Bhutta, Z A

Naqvi, S H

English

eCommons@AKU

eCommons@AKUDepartment of Paediatrics and Child Health Division of Woman and Child HealthJune 1991Successful eradication of Flavobacteriummeningosepticum neonatal meningitis withceftizoximeZ A. BhuttaAga Khan University, zulfiqar.bhutta@aku.eduS H. NaqviAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatrPart of the Pediatrics CommonsRecommended CitationBhutta, Z. A., Naqvi, S. H. (1991). Successful eradication of Flavobacterium meningosepticum neonatal meningitis with ceftizoxime.Journal of Pakistan Medical Association, 41(6), 141-142.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatr/617SUCCESSFUL ERADICATION OF FLAVOBACTERIUMMENINGOSEPTICUM NEONATAL MENINGITIS WITHCEFTIZOXIMEPages with reference to book, From 141 To 142 Zulfiqar A. Bhutta, Shehla H Naqvi ( Department of Paediatrics, The Aga Khan University Hospital, Karachi. ) Flavobacterium meningosepticum is a gram negative, opportunistic organism which has beenimplicated in a number of outbreaks of sepsis and meningitis in newborn nurseries1-4. The infection isusually associated with a very high mortality3,4. F. meningosepticum is usually resistant to most of thecommonly used antibiotics5 and successful therapy has posed problems. We present a case report of F.meningosepticum meningitis caused by a multiply drug resistant strain of the organism.CASE REPORT A four day old newborn male was transferred to Aga Khan University Hospital (AKUH) from anotherhospital with a history of left side seizures for 48 hours. The baby was born at full term, afterspontaneous vaginal delivery to a primipara who was hypertensive during pregnancy. Birth weight was2.3kg. There were no immediate problems, but two hours after birth the baby became jittery. Bloodglucose was 32 mg/dl and serum calcium was 7.5 mg/dl. Glucose and calcium gluconate were givenintravenously. Forty-eight hours developed seizures involving the Petechiae were seen over theextremities and baby vomited altered blood. Platelet count was 25 x 109/L but prothrombin time andpartial thromboplastin time was not prolonged. Diazepam was used to control seizures and as sepsiswas suspected, cefotaxime and amikacin were given intravenously. The patient had an apneic episodefollowing which he was transferred to AKUH. At AKUH the baby was found to be hypotonic with nospontaneous movements. B.P. was normal 73/50 mmllg, HR 170/mm, RR 32/mm. Temp. was 37°C.Skin perfusion was poor. A loud systolic (2/6) murmur was present. Apneic episodes of 20-25 secondsoccurred every 5-10 minutes. Liver was palpable two cm below the right costal margin. Length andhead circumference were at 25th percentile while weight was at the 5th percentile. The baby wasassessed to be small for gestational age with postnatal sepsis and patent ductus arteriosus. Lumbarpuncture was done after infusion of platelets and fresh frozen plasma. CSF cell count and chemistrycould not be done due to the small sample obtained. Cefotaxime and Amikacin were continued afterblood and CSF cultures. Serum bilirubin had risen to total of 24.3 mg/dl with 20.3 mg/dl unconjugatedfraction. Exchange transfusion was performed and the baby was mechanically ventilated. Abdominaldistension was a persistent problem but no radiologic signs of necrotizing enterocolitis were seen.Blood and CSF cultures remained negative, but as they were obtained after the institution ofantimicrobial therapy, antibiotics were continued. Cranial ultrasonography revealed a leftsubependymal hemorrhage on day of admission. Seizure continued despite adequate anticonvulsanttherapy. Platelets remained low. Cranial computerized tomography was performed on seventh hospitalday and showed dilatation of ventricular system with contrast enhancement suggestive of ventriculitis.Ventricular CSF was examined (Table)and found to be abnormal with Grain negative bacilli seen on gram stain. Initially the organism whichwas cultured from CSF was suspected to be Pseudomonas and therapy was changed to carbenicillin andtobramycin. These were discontinued when the isolate was identified as F. meningosepticum which wassusceptible to ceftizoxime and ofloxacin and resistant to carbenicillin, gentamicin, tobramycin,amikacin, ceftriaxone, cefotaxime, polymyxin B and rifampicin on disc diffusion/testing. Asceftazidime was not readily available, rifampicin was started in a dosage of 15 mg/Kg/day I.V Q 12Halongwith ceftazidime 100 mg I.V + Q 12H. Ventricular CSF was reexamined 48 hours after startingrifampicin and ceftazidime therapy, and againyielded F. meningosepticum. Ceftizoxime was substitutedfor ceftazidime and rifampicin at this stage (five days after diagnosis of ventriculitis). Severe recurrentseizures which had persisted, ceased four days after starting ceftizoxime and platelet count which waspersistently low, became normal (168000/cumm). Ventricular CSF was found to be sterile one weekafter the initiation of this therapy. The patient started feeding and gaining weight. Treatment wascontinued for two more weeks after documenting sterilization of CSF when rifampicin and ceftizoximewere discontinued. The progressive improvement in laboratory studies is shown in table. Patient wasdischarged home however, with instructions to return for repeat CSF examination. The parents did notbring him back for one and a half months at which time he was found to have obvious hydrocephalus.Head circumference had increased to 44 cm from 33.5 cm at discharge. His neurologic examinationshowed increased tone and marked hyperreflexia. Sunset appearance of eyes was present. He had alsogained weight from 2.15 Kg at discharge to 4.5 kg. A ventriculoperitoneal shunt was placed and childwas discharged after 9 days hospitalization. Ventricular CSF cultured at this time was sterile. He hassubsequently been reviewed at 9 months of age and has significantly developmental delay withincreased tone in both lower limbs.DISCUSSION Flavobacterium meningosepticum is usually a water borne organism and has been known to proliferatein wash basins and aqueous antiseptic solutions6, leading to hospital outbreaks. There have been veryfew cases reported from the South Asian subcontinene7. The Aga Khan University Hospital in Karachihas neonatal tertiary care facilities and consequently receives patients from a large referral population.Over the last three years 88 cases of culture proven cases of neonatal septicemia and/or meningitis wereadmitted to the newborn care services at AKUH. Flavobacterium meningosepticum was isolated in twocases (2.3%). Both the cases were referred from outside facilities and were not associated withoutbreaks in the referring hospitals. Successful treatment of the F. meningosepticum infection poses anumber of difficulties as the antibiotic susceptibility pattern is unique. The organism is usually resistantto conventional first line antibiotics used in the neonatal period such as penicillin, gentamicin,ampicillin and kanamycin. However, therapeutic success has been described with intraventricularerythromycin8 intraventricular with intravenous rifampicin9 and recently with intravenoustrimethoprim-sulfa5. Our patient was referred from outside and did not have any identifiable riskfactors for sepsis other than intrauterine growth retardation. The baby developed signs of meningitiswithin 48 hours after birth suggesting early acquisition of the infection. Although the organism wasresistant to rifampicin and ceftazidime on disc diffusion testing, ceftizoxime was not readily availableand an interim therapy was initiated with these drugs. Ceftizoxime is a newer third generationcephalosporin and has been used in the therapy of gram positive and negative meningitis10. However,to our knowledge, there are no case reports of successful treatment with ceftizoxime in multiply drugresistant meningitis. We were able to sterilize the CSF in our case, but the baby developed obstructivehydrocephalus and neurological sequelae. This is understandable in view of the delay in initiation ofappropriate therapy (15 days from onset of illness). Infection with F. meningosepticum had also beenassociated with a high incidence of neurological sequelae3,4. Third generation cephalosporins haverevolutionized the therapy and outcome of gram negative meningitis and our experience indicates thatceftazidime may also prove useful in the treatment of F. meningosepticum sepsis and meningitis alsowhich have posed severe problems in therapy todate.REFERENCES 1. Abrahamsen, T., Finne, P. H. and Lingaas, E. Flavobacterium meningosepticum infections in aneonatal intensive care unit. Acta Paediatr. Scand., 1989; 78: 51.2. Cabrera, H. A. and Davis, 0. H. Epidemic meningitis of the newborn caused by flavobacteria. I.Epidemiology and bacteriology. Am. J. Dis. Child., 1961; 101: 289.3. Ratner, H. Flavobacterium meningosepticum. Infect. Control, 1984; 5: 237.4. George, it M., Cochran, C. P. and Wheeler, W. E. Epidemic meningitis of the newS horn caused byflavobacteria. II. Clinical manifeatationa and treatment. Am. 3. Dia. Child., 1961; 101: 2%.5. Thong. 84. L., Puthucheary, S. D. and Lee, EL Flavobacterium meningosepticum infection; anepidemiological study in a newborn nursery. .1. Clin. Pathol., 1981; 34: 429.7. Golcul, B. N., Chandramukhi, A., Ravikumar, R. and Aroor, S. Flavobacterium meningosepticummeningitia in a neonate. IndianJ. Pediatr., 1989; 56: 524.8. Maderazo, E. 0., Bassaria, H. P. and Quintiliani, R. Flavobacterium meningosepticum meningitia insnewborn infant. 3. Pediatr., 1974; 85: 675.9. Lee, EL, Robinson, M.J., Thong, M.L and Puthuchesry, S.D. Rifamycin in neonatal liavobacteriameningitis. Arch. Dis. Child., 1976; 51: 209.10. Cable, D., Edralin, 0. and Overturf, 0. D. Human cerebrospioal fluid phar macokinetica andtreatment of bacterial meningitis with ceftizoxime. 3. Antimicrob. Chemother., 1982: 10 (Supple c.):121.

Successful eradication of Flavobacterium meningosepticum neonatal meningitis with ceftizoxime

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1616&amp;context=pakistan_fhs_mc_women_childhealth_paediatr

Successful eradication of Flavobacterium meningosepticum neonatal meningitis with ceftizoxime

Abstract

Similar works

Full text

Available Versions

eCommons@AKU