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Author: Zhu Minli, Hu Qianhong, Mai Jingyun, Lin Zhenlang
Neonatal purulent meningitis is a serious infectious disease in the neonatal period, with high mortality, survivors can retain different degrees of neurological sequelae, and early effective antibiotic therapy is essential to reduce mortality and reduce sequelae. In recent years, there have been many reports of neonatal purulent meningitis, but due to the low detection rate of pathogenic bacteria, there are few reports on pathogenic bacteria in large samples, and the pathogenic bacteria species are closely related to geographical location, chronological changes and age of onset.
In order to understand the distribution law and drug resistance characteristics of neonatal purulent meningitis pathogens in this region, this study retrospectively analyzed 112 cases of neonatal purulent meningitis that had been positive for pathogen culture in our hospital in the past 10 years, which provided a reference for clinical diagnosis and treatment.
Objects and methods
1. Research objects
A retrospective study was conducted on all children with neonatal purulent meningitis admitted to the Department of Neonatology of the Second Affiliated Hospital of Wenzhou Medical University and Yuying Children's Hospital from January 2004 to December 2013. Inclusion criteria:
(1) Clinical manifestations of neonatal infection and neonatal purulent meningitis;
(2) Routine and biochemical examination of cerebrospinal fluid is consistent with purulent meningitis cerebrospinal fluid changes;
(3) Pathogenic bacteria are detected in blood culture or cerebrospinal fluid culture, and pathogenic bacteria that may be contaminated are excluded: for common pathogenic bacteria that are easily contaminated, such as coagulase-negative staphylococcus (CNS), it is necessary to have two positive blood cultures or clinical treatment according to its susceptibility, otherwise it is judged to be specimen contamination.
2. Research methods
1. Data collection: Clinical data such as clinical features, infection-related laboratory examinations, cranial imaging data, treatment process and treatment outcome of 112 children with neonatal purulent meningitis were collected by special personnel.
2. Culture, identification and susceptibility test of bacteria: blood, ascites, pus and cerebrospinal fluid specimens are inoculated on 5% sheep blood agar plates and incubated in a 35 °C incubator for 18 to 24 hours. Suspicious colonies on the blood plate were selected for isolation and purification, and colonies were identified with the WALKAWAY-96SI automatic analyzer NUC33 card.
From January 2004 to October 2007, the drug susceptibility test was detected by the liquid broth dilution method, and from January 2004 to October 2007, the test was applied to the test kit ATB STREP5 (French company Biomerier), and from November 2007 to December 2013, the MSTRP+1 slat was used to be tested at Microscan Walk Away 96 SI, with reference to the 2004 to 2013 judgment standards of the American Association for Standardization of Clinical Laboratories (CLSI). The quality control bacteria case was purchased from the Clinical Inspection Center of the Ministry of Health.
3. Statistical analysis: SPSS 17.0 statistical software is used to statistically analyze the data, the counting data is expressed in rate, and the comparison between groups is tested by χ2. P<0.05 for the difference was statistically significant.
Results
I. General Information:
From 2004 to 2013, a total of 309 cases of neonatal purulent meningitis were confirmed in the Department of Neonatology of our hospital, and 112 cases of pathogenic bacteria were detected. 46 cases in 04-08 and 66 cases in 09-13. There were 64 males and 48 females, gestational age 26+5-41+6w, 23 cases of preterm birth, 89 cases of term, birth weight: 27 cases of < 2.5 kg (including 7 cases of < 1.5 kg, 1 case of < 1.0 kg), 85 cases of ≥ 2.5 kg, 97 cases born in hospital, 15 cases born in private clinics or at home, and delivery methods: 81 cases of vaginal birth and 31 cases of caesarean section. Age of onset: 20 cases of early-onset type (onset within 3 days after birth) and 92 cases of late-onset type (onset on the 4th to 28th day after birth).
II. Clinical Manifestations:
The clinical manifestations of 112 children were diverse, and common symptoms: 88 cases of fever (body temperature ≥ 38 °C), 53 cases of eating less or feeding difficulties, 41 cases of convulsions, 13 cases of shortness of breath or moaning, 11 cases of vomiting, 10 cases of cyanosis, and 7 cases of abdominal distention. Common positive signs: 42 cases of poor response, 29 cases of abnormal muscle tone, 28 cases of anterior fontanillary tension or bulging, 27 cases of pathological jaundice, and 16 cases of irregular or apnea.
3. Auxiliary inspection
1． Non-specific test
There were 46 cases of peripheral blood routine abnormalities: 20 ×109/L 28 cases of white blood cell >, 5 × 109/L cases of white blood cell <, 100 cases of platelet < 100× 109/L 16 cases (including 5 cases of combined leukocyte elevation and 3 cases of combined leukocyte decline). There were 81 cases of C-reactive protein abnormalities (> 10 mg/L): 24 cases were 50-100 mg/L, and 28 cases were > 100 mg/L. Cerebrospinal fluid examination results: 50×106/L 18 cases of white blood cell <, 54 cases of ×106/L (50-1000), ×106/L 32 cases of (1000-10000), 8 cases of > 10000×106/L, 70 cases of protein < 3 g/L, 42 cases of >3 g/L (19 cases of > 5 g/L).
2． Pathogen detection and susceptibility results
Among the 309 children with neonatal purulent meningitis diagnosed from 2004 to 2013, 106 cases were positive for blood culture, except for 6 cases of staphylococcus epidermidis that were clinically considered contaminated, a total of 100 cases, and the detection rate of pathogens was 32.4% (of which 20 cases of CNS infection: 1 case of cerebrospinal fluid culture was positive, of the remaining 19 cases, 15 cases of 2 blood cultures were the same bacteria, and 9 cases improved after changing to vancomycin or linezolid according to drug sensitivity, so the clinical consideration was considered infection).
There were 30 positive CSF cultures, with a detection rate of 9.7%, namely 10 cases of Streptococcus lactobacillus, 8 cases of Escherichia coli, Staphylococcus aureus, Streptococcus bovis, Streptococcus constellation, Staphylococcus manthus, Enterococcus faecalis, Corynebacterium, Enterobacter pussus, Bacillus Essens, Proteus mirabilis, Acinetobacter baumannii and O-S. shiga-like monocellum.
Blood culture and cerebrospinal fluid were positive (all of the same bacteria) in a total of 18 cases: 7 cases of Streptococcus aerosinosa, 6 cases of Escherichia coli, Streptococcus bovis, Staphylococcus aureus, Enterobacter pussibularis, Bacillus and O.s. shigae.
5 other cultures were positive (all blood cultures were positive): 4 cases of Staphylococcus aureus culture, 1 case of ascites culture of Escherichia coli, the drug susceptibility was the same as blood culture. A case of breast-free streptococcus was detected in a maternal blood culture, and the drug susceptibility was the same as that of the child's blood culture.
Among the 112 children with positive pathogenic bacteria cultures, 62 cases (55.4%) of gram-positive bacteria, 50 cases (44.6%) of gram-negative bacteria, and a total of 92 cases of the top 5 bacteria, in order:
●32 cases of Escherichia coli (28.6%)
●CNS 20 cases (17.9%: 7 cases of Staphylococcus epidermidis, 6 cases of hemolytic staphylococcus, 3 cases of Staphylococcus manophyllus, Staphylococcus aerophylococcus, Staphylococcus warners, Staphylococcus squirrels and Staphylococcus mimicriation 1 case each)
●18 cases of streptococcus (16.1%: 15 cases of streptococcus aureus, 1 case of streptococcus constellation, streptococcus ornithus, and streptococcus bovis)
●13 cases of enterococcus (11.6%: 7 cases of Enterococcus faecalis, 5 cases of Enterococcus faecalis, 1 case of Enterococcus aymium arvosa)
●9 cases of Staphylococcus aureus (8.0%)
There were 18 other gram-negative bacilli, and the distribution was as follows: 4 cases of Klebsiella pneumoniae, 2 cases of Acinetobacter baumannii, Pseudomonas aeruginosa, and Bacillus bacillus, and 1 case of Enterobacter pussus, Proteus mirabilis, Salmonella Essens, O.d. shiga, Burkholderia onion, bacteroides, alkali-producing bacillus, and Serratia mucinalis.
There were 2 other gram-positive bacteria: 1 case each of Corynebacterium and Garcinia cambogia. There were 7 cases of hospital infection, the pathogens were: 2 cases of Klebsiella pneumoniae, 1 case of Escherichia coli, Serratia saccharyces, Enterococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis.
The composition of pathogenic bacteria in the first and second 5 years, preterm birth and term, and early-onset and late-onset pathogens is detailed in Tables 1, 2 and 3, and the susceptibility of some pathogenic bacteria is shown in Tables 4 and 5.
Table 1. Comparison of pathogenic composition of neonatal purulent meningitis for 5 years before and after [example (%)]
Table 2. Comparison of pathogenic pathogens of preterm birth and term neonatal purulent meningitis [Example (%)]
Table 3. Comparison of pathogenic pathogens of early-onset and late-onset neonatal purulent meningitis [example (%)]
Table 4. Analysis of drug resistance results of common Gram-positive bacteria in neonatal purulent meningitis [n (%)]
Table 5. Analysis of drug resistance results of partial Gram-negative bacteria susceptibility test for neonatal purulent meningitis [n (%)]
3. Cranial imaging examination
A total of 36 exceptions were observed. There were 19 cases of abnormal brain parenchymal density, 17 cases of ventricular dilation (including 13 cases of hydrocephalus), 9 cases of intracranial hemorrhage, 4 cases of subdural effusion, 3 cases of ventricular vasculitis, and 2 cases of brain abscess. The distribution of radiographic abnormal pathogens is detailed in Table 7.
4. Treatment and outcome
After the diagnosis of purulent meningitis, most children are selected for three generations of cephalosporin or meropenem combined with penicillins, and some are selected for three generations of cephalosporin or meropenem alone, after the pathogenic bacteria are identified, the sensitive antibiotics are appropriately adjusted with reference to the results of the susceptibility test, and the corresponding symptomatic supportive treatment is given. There were 14 cases of serious complications during the course of the disease: 12 cases of central respiratory failure, 5 cases of septic shock, 5 cases of multi-organ function impairment, and 2 cases of cerebral hernia.
Outcome: 69 cases were cured (clinical symptoms disappeared, cerebrospinal fluid examination was normal, and pathogen culture was negative), 23 cases were automatically discharged from the hospital, 9 cases were automatically discharged from the hospital after not curing, and 11 cases died (including 9 deaths after abandoning treatment due to serious complications): 7 cases in 04-08 (mortality rate 7/46, 15.2%), 4 cases in 09-13 years (mortality rate 4/66, 6.1%).
The pathogens of the deaths were: 5 cases of Escherichia coli, 2 cases of Streptococcus aerophyllum, 1 case of Burkholderia onion, Pseudomonas aeruginosa, Enterococcus faecalis and Enterococcus faecalis. Poor prognosis included cranial imaging abnormalities, complicated by serious complications and death, a total of 47 cases, accounting for 42.0%, as detailed in Table 6.
Table 6. Distribution of pathogens in neonatal purulent meningitis with cranial imaging abnormalities, serious complications, and deaths
(To be continued)
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