Neonatal <i>Citrobacter</i> meningitis: Pathogenesis of cerebral abscess formation

Foreman, Susan D.; Smith, Edward E.; Ryan, Nell J.; Hogan, Gwendolyn R.

doi:10.1002/ana.410160606

Cited by 42 publications

(22 citation statements)

References 29 publications

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“…This finding is in contrast to the results reported by Jadavji et al [18] who found 10/74 (14%) patients to be younger than 1 year of age. Brain abscess in neonates and young infants occurs almost exclusively secondary to gram-negative bacterial meningitis [10,13,21,22,29,31]. Early and adequate treatment of gramnegative infections, and the absence of types of bacteria with tendency for brain abscess formation such as Citrobacter species, could -at least in part -explain this striking difference in age distribution.…”

Section: Discussionmentioning

confidence: 96%

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Brain abscess in childhood-long-term experiences

1991

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A retrospective evaluation was performed on 28 cases of paediatric brain abscess (male: female ratio 2.5:1; mean age 9.4 years; range 2.8-16 years) diagnosed between 1967 and 1987. In 46%, congenital cyanotic heart disease was identified as a predisposing factor, likewise sinusitis, otitis media or mastoiditis in 29% and immunodeficiency in 11%. Pathogenesis remained unclear in 14%. Initial symptoms and signs were predominantly nonspecific; loss of consciousness occurred in 32% of cases, neurological deficit and seizures each in 25%. Since the availability of CT, both diagnostic delay after hospital admission and mortality were substantially reduced: mean delay from 8.4 to 3.0 days, and mortality from 23% to 0%. Seventeen patients (61%) had follow up examinations 9.6 years (mean) after the acute illness (range 1-21 years). Neurological sequelae were diagnosed in 35% of cases, epilepsy in 29%, epileptic potentials during EEG in 12%, and CNS scars in 50%. Psychological testing revealed no statistically significant differences compared to normal populations. CNS scars, and epilepsy and/or epileptic potentials were more common after excision (7 patients) when compared to patients treated by aspiration and/or antibiotics alone (21 patients). It is concluded that excision of brain abscess should be avoided whenever possible. Therapy of choice consists of the administration of adequate antibiotics with or without CT-guided needle aspirations.

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Section: Discussionmentioning

confidence: 96%

“…Major debate focuses on the question whether conservative treatment with antibiotics alone may be successful in managing brain abscess [2,4,13,17,20,21,23,26,28,30]. Of our patients, 29% had no surgical treatment.…”

Section: Discussionmentioning

confidence: 97%

Brain abscess in childhood-long-term experiences

1991

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“…Although the reasons for such a high association are not completely understood, it is possibly related to the development of cerebral vasculitis, with subsequent infarction and bacterial invasion of necrotic brain tissue [12,Class III]. C. diversus can cause either sporadic or epidemic neonatal meningitis [13,14,Class III].…”

Section: Introductionmentioning

confidence: 99%

Meningitis in the neonate

Kimberlin

2002

Curr Treat Options Neurol

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Group B beta-hemolytic streptococci and Escherichia coli strains account for approximately two thirds of all cases of neonatal meningitis, while bacteria that typically account for meningitis in older age groups (Haemophilus influenzae type B, Neisseria meningitidis, and Streptococcus pneumoniae) are infrequent causes of meningitis in the neonatal population. As with other medical problems in neonates, signs and symptoms of bacterial infection of the central nervous system are generally few in number and nonspecific in nature. Manifestations that can suggest meningitis, as well as other serious illnesses, include temperature instability, lethargy, respiratory distress, poor feeding, vomiting, and diarrhea. Signs suggestive of meningeal irritation, including stiff neck, bulging fontanelle, convulsions, and opisthotonus, occur only in a minority of neonates with bacterial meningitis and cannot be relied on solely to identify such patients. Ampicillin and either gentamicin or cefotaxime are recommended for initial empiric therapy of neonatal meningitis. When the results of the cerebrospinal fluid (CSF) culture and susceptibilities are known, therapy can be narrowed to cover the specific pathogen identified. In general, penicillin G or ampicillin is preferred for group B streptococcal meningitis, ampicillin for Listeria monocytogenes meningitis, and ampicillin plus either an aminoglycoside or cefotaxime for gram-negative meningitis. For the very low birth weight neonate who has been in the nursery for a prolonged period of time, organisms such as enterococci and gentamicin-resistant gram-negative enteric bacilli must also be considered. In patients with long-term vascular catheters, Staphylococcus aureus or coagulase-negative staphylococci must also be considered. Empiric combinations of antibiotics for such patients would include ampicillin or vancomycin, plus amikacin or cefotaxime. All neonates should undergo repeat CSF examination and culture at 48 to 72 hours after initiation of therapy. If organisms are observed on gram stain, modification of the therapeutic regimen should be considered, and neuroimaging should be performed. In general, therapy should be continued for 14 to 21 days for neonatal meningitis caused by group B streptococci or L. monocytogenes, and for at least 21 days for disease caused by gram-negative enteric bacilli. All patients with neonatal meningitis should have hearing and development monitored serially. The first audiologic evaluation should occur 4 to 6 weeks after resolution of the meningitis.

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“…This particular gram-negative organism has been associated with very aggressive meningitis and complications of brain abscess, subdural empyema, and frank brain infarction in neonates [1, 2, 3, 4]. It is sometimes associated with omphalitis, and numerous recent studies have addressed its virulence [5, 6, 7]. It is not uncommon to see rapidly aggressive bilateral brain abscesses when this occurs, and associated infarcts could explain the cystic encephalomalacia seen in this patient, even with the bifrontal distribution seen.…”

Section: Differential Diagnosismentioning

confidence: 99%

“…It is not uncommon to see rapidly aggressive bilateral brain abscesses when this occurs, and associated infarcts could explain the cystic encephalomalacia seen in this patient, even with the bifrontal distribution seen. The precise pathophysiological reasons why Citrobacter causes large abscesses is not known, but secondary vasculitis causing large areas of infarction are likely involved [5]. If the bacteriological data indicate that the species is Citrobacter diversus, the species is associated with abscess formation in neonates, we would be forced to conclude that this is a real isolate and treat the child for Citrobacter abscess, even with the unimpressive history for sepsis; this organism would be rare as a contaminant in this setting, and the infection would be a treatable cause of the devastating neurological disease in this infant.…”

Section: Differential Diagnosismentioning

confidence: 99%