Declines in Pediatric Bacterial Meningitis in the Republic of Benin Following Introduction of Pneumococcal Conjugate Vaccine: Epidemiological and Etiological Findings, 2011-2016.

BACKGROUND: Pediatric bacterial meningitis (PBM) remains an important cause of disease in children in Africa. We describe findings from sentinel site bacterial meningitis surveillance in children <5 years of age in the Republic of Benin, 2011-2016. METHODS: Cerebrospinal fluid (CSF) was collected from children admitted to Parakou, Natitingou, and Tanguieta sentinel hospitals with suspected meningitis. Identification of Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae, and Neisseria meningitidis (meningococcus) was performed by rapid diagnostic tests, microbiological culture, and/or polymerase chain reaction; where possible, serotyping/grouping was performed. RESULTS: A total of 10 919 suspected cases of meningitis were admitted to the sentinel hospitals. Most patients were 0-11 months old (4863 [44.5%]) and there were 542 (5.0%) in-hospital deaths. Overall, 4168 CSF samples were screened for pathogens and a total of 194 (4.7%) PBM cases were confirmed, predominantly caused by pneumococcus (98 [50.5%]). Following pneumococcal conjugate vaccine (PCV) introduction in 2011, annual suspected meningitis cases and deaths (case fatality rate) progressively declined from 2534 to 1359 and from 164 (6.5%) to 14 (1.0%) in 2012 and 2016, respectively (P < .001). Additionally, there was a gradual decline in the proportion of meningitis cases caused by pneumococcus, from 77.3% (17/22) in 2011 to 32.4% (11/34) in 2016 (odds ratio, 7.11 [95% confidence interval, 2.08-24.30]). Haemophilus influenzae meningitis fluctuated over the surveillance period and was the predominant pathogen (16/34 [47.1%]) by 2016. CONCLUSIONS: The observed decrease in pneumococcal meningitis after PCV introduction may be indicative of changing patterns of PBM etiology in Benin. Maintaining vigilant and effective surveillance is critical for understanding these changes and their wider public health implications

Suggested guideline for use of antibiotics in prophylaxis and suspected secondary infections.

<p>* Ciprofloxacin is not generally recommended for use in children, but appears relatively safe <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002010#pntd.0002010-Grayson1" target="_blank">[36]</a>.</p

Susceptibility of cultured organisms (other than <i>M. ulcerans</i>) in Buruli ulcer lesions in Benin.

<p>Cultures taken from both the center and the border of the ulcer at start of treatment in patients followed longitudinally were included, leading to a different number of cultures than in <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002010#pntd-0002010-t004" target="_blank">Table 4</a>.</p

Antibiotic treatment given to patients for different Buruli ulcer related indications.

<p>Antibiotic treatment given to patients for different Buruli ulcer related indications.</p

Sensitivity of the cultured MRSA.

<p>Sensitivity of the cultured MRSA.</p

Results of cultures in 71 patients before, during or after treatment with streptomycin and rifampicin.

<p>For patients followed longitudinally, only cultures from the center of the ulcer were included at inclusion (cultures from border gave similar results).</p

Clinical signs reported before start of antibiotics for a suspected secondary infected BU.

<p>WBC = White Blood cell Count.</p

Number of days of prescribed antibiotics per 100 days in hospital.

*<p>Standard treatment of <i>M. ulcerans</i> with 56 days of rifampicin and streptomycin not included in this table.</p

Towards Rational Use of Antibiotics for Suspected Secondary Infections in Buruli Ulcer Patients

<p>Background: The emerging disease Buruli ulcer is treated with streptomycin and rifampicin and surgery if necessary. Frequently other antibiotics are used during treatment.</p><p>Methods/Principal Findings: Information on prescribing behavior of antibiotics for suspected secondary infections and for prophylactic use was collected retrospectively. Of 185 patients that started treatment for Buruli ulcer in different centers in Ghana and Benin 51 were admitted. Forty of these 51 admitted patients (78%) received at least one course of antibiotics other than streptomycin and rifampicin during their hospital stay. The median number (IQR) of antibiotic courses for admitted patients was 2 (1, 5). Only twelve patients received antibiotics for a suspected secondary infection, all other courses were prescribed as prophylaxis of secondary infections extended till 10 days on average after excision, debridement or skin grafting. Antibiotic regimens varied considerably per indication. In another group of BU patients in two centers in Benin, superficial wound cultures were performed. These cultures from superficial swabs represented bacteria to be expected from a chronic wound, but 13 of the 34 (38%) S. aureus were MRSA.</p><p>Conclusions/Significance: A guide for rational antibiotic treatment for suspected secondary infections or prophylaxis is needed. Adherence to the guideline proposed in this article may reduce and tailor antibiotic use other than streptomycin and rifampicin in Buruli ulcer patients. It may save costs, reduce toxicity and limit development of further antimicrobial resistance. This topic should be included in general protocols on the management of Buruli ulcer.</p>