Antimicrobial Resistance Pattern of Bacterial Meningitis Among Patients in Quetta, Pakistan

Introduction Bacterial meningitis (BM) is a lethal infectious disease that persists as a substantial cause of morbidity and mortality. The antimicrobial drug resistance in BM pathogens poses a major threat to the community while raising challenges for clinicians. For the first time, we elucidate the incidence rate of BM and its drug resistance among the population of Quetta, Balochistan. Methods A cross-sectional study was conducted (from January 2018 to March 2021) among meningitis patients admitted to government hospitals in Quetta. The cerebrospinal fluid (CSF) specimen was collected and processed for microbiological and cytological analysis. Bacterial isolates were identified and confirmed using phylogenetic analysis of the 16S rRNA gene. Results We found 35.9% (321/894) confirmed cases of BM among the population of Quetta, Balochistan. The identified bacterial isolates comprised Streptococcus pneumoniae 14.7% (130/894), Staphylococcus aureus 6.9% (61/894), Neisseria meningitidis 5.7% (51/894), Haemophilus influenzae 2.5% (22/894), Escherichia coli 4.5% (40/894), and Klebsiella pneumoniae 1.9% (17/894). A high percentage in male patients of 20.8% (186/894) was identified as compared to female patients of 15.1% (135/894). Extreme age groups such as infants (age range: 1 month to 1 year) and adults (age range: 61 years to 99 years) with low immunity were critically affected by BM. Clinical parameters such as abnormal CSF appearance, pH, and high WBCs in BM patients with endocarditis as the underlying disease were significantly at elevated risk of fatal outcome. 16S rRNA gene phylogenetic analysis confirmed the evolutionary similarity of isolated strains with prevailing pathogenic strains in Asia. Furthermore, age was identified as a significant risk factor for clinical outcomes. Conclusion The majority of the identified BM patients belonged to rural areas with limited health-care facilities and paramedic staff. The high case fatality rate 11% demonstrates increased antibiotic resistance among BM isolates, thereby stimulating its devastation in underdeveloped regions. Timely detection and intensive treatment of BM may improve critical outcomes in patients.

[1]  Xingyuan Yang,et al.  Antibiotic resistance in Pakistan: a systematic review of past decade , 2021, BMC Infectious Diseases.

[2]  Abiye Tigabu,et al.  Bacterial Meningitis Among Adult Patients at University of Gondar Comprehensive Specialized Referral Hospital , 2020, Infection and drug resistance.

[3]  G. Zhuang,et al.  Spatiotemporal clustering analysis of Expanded Program on Immunization (EPI) vaccination coverage in Pakistan , 2020, Scientific Reports.

[4]  B. T. Tadesse,et al.  Antimicrobial sensitivity profile and bacterial isolates among suspected pyogenic meningitis patients attending at Hawassa University Hospital: Cross-sectional study , 2020, BMC Microbiology.

[5]  M. Antonio,et al.  Declines in Pediatric Bacterial Meningitis in the Republic of Benin Following Introduction of Pneumococcal Conjugate Vaccine: Epidemiological and Etiological Findings, 2011–2016 , 2019, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[6]  Zuqin Yang,et al.  Hyponatremia in Children With Bacterial Meningitis , 2019, Front. Neurol..

[7]  R. Cohen,et al.  Combination therapy with ciprofloxacin and third-generation cephalosporin versus third-generation cephalosporin monotherapy in Escherichia coli meningitis in infants: a multicentre propensity score-matched observational study. , 2019, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[8]  F. Maoulainine,et al.  Bacterial Meningitis Profile in Newborns: Is the Epidemiology Changing? , 2018, The Open Infectious Diseases Journal.

[9]  L. Davis.  Acute Bacterial Meningitis , 2018, Continuum.

[10]  M. Skurnik,et al.  The relationship between phylogenetic classification, virulence and antibiotic resistance of extraintestinal pathogenic Escherichia coli in İzmir province, Turkey , 2018, PeerJ.

[11]  Anouk M. Oordt-Speets,et al.  Global etiology of bacterial meningitis: A systematic review and meta-analysis , 2018, PloS one.

[12]  Sudhir Kumar,et al.  MEGA X: Molecular Evolutionary Genetics Analysis across Computing Platforms. , 2018, Molecular biology and evolution.

[13]  Jing Ma,et al.  Prevalence and antibiotic resistance profiles of cerebrospinal fluid pathogens in children with acute bacterial meningitis in Yunnan province, China, 2012-2015 , 2017, PloS one.

[14]  J. Zunt,et al.  2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. , 2017, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[15]  N. Jamil,et al.  Detection of meningococcal meningitis in cerebrospinal fluid of patients with neurological disorders in government hospitals of Karachi. , 2016, JPMA. The Journal of the Pakistan Medical Association.

[16]  F. Zeeshan,et al.  Childhood Acute Bacterial Meningitis: Clinical Spectrum, Bacteriological Profile and Outcome. , 2016, Journal of the College of Physicians and Surgeons--Pakistan : JCPSP.

[17]  B. Grenfell,et al.  Seasonal dynamics of bacterial meningitis: a time-series analysis , 2016, The Lancet. Global health.

[18]  J. Harris,et al.  Molecular Identification of Staphylococcus aureus in Airway Samples from Children with Cystic Fibrosis , 2016, PloS one.

[19]  A. Attaran,et al.  Fatal Bacterial Meningitis Possibly Associated with Substandard Ceftriaxone--Uganda, 2013. , 2016, MMWR. Morbidity and mortality weekly report.

[20]  I. Mandomando,et al.  Frequency of Pathogenic Paediatric Bacterial Meningitis in Mozambique: The Critical Role of Multiplex Real-Time Polymerase Chain Reaction to Estimate the Burden of Disease , 2015, PloS one.

[21]  K. Kim.  Neonatal Bacterial Meningitis , 2015 .

[22]  M. Cohen-Wolkowiez,et al.  Bacterial meningitis in infants. , 2015, Clinics in perinatology.

[23]  D. Dominey-Howes,et al.  The Antimicrobial Resistance Crisis: Causes, Consequences, and Management , 2014, Front. Public Health.

[24]  Jie Luo,et al.  Comparative study of bacteriological culture and real-time fluorescence quantitative PCR (RT-PCR) and multiplex PCR-based reverse line blot (mPCR/RLB) hybridization assay in the diagnosis of bacterial neonatal meningitis , 2014, BMC Pediatrics.

[25]  A. Afifi,et al.  Epidemiology and Risk Factors Associated with Developing Bacterial Meningitis among Children in Gaza Strip , 2014, Iranian journal of public health.

[26]  C. Giske,et al.  Epidemiology of extended-spectrum β-lactamase-producing Escherichia coli in Sweden 2007-2011. , 2014, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[27]  S. Ladhani,et al.  Trends in bacterial, mycobacterial, and fungal meningitis in England and Wales 2004-11: an observational study. , 2014, The Lancet. Infectious diseases.

[28]  R. Hajjeh,et al.  Bacterial meningitis surveillance in the Eastern Mediterranean region, 2005-2010: successes and challenges of a regional network. , 2013, The Journal of pediatrics.

[29]  A. van der Ende,et al.  Endocarditis in Adults With Bacterial Meningitis , 2013, Circulation.

[30]  M. Reis,et al.  Accuracy of real-time PCR, Gram stain and culture for Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae meningitis diagnosis , 2013, BMC Infectious Diseases.

[31]  P. Reddy,et al.  Pattern and antibiogram of bacterial meningitis in children at a tertiary care hospital , 2013 .

[32]  F. Raymond,et al.  Bacterial Meningitis and Pneumococcal Serotype Distribution in Children in Cameroon , 2012, The Pediatric infectious disease journal.

[33]  Elmar Pruesse,et al.  SINA: Accurate high-throughput multiple sequence alignment of ribosomal RNA genes , 2012, Bioinform..

[34]  R. Pebody,et al.  Effective management in clusters of pneumococcal disease: a systematic review. , 2011, The Lancet. Infectious diseases.

[35]  W. Schaffner,et al.  Bacterial meningitis in the United States, 1998-2007. , 2005, The New England journal of medicine.

[36]  Diederik van de Beek,et al.  Epidemiology, Diagnosis, and Antimicrobial Treatment of Acute Bacterial Meningitis , 2010, Clinical Microbiology Reviews.

[37]  J. Stockman.  Traumatic lumbar punctures in neonates: test performance of the cerebrospinal fluid white blood cell count , 2010 .

[38]  K. Kim.  Acute bacterial meningitis in infants and children. , 2010, The Lancet. Infectious diseases.

[39]  K. Riesenberg,et al.  Attributable Mortality Rate for Carbapenem-Resistant Klebsiella pneumoniae Bacteremia , 2009, Infection Control & Hospital Epidemiology.

[40]  A. Zaidi,et al.  Surveillance of pneumococcal meningitis among children in Sindh, southern Pakistan. , 2009, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[41]  E. Fish.  The X-files in immunity: sex-based differences predispose immune responses , 2008, Nature Reviews Immunology.

[42]  M. Bissell,et al.  Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis , 2008 .

[43]  Dewesh Agrawal,et al.  Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. , 2007, JAMA.

[44]  V. Fowler,et al.  Neonatal Meningitis: What Is the Correlation Among Cerebrospinal Fluid Cultures, Blood Cultures, and Cerebrospinal Fluid Parameters? , 2006, Pediatrics.

[45]  Cheng-Hsien Lu,et al.  Seizures complicating infantile and childhood bacterial meningitis. , 2004, Pediatric neurology.

[46]  A. Costello,et al.  Serious bacterial infections in newborn infants in developing countries , 2004, Current opinion in infectious diseases.

[47]  C. Hart,et al.  Meningococcal Disease , 1974, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[48]  X. Sáez-Llorens,et al.  Bacterial meningitis in children. , 2005, Pediatric clinics of North America.

[49]  H. Chang,et al.  Community-Acquired Spontaneous Bacterial Meningitis in Adult Diabetic Patients: An Analysis of Clinical Characteristics and Prognostic Factors , 2002, Infection.

[50]  W. Poole,et al.  Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants. , 2002, The New England journal of medicine.

[51]  B. Foxman,et al.  Molecular epidemiology: focus on infection. , 2001, American journal of epidemiology.

[52]  R. Polin,et al.  Neonatal bacterial meningitis. , 2001, Seminars in neonatology : SN.

[53]  M. Ferraro.  Performance standards for antimicrobial susceptibility testing , 2001 .

[54]  Cheng-Hsien Lu,et al.  Adult bacterial meningitis in southern Taiwan: epidemiologic trend and prognostic factors , 2000, Journal of Neurological Sciences.

[55]  C. Choi,et al.  Bacterial meningitis. , 1992, Clinics in geriatric medicine.

[56]  R. Daynes,et al.  Dihydrotestosterone exerts a depressive influence on the production of interleukin-4 (IL-4), IL-5, and gamma-interferon, but not IL-2 by activated murine T cells. , 1991, Blood.

[57]  J. Gruber.  Bacterial meningitis in the United States, 1978 through 1981: The national bacterial meningitis surveillance study , 1985 .

[58]  K J Ryan,et al.  Antimicrobial Susceptibility Testing , 2016, Advances in Experimental Medicine and Biology.