurgery Clinic between May 2016 and November 2017. The demographic, clinical, biochemical, CSF cell count, CSF biochemistry, and CSF culture results of 119 patients were recorded., Results: The study group consisted of 39 patients diagnosed with post-neurosurgical meningitis. The control group comprised of 80 patients without pleocytosis, who had undergone lumbar puncture due to various indications. In the study group, 59% of the patients had fever, 66.7% had deterioration in the level of consciousness, and 35.9% had neck stiffness. The levels of IL-8 (96.5 ng/L vs. 86.6 ng/L, p < 0.001), IL-12 (10.1 ng/L vs. 3 ng/L, p < 0.001), and lactate (5.9 mmol/L vs. 2.1 mmol/L, p < 0.001) were higher in the CSF of the patient group compared to the control group. However, IL-13 (32.7 ng/L vs. 42.5 ng/L, p=0.003) and IFN gamma (73.3 ng/L vs. 260.4 ng/L, p < 0.001) levels were lower in patients compared to controls. The mortality rate in post-neurosurgical meningitis patients was estimated to be 35.9%., Conclusion: Post-neurosurgical meningitis prolongs the duration of hospital stay and causes long-term sequelae. Therefore, measurement of CSF cytokine and lactate levels alongside meningitis diagnostic processes may facilitate early and accurate diagnosis. Measuring CSF lactate is inexpensive and cost effective, particularly in post-neurosurgical patients.

In Japan, pneumococcal vaccine has been routinely administered since 2010 to prevent invasive pneumococcal diseases such as Streptococcus pneumoniae meningitis. We describe a case of pneumococcal meningitis in a 7-month-old girl who had received three doses of 13-valent pneumococcal conjugate vaccine. Brain magnetic resonance imaging showed infarcts in the right frontal region, and she was treated with antibiotics, intravenous immunoglobulin, dexamethasone, and edaravone. On day 27, an enhanced brain CT scan showed improvement of abnormal findings in the frontal region, except for slight atrophy. The S. pneumoniae serotype was 12F, which is not included in the 13-valent pneumococcal conjugate vaccine. A future vaccine is expected to use cross-reactivity to target common antigens.

Background: Leptospirosis is a reemerging zoonosis with a worldwide distribution and a wide range of clinical manifestations. We report a case of leptospirosis meningitis in a previously healthy woman infected by her pet mouse., Case Presentation: A 27-year-old Caucasian woman with pet mice presented to our institute with a 1 week history of fever, headache, myalgia, vomiting, diarrhea, and dark urine. Her admission examination revealed neck stiffness, conjunctivitis, and icteric sclera. Her liver enzymes, bilirubin, white blood cell count, and C-reactive protein were elevated. Her cerebrospinal fluid showed an elevated white blood cell count. Polymerase chain reactions using her cerebrospinal fluid, blood, and urine showed negative results for leptospirosis, but the result of her microagglutination test was positive for Leptospira interrogans serovar sejroe with a more than threefold increase in paired sera. The patient was treated with ceftriaxone for 1 week, and her condition steadily improved., Conclusions: This case report raises awareness of pet rodents as sources of leptospirosis. Leptospirosis meningitis should be considered in patients with meningeal symptoms and pet rodents.

Background: Streptococcus oralis belongs to the Streptococcus mitis group and is part of the normal flora of the nasal and oropharynx (Koneman et al., The Gram-positive cocci part II: streptococci, enterococci and the 'Streptococcus-like' bacteria. Color atlas and textbook of diagnostic microbiology, 1997). Streptococcus oralis is implicated in meningitis in patients with decreased immune function or from surgical manipulation of the central nervous system. We report a unique case of meningitis by Streptococcus oralis in a 58-year-old patient with cerebral spinal fluid leak due to right sphenoid meningoencephalocele., Case Presentation: A 58-year-old female presented in the emergency department due to altered mental status, fevers, and nuchal rigidity. Blood cultures were positive for Streptococcus oralis. Magnetic resonance stereotactic imaging of head with intravenous gadolinium showed debris in lateral ventricle occipital horn and dural thickening/enhancement consistent with meningitis. There was also a right sphenoidal roof defect, and meningoencephalocele with cerebrospinal fluid leak as a result. The patient was treated with ceftriaxone and had endoscopic endonasal repair of defect. She had complete neurologic recovery 3 months later., Conclusions: Cerebrospinal fluid leak puts patients at increased risk for meningitis. Our case is unique in highlighting Streptococcus oralis as the organism implicated in meningitis due to cerebrospinal fluid leak.

Background: Aetiological data for neonatal infections are essential to inform policies and programme strategies, but such data are scarce from sub-Saharan Africa. We therefore completed a systematic review and meta-analysis of available data from the African continent since 1980, with a focus on regional differences in aetiology and antimicrobial resistance (AMR) in the past decade (2008-18)., Methods: We included data for microbiologically confirmed invasive bacterial infection including meningitis and AMR among neonates in sub-Saharan Africa and assessed the quality of scientific reporting according to Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI) checklist. We calculated pooled proportions for reported bacterial isolates and AMR., Findings: We included 151 studies comprising data from 84 534 neonates from 26 countries, almost all of which were hospital-based. Of the 82 studies published between 2008 and 2018, insufficient details were reported regarding most STROBE-NI items. Regarding culture positive bacteraemia or sepsis, Staphylococcus aureus, Klebsiella spp, and Escherichia coli accounted for 25% (95% CI 21-29), 21% (16-27), and 10% (8-10) respectively. For meningitis, the predominant identified causes were group B streptococcus 25% (16-33), Streptococcus pneumoniae 17% (9-6), and S aureus 12% (3-25). Resistance to WHO recommended β-lactams was reported in 614 (68%) of 904 cases and resistance to aminoglycosides in 317 (27%) of 1176 cases., Interpretation: Hospital-acquired neonatal infections and AMR are a major burden in Africa. More population-based neonatal infection studies and improved routine surveillance are needed to improve clinical care, plan health systems approaches, and address AMR. Future studies should be reported according to standardised reporting guidelines, such as STROBE-NI, to aid comparability and reduce research waste., Funding: Uduak Okomo was supported by a Medical Research Council PhD Studentship., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Bacterial meningitis remains a major disease affecting children in Côte d'Ivoire. Thus, with support from the World Health Organization (WHO), Côte d'Ivoire has implemented pediatric bacterial meningitis (PBM) surveillance at 2 sentinel hospitals in Abidjan, targeting the main causes of PBM: Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae, and Neisseria meningitidis (meningococcus). Herein we describe the epidemiological characteristics of PBM observed in Côte d'Ivoire during 2010-2016., Methods: Cerebrospinal fluid (CSF) was collected from children aged <5 years admitted to the Abobo General Hospital or University Hospital Center Yopougon with suspected meningitis. Microbiology and polymerase chain reaction (PCR) techniques were used to detect the presence of pathogens in CSF. Where possible, serotyping/grouping was performed to determine the specific causative agents., Results: Overall, 2762 cases of suspected meningitis were reported, with CSF from 39.2% (1083/2762) of patients analyzed at the WHO regional reference laboratory in The Gambia. In total, 82 (3.0% [82/2762]) CSF samples were positive for bacterial meningitis. Pneumococcus was the main pathogen responsible for PBM, accounting for 69.5% (52/82) of positive cases. Pneumococcal conjugate vaccine serotypes 5, 18C, 19F, and 6A/B were identified post-vaccine introduction. Emergence of H. influenzae nontypeable meningitis was observed after H. influenzae type b vaccine introduction., Conclusions: Despite widespread use and high coverage of conjugate vaccines, pneumococcal vaccine serotypes and H. influenzae type b remain associated with bacterial meningitis among children aged <5 years in Côte d'Ivoire. This reinforces the need for enhanced surveillance for vaccine-preventable diseases to determine the prevalence of bacterial meningitis and vaccine impact across the country., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Pediatric bacterial meningitis (PBM) causes severe morbidity and mortality within Togo. Thus, as a member of the World Health Organization coordinated Invasive Bacterial Vaccine Preventable Diseases network, Togo conducts surveillance targeting Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae, at a sentinel hospital within the capital city, Lomé, in the southernmost Maritime region., Methods: Cerebrospinal fluid was collected from children <5 years with suspected PBM admitted to the Sylvanus Olympio Teaching Hospital. Phenotypic detection of pneumococcus, meningococcus, and H. influenzae was confirmed through microbiological techniques. Samples were shipped to the Regional Reference Laboratory to corroborate results by species-specific polymerase chain reaction., Results: Overall, 3644 suspected PBM cases were reported, and 98 cases (2.7%: 98/3644) were confirmed bacterial meningitis. Pneumococcus was responsible for most infections (67.3%: 66/98), followed by H. influenzae (23.5%: 23/98) and meningococcus (9.2%: 9/98). The number of pneumococcal meningitis cases decreased by 88.1% (52/59) postvaccine introduction with 59 cases from July 2010 to June 2014 and 7 cases from July 2014 to June 2016. However, 5 cases caused by nonvaccine serotypes were observed. Fewer PBM cases caused by vaccine serotypes were observed in infants <1 year compared to children 2-5 years., Conclusions: Routine surveillance showed that PCV13 vaccination is effective in preventing pneumococcal meningitis among children <5 years of age in the Maritime region. This complements the MenAfriVac vaccination against meningococcal serogroup A to prevent meningitis outbreaks in the northern region of Togo. Continued surveillance is vital for estimating the prevalence of PBM, determining vaccine impact, and anticipating epidemics in Togo., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Objective: To determine the risk of bacterial meningitis in infants aged 29-90 days with evidence of urinary tract infection (UTI)., Methods: PubMed (MEDLINE), Embase, and the Cochrane Library were systematically searched for studies reporting rates of meningitis in infants aged 29-90 days with abnormal urinalysis or urine culture. Observational studies in infants with evidence of UTI who underwent lumbar puncture (LP) reporting age-specific event rates of bacterial meningitis and sterile cerebrospinal fluid pleocytosis were included. Prevalence estimates for bacterial meningitis in infants with UTI were pooled in a random effects meta-analysis., Results: Three prospective and 17 retrospective cohort studies were included in the meta-analysis. The pooled prevalence of concomitant bacterial meningitis in infants with UTI was 0.25% (95% CI, 0.09%-0.70%). Rates of sterile pleocytosis ranged from 0% to 29%. Variation in study methods precluded calculation of a pooled estimate for sterile pleocytosis. In most studies, the decision to perform a LP was up to the provider, introducing selection bias into the prevalence estimate., Conclusions: The risk of bacterial meningitis in infants aged 29-90 days with evidence of UTI is low. A selective approach to LP in infants identified as low risk for meningitis by other clinical criteria may be indicated., (Published by Elsevier Inc.)

Background: Otitis media (OM) is a common childhood infection that may result in bacterial meningitis (BM). However, OM-associated BM remains poorly characterized. We aimed to study the occurrence, clinical presentation and outcome of this type of childhood BM in Luanda, Angola., Methods: Five hundred twelve children from our previous clinical BM trial, with the ear meticulously examined, were analyzed whether they had or not OM, and according to their age, ≤12 month old and >12 month old. Prospectively collected clinical data, laboratory test results and outcome for these groups were assessed., Results: Sixty-two children (12%) had OM-associated BM, of whom 39 had otorrhea. Ear discharge was more common in older children (median age 45 months old vs. 12 months old; P < 0.001). Children with OM often showed an additional infectious focus (n = 20, 32% vs. n = 82, 18%; P = 0.016), were dehydrated (n = 16, 26% vs. n = 66, 15%; P = 0.04), and showed higher odds of complicated clinical course or death (odds ratios 2.27, 95% CI: 1.004-5.15, P = 0.049) compared with children without OM. The >12-month-old children with OM often arrived in poor clinical condition with coma and/or ptosis. Otorrhea was associated with HIV positivity. Infants with otorrhea frequently lived under poor socioeconomic conditions., Conclusions: Children with OM-associated BM were prone to many problems, such as being especially ill at presentation, undergoing a difficult clinical course and showing a higher risk of complicated or fatal outcome. HIV infection and malnutrition were common in children with otorrhea, which was also associated with low socioeconomic status.

Meningitis is a rare but serious complication in patients with Currarino syndrome. We present a 6-year-old girl with a fulminant meningitis due to an enterothecal fistula involving the anterior sacral meningocele. Initial treatment consisted of broad-spectrum intravenous antibiotic therapy and laparoscopic construction of a deviating double-loop ileostomy. This was followed by an elective posterior neurosurgical approach with a sacral laminectomy, evacuation of the empyema, and securing the disconnection of the anterior meningocele from the thecal sac, 10 days after initial hospital admission. The girl made a good postoperative recovery. The treatment strategy in the setting of meningitis due to an inflamed anterior meningocele is discussed and the available literature on the topic is reviewed.

We report the case of a Ureaplasma parvum meningitis in an immunocompetent patient, 17 days after surgical ablation of a craniopharyngioma. Presence of U. parvum in the cerebrospinal fluid was assessed by 16S rDNA sequencing and U. parvum specific PCR. This article details a surprising complication in an adult of a transphenoidal surgery for ablation of a craniopharyngioma. This is the first case, to our knowledge, of U. parvum meningitis in an adult patient., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The epidemiologic trend of acute bacterial meningitis can change more dramatically than any other bacterial disease, and a decrease in spontaneous adult bacterial meningitis (ABM) has been noted in serial studies of the epidemiologic trend of ABM in Taiwan. The purpose of this study was to analyze the clinical characteristics, laboratory data and therapeutic outcomes of 149 patients with spontaneous Gram-negative (G(-)) ABM collected during a study period of 31 years (1986-2016). The 149 patients included 107 men and 42 women, aged 18-86 years. The common underlying conditions were diabetes mellitus, liver cirrhosis and alcoholism, and the leading clinical presentations were fever, altered consciousness and septic shock. Compared the clinical characteristics of the patients identified in the study period of 2001-2106 to the patients identified in the study period of 1986-2000, the former group of patients had a significantly higher incidence of systemic malignance. In the recent 16 years (2001-2016), Klebsiella pneumoniae, Pseudomonas spp. and Escherichia coli were the leading three implicated bacterial pathogens of spontaneous G(-) ABM, accounting for 61.3% (38/62), 11.3% (7/62) and 11.3% (7/62%) of all cases, respectively. The overall mortality rate from spontaneous G(-) ABM was high (47.0%, 70/149) and the presence of septic shock and lower cerebrospinal fluid glucose level were significant prognostic factors. Because of the decreasing incidence of spontaneous ABM in Taiwan, close examination of this specific infectious syndrome is important in order to monitor the epidemiologic trend and improve the therapeutic strategy., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

A 52-year-old man was admitted to our hospital because of two episodes of bacterial meningitis within a 6-month period. CSF examination showed neutrophilic pleocytosis with marked elevation of protein and hypoglycorrhachia, but the inflammatory reaction was mild and blood and CSF cultures were negative. At the time of the second admission, intermittent watery nasal discharge caused by CSF rhinorrhea was evident. CT and MR imaging revealed a tiny clival bone defect, and transnasal endoscopic repair was performed successfully. The pathological diagnosis was chordoma based on immunohistochemical staining for brachyury. Although chordoma presenting as recurrent bacterial meningitis occurs extremely rare, asking patients detailed questions about the CSF rhinorrhea must be essential for disclosing unclear infection sources.

Background: Negative-pressure hydrocephalus is a rare condition with the development of symptomatic hydrocephalus despite subnormal intracranial pressure (ICP). The etiology remains unclear. Some authors proposed that the differential pressure between the ventricular space and the subarachnoid space over cerebral convexity leads to the development of ventriculomegaly, namely as the transmantle pressure theory., Case Description: A 49-year-old patient with a left Sylvian fissure arachnoid cyst underwent several surgeries including cystoperitoneal shunts and fenestrations of the cyst. The patient developed a cerebrospinal fluid fistula from the cranial wound was complicated by bacterial meningitis. Consequently, the shunt was removed, and external cyst drainage was placed. After 9 days, the patient developed acute hydrocephalus requiring external ventricular drainage (EVD). Two days later, after overdrainage of the external cyst drain, the patient suffered neurologic deterioration. The ICP measured by the EVD was -4 cm H 2 O, and a computed tomography scan demonstrated progression of the hydrocephalus. The external cyst drainage was shut off and the EVD level was adjusted to produce between 5 and 10 mL/hour of cerebrospinal fluid under a subatmospheric pressure set at -5 cm H 2 O, and gradually raised in increments of 1 cm every 3 days until a positive ICP occurred. Once clinical and radiographic stability was accomplished, a programmable ventriculoperitoneal shunt was inserted set to 30 mm H 2 O. A marked clinical and radiologic improvement was observed in the follow-up., Conclusions: This negative-pressure hydrocephalus case report supports the main role of the transmantle pressure theory. The subatmospheric EVD method and a low-pressure valve resulted in excellent clinical and radiographic outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Granulibacter bethesdensis is a pathogen reported to cause recurrent lymphadenitis exclusively in persons with chronic granulomatous disease. We report a case of fatal meningitis caused by a highly virulent G. bethesdensis strain in an adolescent in Europe who had chronic granulomatous disease.

Background: Owing to its antibacterial properties, ceftaroline could be attractive for prevention or treatment of bacterial post-neurosurgical meningitis/ventriculitis. However, few data are available concerning its meningeal concentrations., Objectives: To investigate ceftaroline CSF pharmacokinetics in ICU patients with an external ventricular drain (EVD)., Methods: Patients received a single 600 mg dose of ceftaroline as a 1 h intravenous infusion. Blood and CSF samples were collected before and 0.5, 1, 3, 6, 12 and 24 h after the end of the infusion. Concentrations were assayed in plasma and CSF by LC-MS/MS. A two-step compartmental pharmacokinetic analysis was conducted. Ceftaroline plasma data were first analysed, and thereafter plasma parameters estimated and corrected for protein binding of 20% were fixed to fit unbound CSF concentrations. In the final model, parameters for both plasma and CSF data were simultaneously estimated., Results: Nine patients with an EVD were included. The Cmax was 18.29 ± 3.33 mg/L in plasma (total concentrations) and at 0.22 ± 0.17 mg/L in CSF (unbound concentration). The model-estimated CSF input/CSF output clearance ratio was 9.4%, attesting to extensive efflux transport at the blood-CSF barrier., Conclusions: Ceftaroline CSF concentrations are too low to ensure prophylactic protection against most pathogens with MICs between 1 and 2 mg/L, owing to its limited central distribution., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Rationale: Trans-sacral epiduroscopic laser decompression (SELD) is a noninvasive pain-relieving procedure for treatment of herniated lumbar disc (HLD), and is known to have positive effects in alleviating lower back pain or radicular leg pain after HLD. However, little is known about the possible complications of SELD., Patient Concerns: A 51-year-old woman received SELD with a holmium:yttrium-aluminum-garnet laser for controlling radicular pain due to HLD on L5-S1. However, 5 days after SELD, she complained of headache, and 9 days after the SELD, cauda equine syndrome (CES) symptoms, including motor weakness of both lower extremities (manual muscle testing-left: 3, right: 4), voiding and defecation difficulties, and neuropathic pain, were manifested., Diagnoses: Cerebrospinal fluid (CSF) analysis performed 15 days after the SELD revealed elevated white blood cell count 7560 cells/μL. Staphylococcus hominis sensitive to vancomycin was cultured from CSF. The gadolinium-enhanced magnetic resonance imaging showed diffuse leptomeningeal enhancement along the distal cord and cauda equina. The latency of electrically induced bulbocavernosus reflex (BCR) was delayed in the right side and no response of BCR was presented in the left side. Based on the patient's symptoms and the results of the clinical evaluation, we diagnosed the patient as having a bacterial meningitis and CES., Interventions: The patient received 2 g per day of intravenous vancomycin for 2 months., Outcomes: After treatment with intravenous vancomycin for 2 months, all the CES symptoms were completely resolved., Lessons: In this study, we described a patient who had bacterial meningitis after SELD. During SELD, clinicians should keep in mind the possibility of infection.

Aims: To evaluate the efficacy of our methods for decreasing the incidence of post-operative central nervous system infections (PCNSI) and to assess the type of microbiology and risk factors associated with PCNSI., Methods: This prospective study was performed at First Affiliated Hospital, College of Medicine, Zhejiang University, which is a major medical centre in eastern China. The study included adult patients who underwent cranial surgery from January 2014 to October 2015 at this institution and survived for more than 7 days . The demographic information and clinical data of the patients were recorded for every operation and the incidence of PCNSI and the type of microbiology were analysed separately for patients undergoing craniotomy and those undergoing cranial burr-hole surgery. Prior to initiation of the study, our research team had developed and implemented a series of methods for reducing infection rates in our department., Results: A total of 1,616 cranial surgery procedures were assessed in the present study; 1,236 craniotomy/craniectomy operations and 380 cranial burr-hole surgery operations. Of these procedures, 29 were complicated by PCNSI (27 cases with meningitis/ventriculitis and two with intracranial abscess/empyema). The overall incidence of PCNSI was 1.8%, while the incidence of craniotomy/craniectomy operations was 2.0% (25 cases) and that of burr-hole surgery operations was 1.1% (four cases); the most common microorganism was Staphylococcus. Of the patients who underwent cranial burr-hole surgery, the only independent risk factor for PCNSI was the absence of prophylactic antibiotics. There were no independent risk factors for craniotomy/craniectomy operations., Conclusions: In the present large-sample study, the incidence of PCNSI was 1.8%, which was dramatically lower than that of a previous study performed by our research group.

Objectives: Streptococcus agalactiae (group B streptococcus, GBS) is an uncommon cause of bacterial meningitis in adults. We describe clinical characteristics, serotype distribution and outcome of adult GBS meningitis., Patients and Methods: Patients aged 16 years or older with GBS cultured in cerebrospinal fluid included in two prospective nationwide cohort studies performed in the Netherlands between 1998-2002 and 2006-2017 were evaluated., Results: We identified 33 patients with GBS meningitis with a median age of 58 years of whom 22 were male (67%). The mean annual incidence was .16 per 1.000.000 adults. Ten patients (30%) had an immunocompromised state, which was due to alcoholism in 6 (18%) and diabetes mellitus in 4 (12%). Eleven patients (33%) had a distant focus of infection of whom 4 had endocarditis (13%). Seven patients (21%) died and 6 (18%) survivors had sequelae causing disability, including reduced vision and blindness due to endophthalmitis (n = 2). Twenty patients (61%) made a full recovery. Most common bacterial serotypes were serotype III (41%) and Ia (25%). Serotype V was associated with increased mortality (3 of 4 [75%] serotype V died vs. 4 of 28 [14%] other serotypes, P = .025)., Conclusion: GBS is a rare cause of meningitis in adults that more frequently occurs in patients with underlying comorbidities. Patients should be carefully evaluated for distant foci of infection. GBS serotype V is associated with poor outcome., (Copyright © 2018 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Infections associated with neurosurgical procedures are serious complications that contribute to the morbidity and mortality of neurocritical patients, as well as to the prolongation of the stay in the ICU and the hospital. The diagnosis is complex since there is no gold standard, so it is based on clinical suspicion, CSF physical-chemical examination, and microbial isolation. Treatment should be initiated early, guided by local epidemiology. The duration will depend on the causative microorganism, its sensitivity and the availability of antibiotic treatments that are effective at the site of infection. The implementation of preventive measures with proven efficacy minimizes the risk of infection. This SADI-SATI intersociety update reviews relevant data recently published on this area at the national at international level regarding epidemiology, diagnostic methodologies, therapeutic approaches, and prevention guidelines.

Objective: To compare the risk of serious bacterial infection between infants aged ≤60 days who are febrile in the emergency department (ED) and those who have only a history of fever and are afebrile on arrival to the ED., Study Design: In this secondary analysis of a multicenter prospective study using data collected between December 2008 and May 2013, we compared the rate of serious bacterial infection (urinary tract infection [UTI], bacteremia, and/or bacterial meningitis) between infants who have a history of fever but are afebrile on arrival to the ED and those with fever documented in the ED (rectal temperature ≥38.0 °C) using relative risk (RR) with 95% CI. Stratified analyses were performed for age (≤28 and 29-60 days) and serious bacterial infection type. Infants born prematurely and those with a clinical focal infection or serious illness were excluded., Results: A total of 3825 infants (mean age, 35.2 days; 56.9% male) were included. Of the 1233 (32.2%) who were afebrile in the ED, 108 (8.8%) had a serious bacterial infection (UTI, n = 94 [7.6%]; bacteremia, n = 19 [1.5%]; bacterial meningitis, n = 8 [0.6%]). Of the 2592 infants (67.8%) who were febrile in the ED, 331 (12.8%) had a serious bacterial infection (UTI, n = 285 [11.0%]; bacteremia, n = 61 [2.4%]; bacterial meningitis, n = 17 [0.7%]). The RR for serious bacterial infection for afebrile vs febrile infants was 0.68 (95% CI, 0.56-0.84). A lower risk of serious bacterial infection was also seen among afebrile vs febrile infants aged ≤28 days (RR, 0.69; 95% CI, 0.52-0.93) and age 29-60 days (RR, 0.67; 95% CI, 0.50-0.89)., Conclusions: The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Rationale: Iatrogenic cerebrospinal fluid (CSF) rhinorrhea in a bilateral frontal decompressive craniectomy patient triggered by strenuous sport is rare. To the best of our knowledge, no similar case has yet been reported., Patient Concerns: Herein, we report a case of CSF rhinorrhea in a 37-year-old man. He had previously suffered a traumatic brain injury in a traffic accident, and a subsequent bilateral frontal decompressive craniectomy operation was performed. Based on the frontal skull defect peculiarity, strenuous exercise may have caused drastic CSF pressure waves to tear the dura mater of the anterior skull base, resulting in CSF rhinorrhea., Diagnoses: The thin-slice computerized tomography (CT) images revealed a frontal skull defect and the open frontal sinus. In addition, in the opened frontal sinus, low-density liquid-filled areas were visible., Interventions: During surgery, the torn dura was carefully repaired, and the frontal sinus was filled with temporal muscle, fascia, and fibrin glue. A simultaneous cranioplasty was performed., Outcomes: The patient was followed-up postoperatively for 12 months to date without rhinorrhea recurrence. Recovery was uneventful., Lessons: Patients with skull defects should avoid strenuous sports, and cranioplasty should be performed as early as possible in order to decrease the likelihood of a dural tear and prevent the occurrence of CSF leakage. After cranioplasty, the skull should be restored to a closed state to reduce the damaging effects of CSF waves during movement. It is important to maintain normal intracranial pressure to reduce the recurrence rate of CSF rhinorrhea.

Rationale: The transsphenoidal surgical (TS) approach to sellar masses is the preferred surgical route in most cases. Secondary pituitary abscess (PA) following TS is an extremely rare but serious postoperative complication with potentially high disability and mortality., Patient Concerns: We describe an uncommon case of secondary PA in a 42-year-old woman, who underwent uncomplicated transsphenoidal procedures without cerebrospinal fluid leak, to treat primary Rathke cleft cyst. Without obvious cause, the patient suffered recurrent meningitis with complaints of headache, hyperpyrexia, and chills from 1 month after the operation., Diagnosis: There were no significant imaging findings until a new rim-enhancement lesion was seen in the sellar region on magnetic resonance imaging during the 6th episode of meningitis 11 months after the initial surgery. A diagnosis of secondary PA was considered; INTERVENTIONS:: Therefore, she underwent a 2nd TS with pus evacuation and antibiotic treatment., Outcomes: She improved remarkably and had no recurrence of symptoms during the 9-month follow-up., Lessons: Our aim was to present this rare case and discuss the most likely etiologies and preventive measures for this condition. In patients with recurrent meningitis but dormant imaging manifestations after TS, the possibility of secondary PA should considered. Adequate surgical drainage with microbiology-guided antibiotic therapy is the 1st choice for treatment.

Background: Bacterial meningitis is a significant cause of morbidity and mortality worldwide among children aged 1-59 months. We aimed to describe its burden in South Asia, focusing on vaccine-preventable aetiologies., Methods: We searched five databases for studies published from January 1, 1990, to April 25, 2017. We estimated incidence and aetiology-specific proportions using random-effects meta-analysis. In secondary analyses, we described vaccine impact and pneumococcal meningitis serotypes., Results: We included 48 articles cumulatively reporting 20,707 cases from 1987 to 2013. Mean annual incidence was 105 (95% confidence interval [CI], 53-173) cases per 100,000 children. On average, Haemophilus influenzae type b (Hib) accounted for 13% (95% CI, 8-19%) of cases, pneumococcus for 10% (95% CI, 6-15%), and meningococcus for 1% (95% CI, 0-2%). These meta-analyses had substantial between-study heterogeneity (I 2  > 78%, P < 0.0001). Among studies reporting only confirmed cases, these three bacteria caused a median of 78% cases (IQR, 50-87%). Hib meningitis incidence declined by 72-83% at sentinel hospitals in Pakistan and Bangladesh, respectively, within two years of implementing nationwide vaccination. On average, PCV10 covered 49% (95% CI, 39-58%), PCV13 covered 51% (95% CI, 40-61%), and PPSV23 covered 74% (95% CI, 67-80%) of pneumococcal meningitis serotypes. Lower PCV10 and PCV13 serotype coverage in Bangladesh was associated with higher prevalence of serotype 2, compared to India and Pakistan., Conclusions: South Asia has relatively high incidence of bacterial meningitis among children aged 1-59 months, with vaccine-preventable bacteria causing a substantial proportion. These estimates are likely underestimates due to multiple epidemiological and microbiological factors. Further research on vaccine impact and distribution of pneumococcal serotypes will inform vaccine policymaking and implementation., (Copyright © 2018 Elsevier Ltd. All rights reserved.)