%20Shika,%20Zaria_files/page_001.jpg)
Niger J Paed 2013; 40 (1): 70 –74
ORIGINAL
Mado SM
Pattern and antimicrobial sensitivity
Aikhionbare HA
of pathogens in acute bacterial
Akpede GO
meningitis beyond neonatal period
at Ahmadu Bello University
Teaching Hospital (ABUTH) Shika,
Zaria
DOI:http://dx.doi.org/10.4314/njp.v40i1.13
Accepted: 23rd July 2012
Abstract The
causative agents
of
terial meningitis in this study was
acute bacterial meningitis vary from
6.9%. Sixty-six patients with acute
Mado SM
(
)
Aikhionbare HA
time to time and from place to place.
bacterial meningitis were identified
Department of Paediatrics,
In
addition, changes in pathogen’s
using 3 diagnostic methods (Gram
Ahmadu Bello University Teaching
sensitivity to antibiotics in use occur.
stain, culture and LPA). The 3 com-
Hospital, Zaria, Nigeria
The
study was undertaken to identify
monest organisms were
Streptococ-
Email: sanimado@yahoo.co.uk
the
pattern and susceptibility of
cus pneumoniae 34
(51.5%), Hae-
Tel: +2347037962150
pathogens to antibiotics among chil-
mophilus influenzae 18
(27.3%),
dren beyond neonatal period for
and
Neisseria
meningitidis
12
Akpede GO
prompt empirical treatment of this
(11.2%). The sensitivity of the iso-
Department of Paediatrics,
important cause of morbidity and
lates to three commonly used non-
Irrua Specialist Teaching Hospital,
Edo
State. Nigeria
mortality especially in developing
cephalosporin
antibiotics
was
countries.
chloramphenicol 74.4%, penicillin
Objective. To
identify the
pattern and
38.5%, and ampicillin 2.6%. The
susceptibility of pathogens in acute
sensitivity to the cephalosporin was
bacterial meningitis among children
cefotaxime 97.4%, and ceftriaxone
aged one month to 12 years at
89.7% while that to Ofloxacin, a
ABUTH Shika, Zaria.
quinolone, was 100%.
Method: This
was a
prospective
Conclusion: The
three commonest
study carried out in children present-
bacterial agents causing post neona-
ing to Emergency Pediatric Unit of
tal meningitis were
Streptococcus
ABUTH Shika, Zaria, from October
pneumoniae , Haemophilus
influen-
2005 to September 30 , 2006.
th
1
st
zae ,
and Neisseria meningitidis
.
Children who met the inclusion crite-
There is an increasing resistance to
ria for lumbar puncture were con-
the three commonly used non-
secutively recruited. Cerebrospinal
c
e p h a l o s p o r i n
a
n t i b i o t i c s
fluid (CSF) samples were collected
(chloramphenicol, ampicillin and
for microscopy, culture, sensitivity,
penicillin) and hence, cefotaxime or
and Latex Particle Agglutination
ceftriaxone should be used in the
(LPA) test. Sixty-six (66) patients
empirical treatment of children with
satisfied the criteria for acute bacte-
suspected acute bacterial meningitis
rial meningitis and were studied.
beyond neonatal period.
Results: The
prevalence of
acute bac-
Introduction
type b) vaccine era.
4,5
The predominance of Hib in in-
fancy and toddlers in pre Hib vaccine era was more in
Acute bacterial meningitis is an important cause of mor-
developed countries,whereas reports from African stud-
bidity and mortality throughout the world. It is among
1
ies including Nigeria found
Streptococcus pneumoniae
the commonest neurological disorders in children in the
and Neisseria
meningitidis as the two most important
pathogens.
6
tropical countries. it is of note that the disease remains a
2
significant cause of morbidity and mortality in many
developing countries despite advances in medical treat-
The causative agents of meningitis varies from place to
ment.
2,3
it
has been observed that many pathogens can
place and alsotheir antibiotic susceptibility and therefore
cause meningitis, but however,
Haemophilus influenzae
knowledge of the locally predominant organisms in dif-
was reported to be the common cause in infancy and
ferent age groups and their sensitivity pattern is essential
toddler-age group in pre-Hib (
Haemophilus influenzae
for effective chemotherapy. Furthermore,for a poten-
%20Shika,%20Zaria_files/page_002.jpg)
71
tially fatal infection like childhood meningitis,the need
reactions slides. Each card has seven reaction fields cor-
for periodic assessment of the continuing sensitivity of
responding to the reagents. Forty microlitre of test speci-
the causative agents to antimicrobial in use is necessary.
men was dispensed to each field and thoroughly mixed
This is particularly necessary especially where non- ex-
using the stirrer (supplied with the kits) for each field
istenceof rapid investigative modalities leave the clini-
the mixture covered the entire field completely. For the
cian with no choice but to initiate empirical treatment.
plastic reaction slides, it was ensured that the latex-
The objectives of the current study were therefore, to
sample mixture migrated into the capillary of each slide.
identify the pattern and antimicrobial sensitivity of
The result was read within 10 minutes. A uniform white
pathogens in acute bacterial meningitis beyond neonatal
precipitate appearing in only the reaction field was con-
period at ABUTH Shika, Zaria.
sidered positive, indicating the presence of antigen of
the corresponding organism. The test was considered
negative if the mixture remained homogenous.
Subjects and Methods
Data collected were entered into computer and Epi-info
version 3.3.2 was used for analysis. Simple tables were
The study was conducted in the Emergency Pediatric
drawn for the frequencies and percentages. Chi –square
Unit (EPU) of ABUTH Shika, Zaria from October 1
st
test
was used for comparison of proportions. A p-value
2005 to September 30 , 2006. The approval of ABUTH
th
< 0.05 was considered statistically significant.
Shika, Zaria Ethical Committee was sought for and ob-
tained before the commencement of the study. Also in-
formed parental/Care giver consent was sought before
lumbar puncture (LP).Children aged one month to 12
years with suspected acute bacterial meningitis had LP.
Results
The criteria for LP for children < 18 months are as fol-
lows: presence of fever and convulsion with or without
Sixty-six patients who met the inclusion criteria were
either vomiting, irritability, loss of consciousness, and/
studied. During the study period, 956 children aged one
or
bulging anterior fontanelle while for children > 18
month to 12 years were admitted into EPU. The preva-
months, LP was done in the presence of: (a) fever and
lence of bacterial meningitis was 6.9% (66 of 956).
convulsion plus presence or absence of typical signs of
Thirty-nine (59.1%) patients were males and 27 (40.9%)
meningeal irritation (defined by neck stiffness, positive
females. The ages ranged from one month to 12 years
Kernig’s and/ or Brudzinski’s sign), (b) fever without
with a mean age (+_1 SD) of 42.7 +_ 41.3 months. The
convulsion plus typical signs of meningeal irritation. For
male to female ratio (M: F) was 1.4:1.
the purpose of this study, acute bacterial meningitis was
defined as the presence of at least one of the following
Infections and age
features: bacterial growth on CSF culture, positive CSF
Latex Particle Agglutination (LPA) or an organism seen
The distribution of patients with acute bacterial menin-
on
Gram stain of CSF.
7
The CSF samples collected in
gitis by age is shown in table 1. Twenty-seven (40.9%)
the sterile bottles were subjected to standard Microbiol-
of
the 66 patients with acute bacterial meningitis were
ogy culture, sensitivity, and Gram staining technique.
8
infants, 20 (30.3%) were aged 13 months to four years
CSF culture was regarded as the gold standard method
while 19 (28.8%) were above four years of age.
for the diagnosis of acute bacterial meningitis. The in-
clusion of LPA in the diagnostic methods in this study
Table 1: Distribution
of cases
of acute
bacterial menin-
was done to improve the diagnostic yield as culture of
gitis in 66 patients by age.
some of the bacterial agent from CSF can be difficult
Age
in months
Frequency
Percentage
because of their fastidious nature. Also LPA was in-
cluded in the diagnostic method because the results of
1-2
6
9.1
CSF Gram stain and culture may be altered by prior use
3-12
21
31.8
of
antibiotics, a common problem in developing coun-
13-24
6
9.1
tries. The LPA test was performed on CSF supernatant
9
25-48
14
21.2
using PASTOREX MENINGITIS according to the
manufacturer’s instruction (BIO-RAD France). The test
49-144
19
28.8
Total
66
100
kits can identify Neisseria
meningitidis ,
Haemophilus
influenzae , Streptococcus
pneumoniae , Streptococcus
Pathogens and age
group B ,
and Escherichia coli. The sensitivity of
the test
kits reagent was 70% to 90% while specificity was 95%.
The distribution of pathogens in CSF was
Streptococcus
The CSF supernatant was heated for 3 minutes at 100 C
O
pneumoniae 34
(51.5%), Haemophilus influenzae
18
in
order to denature CSF proteins and to prevent non-
(27.3%), Neisseria
meningitidis 12 (18.2%), Escherichia
specific agglutination and was then centrifuged at 17000
coli 1 (1.5%), and Enterobacter specie 1 (1.5%). Eleven
revolutions per minute (rpm) for five minutes. The re-
(32.4%) of pneumococcus and 12 of
Haemophilus influ-
agents were shaken and one drop (30 microlitre) of each
enzae occurred
during infancy
while only
2 (16.7%)
dispensed to corresponding reaction fields on the latex
cases of Neisseria
meningitidis were present during in-
agglutination card and in the two wells of the two plastic
fancy.
%20Shika,%20Zaria_files/page_003.jpg)
72
Table 2 The distribution of pathogens in CSF of 66 pa-
Table 4: CSF
bacterial isolates
and their
in-vitro antibi-
tients with meningitis
otic sensitivity rates.
Age
groups (months)
Antibiotics
Organisms
1-2
3-12
13-24
25-48
49-144
Total(%)
Organisms
CHL
PEN
AMP
CEF
CEFO
OFL
Streptococcus
1
10
5
10
8
34(51.5)
pneumoniae
Streptococ-
18
11
0
(0)
21
22
22
(95.5)
Haemophilus
3
9
1
3
2
18(27.3)
cus pneumo-
(81.8)
(50)
(100)
(100)
influenzae
niae (n=22)
Neisseria
-
2
-
1
9
12(18.2)
Haemophilus
6
0
(0)
0
(0)
7
9
9
(100)
meningitidis
influenzae
(66.7)
(77.8)
(100)
Escherichia
1
-
-
-
-
1(1.5)
(n=9)
coli*
Neisseria
4
4
0
(0)
6
6
6
(100)
Enterobacter
1
-
-
-
-
1(1.5)
meningitidis
(66.7)
(66.7)
(100)
(100)
species**
(n=6)
Total
6
21
6
14
19
66(100)
Escherichia
1
0
(0)
1
1
1
1
(100)
coli (n=1)
(100)
(100)
(100)
(100)
*Isolated in a 6- week old infant
Enterobacter
0
(0)
0
(0)
0
(0)
0
(0)
0
(0)
1
(100)
**
Isolated in a 2- month old infant
species
(n=1)
Laboratory diagnosis
All
isolates
29
15
1
35
38
39
(n=39)
(74.4)
(38.5)
(2.6)
(89.7)
(97.4)
(100)
The result of the three methods used to identify the
Figures shown as no. (%) sensitive.
aetiological agent in CSF of 66 patients is shown in ta-
CHL
– Chloramphenicol PEN – Penicillin CEF – Ceftriaxone
ble 3. LPA detected 53 (80.3%) of 66 agents in CSF,
CEFO – Cefotaxime
AMP
– Ampicilin
OFL
– Ofloxacin
Gram stain identified 47 (71.2%) and CSF culture iso-
lated 39 (59.1%) organisms. Among the 13 (19.7%)
The sensitivity rate was highest to Ofloxacin 39 (100%)
agents missed by LPA, Gram stain detected 11 organ-
followed by cefotaxime 38 (97.4%) and ceftriaxone 35
isms while culture yielded two. The 27 (40.9%) cases
(89.7%). It was moderate to chloramphenicol 29 (74.4),
that are negative by CSF culture were positive by LPA
and lowest to ampicillin one (2.6%) and penicillin 15
(18) and Gram stain (9).
(38.5%). The sensitivity of pneumococcus to penicillin
and chloramphenicol were 50% and 81.8% respectively
Table 3: Results
of the
3 methods
used to
identify the
while that to ceftriaxone and cefotaxime were 95% and
aetiological agents in the CSF of 66 patients.
100%. The isolates of Neisseria meningitidis had a sen-
Method
Positive
Negative
sitivity rate of 66.7% to both chloramphenicol and peni-
No.(%)
No.(%)
cillin. Thirty-eight (97.4%) of the total isolates were
Gram stain
47
(71.2)
19
(28.8)
resistant to ampicillin. All the isolates of
Haemophilus
influenzae were
resistant to
ampicillin and
penicillin
LPA
53
(80.3)
13
(19.7)
while sensitivities to cefotaxime, ceftriaxone and
Culture
39
(59.1)
27
(40.9)
chloramphenicol were 100%, 77.8, and 66.7% respec-
tively.
Relationship between CSF culture, Gram stain, LPA,
Outcome: Eight
(12.1%) of
66 patients
died while
and the use of antibiotics before presentations
16
(24.2%) had neurologic sequelae.
A
history of use of antibiotics before presentation was
obtained in 30 (45.5%) of 66 patients.Among the 30
patients on antibiotics before presentation 13, 12 and 24
were positive for culture, Gram stain and LPA respec-
Discussion
tively. There was a statistically significant relation be-
tween the use of antibiotics before presentation and
The
prevalence of acute bacterial meningitis in this
negative CSF culture(13/39 (33.3%) versus 17/27
study was 6.9%. This is similar to the prevalence of
6.2% reported from Ibadan. However, the prevalence
10
(62.7%); x = 4.52, p = 0.03) and Gram stain (12/47
2
(25.5%) versus 18/19 (94.7%); x = 14.04, p = 0.00)
2
was higher than the ones reported from Shagamu
(2.8%), Maiduguri (3.5%), Enugu (3.1%), and more
3
9
11
while LPA was not affected by prior use of antibiotics
recently from Ilesa (1.6%). The lower prevalence in
12
(
24/53 (45.3%) versus 6/13 (46.2%); x = 0.06, p =
2
Shagamu as well as in others
10,
11,12
0.79).
may be due to the
differences in methodology. The prevalence of child-
Sensitivity of the pathogens to antibiotics
hood bacterial meningitis over a time frame in Nigeria
seems to be decreasing. The exact reason for the relative
The sensitivity pattern of the 39 bacterial isolates from
decrease in the prevalence of childhood meningitis in
CSF culture to antibiotics is shown in table 4.
Nigeria is not known. In developed countries there is a
decline in the overall prevalence of meningitis as a result
of
reduction in the prevalence of Hib infection due to
Hib vaccine introduction and this vaccine was yet to be
available widely in Nigeria.This study has shown that
meningitis is commoner in males than females. The
%20Shika,%20Zaria_files/page_004.jpg)
73
male preponderance (1.4:1) in this study agrees with the
could not afford. The high rate of susceptibility (100%)
finding of other workers in developing countries.
3
of
organisms to Ofloxacin, a quinolones in this study
Okoroma and Izuora,
13
found a male to female ratio
may be because they are rarely used in children in view
of
1.3:1. Olanrewaju et
al in Shagamu found a male to
of
their potential to cause damage to the growing carti-
female ratio of 2.1:1. The male preponderance may be
lage in these age groups. The high rate (50%) of pneu-
due the relative absence of a gene locus for elaboration
mococcal resistance to penicillin found in this study is
of
immunoglobulin, which was said to be located on the
comparable to that reported previously from
and Kenya. The sensitivity rate of
Neisseria
18
x
chromosomes.
14
Nigeria
9,12
meningitides to
penicillin in
this study
is low
(66.7%).
Infants accounted for 27 (40.9%) of the total patients
The 81.8% pneumococcal sensitivity to chloramphenicol
with meningitis in this study. This finding is similar to
is
also similar to that in previous reports from Nige-
what
has been reported previously.
10,
15, 16
The
incidence
ria.
3,10,12,15
There was an occasional report from Nigeria,
of
meningitis in this age group may be partly due to the
describing a low (30.8%) sensitivity of pneumococcus to
chloramphenicol.
19
vulnerability of their choroid plexus to penetration by
The sensitivity rate of both
Haemo-
bacteria during the septicaemic process, and to low im-
philus influenzae and
meningococcus to
chlorampheni-
munological status.
col was 66.7% each.
The major organism detected in the present study was
The mortality rate of 12.7% in this study compares fa-
Streptococcus pneumoniae ,
which accounted
for 51.5%
vourably with what was obtained in some reports from
16
Nigeria and Libya.
3
while Haemophilus
influenzae was the second most
The overall neurologic sequelae
common pathogen accounting for 27.5% and
Neisseria
rate of 24.2% is similar to that reported by Olanrewaju
et
al from Shagamu, Nigeria, but however, much higher
3
meningitidis accounted
for 18.2%.
This pattern
is in
con-
than the report from Enugu and more recently from
11
trast to that reported from Maiduguri in northeastern
9
Ilesa.
12
Nigeria were Neisseria
meningitidis was the most com-
mon cause of sporadic cases of meningitis accounting
for 36% of the total isolates while
Streptococcus pneu-
moniae occurred
in 29.3%
of cases.
However, the
pat-
tern of predominance of
Streptococcus pneumoniae
in
this study was not different from reports from other cen-
Conclusion
and elsewhere.
5,
6,16
tres in Nigeria
3,
10,12,15
Cerebrospinal
fluid culture is the gold standard for the diagnosis of
The
finding of high rate of resistance to ampicillin and
bacterial meningitis but use of antibiotics prior to pres-
penicillin in this study does not support the continued
entation can significantly reduced the positivity of both
use
of the combination of chloramphenicol with either
CSF
culture and Gram stain as shown in this study. La-
penicillin or ampicillin for empirical treatment of acute
tex particle agglutination test may overcome the limita-
bacterial meningitis and hence, cefotaxime or ceftri-
tion of CSF culture, as bacterial antigens in CSF are not
axone should be commenced pending the outcome of
significantly affected by prior antibiotics use. LPA test
CSF culture result. Also LPA should be included in the
detected more cases (80.3%) than culture (59.1) or Gram
initial evaluation of CSF of children with suspected
stain (71.2%). Despite its limitations of intra specie and
meningitis.
inter specie cross reactions, the test has utility value as
17
result can be obtained within 15 minutes. There is high
Limitation of the study
rate of in-vitro resistance to 2 (ampicillin and penicillin)
of
the three (ampicillin, penicillin and chloramphenicol)
The sample size was too small to describe the sensitivity
commonly used antibiotics. Overall, the sensitivity of
pattern.
isolates to ampicillin was 2.6%, penicillin 38.5%,
chloramphenicol 74.4%, cefotaxime 97.4%, ceftriaxone
Conflict of interest: None
89.7%, and Ofloxacin 100%.
Funding: None.
The relatively free access to antibiotics from patent
medicine store might be contributory to the high rates of
resistance to penicillin and ampicillin. The 74.4% sus-
Acknowledgements
ceptibility rate of isolates to chloramphenicol in this
study was lower than the 89.3% reported from
We
wish to thank the Doctors and Nurses in the Depart-
Maiduguri. The high rates sensitivity to cefotaxime
9
ment of Paediatrics for their efforts during the manage-
(97.4%) and ceftriaxone (89.7%) agrees with previous
ment of these patients. Special thank also goes to the
report from Libya.
16
The low resistance to the cefo-
staff of the Departments of Medical Microbiology, Hae-
taxime and ceftriaxone might be due to their restricted
matology, and Immunology for their assistance during
use owing to their high cost which majority of parents
the
study.
%20Shika,%20Zaria_files/page_005.jpg)
74
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