Staphylococcus aureus meningitis: 26 years' experience at Vancouver General Hospital FREDERICK J. ROBERTS, MD, FRCP[C] JOHN A. SMITH, MD, FRCP[C] KENNETH R. WAGNER, MD, FRCP[C] The records of all patients with Sta- phylococcus aureus meningitis ad- mitted to Vancouver General Hospi- tal between 1956 and 1981 were reviewed. All the patients had clinical and laboratory features of meningi- tis, and in all cases S. aureus was isolated from the cerebrospinal fluid. S. aureus was responsible for 21 (3%) of the 710 cases of acute bacterial meningitis. Therapy with cloxacillin or methicillin, or both, with or without other agents, was successful in 14 of the 21 patients. Three of the 14 patients without ventricular shunts died, 2 with fulmi- nating septicemia and 1 with a post- operative brain abscess treated with cloxacillin. Following shunt removal and antibiotic therapy all seven pa- tients with ventricular shunts sur- vived the infection. Shunt removal may therefore be essential in appro- priate cases. On a etudi. les dossiers de tous les patients hospitalis.s au Vancouver General Hospital entre 1956 et 1981 souffrant de m&ningite . Staphylo- coccus aureus. Tous les patients offraient les caract&istiques clinique et de laboratoire d'une m&ningite. et dans tous les cas S. aureus fut isol. du liquide c.phalo-rachidien. S. aureus .tait responsable de 21(3%) des 710 cas de m.ningite bact&ienne aigue. Le traitement .i la cloxacilline on i. la m&hicilline, on au deux, avec on sans autres m.dicaments, a entrain. la gu.rison de 14 des 21 From the division of microbiology, Vancouver General Hospital Presented in part at the Canadian Congress of Laboratory Medicine, Vancouver, June 19-23, 1982 Reprint requests to: Dr. Frederick J. Roberts, Division of medical microbiology, Vancouver General Hospital, 855 W 12th Ave., Vancouver, BC V5Z M9 patients. Trois des 14 patients qui n avaient pas de derivation ventricu- laire sont d.c.d.s, 2 d'une septicemie fulminante et 1 d'un abc.s cerebral postoperatoire traite . la cloxacil- line. Les sept patients porteurs d'une d&ivation ventriculaire ont surv&u . l'infection apr.s l'enl.vement de la d&ivation. Dans les cas appropri.s, l'enkvement de la derivation pent donc .tre essentiel. Meningitis caused by Staphylococ- cus aureus has not been reviewed in the English literature since 1964,' 6 and all large reviews predate the use of cloxacillin. Also, previous reports did not make a clear distinction between patients with ventricular shunts and those without. We there- fore decided to do an updated review of patients with S. aureus meningi- tis presenting at a large referral hospital. Patients and methods We studied all the patients with S. aureus meningitis who had been admitted to Vancouver General Hospital, a university-affiliated hos- pital with 1500 beds, between 1956 and 1981. The patients were identi- fied from laboratory records, and their charts were retrieved from the medical records department. We also searched for patients coded as having staphylococcal meningitis who might have been overlooked in the review of laboratory records. S.2 aureus meningitis was diag- nosed if the clinical and laboratory features were compatible with men- ingitis and if S. aureus had been isolated in pure culture from at least one sample of cerebrospinal fluid. In one patient S. aureus meningitis was diagnosed at autopsy when the or- ganism was isolated in pure culture from purulent meninges that showed gross and microscopic evidence of acute bacterial meningitis. For the purpose of analysis the patients were classified into two groups: those with ventricular shunts and those without. Cerebrospinal fluid was routinely centrifuged, and the sediment was Gram-stained and then cultured on blood agar, on chocolate agar and in trypticase soy broth. The cultures were incubated in 5% carbon dioxide for 48 hours. Uncentrifuged aliquots were analysed separately for leuko- cyte count and serum glucose and protein levels. S. aureus was identi- fied by its colonial and microscopic morphologic features, catalase reac- tion and coagulase production. Sus- ceptibility testing by agar disc diffusion was done with standard methods.78 The proportions of patients with S. aureus meningitis and with other types of bacterial meningitis were determined from the laboratory re- cords. Results During the study period there were 710 cases of acute bacterial meningitis, 21 (3%) of which were due to S. aureus. There had been an increase in the incidence of this disease, from 1.7% in the first 5-year period to 4.3% in the most recent 5-year period. All of the patients, except for one premature infant, had had a temper- ature greater than 380C sometime before treatment. Nuchal rigidity was found in 5 of the 7 patients with ventricular shunts .and in 12 of the 14 without ventricular shunts. Men- tal disturbances, ranging from con- 1418 CAN MED ASSOC J, VOL. 128, JUNE 15, 1983
Transcript
Staphylococcus aureus meningitis:26 years' experienceat Vancouver General Hospital
FREDERICK J. ROBERTS, MD, FRCP[C]
JOHN A. SMITH, MD, FRCP[C]
KENNETH R. WAGNER, MD, FRCP[C]
The records of all patients with Sta-phylococcus aureus meningitis ad-mitted to Vancouver General Hospi-tal between 1956 and 1981 werereviewed. All the patients had clinicaland laboratory features of meningi-tis, and in all cases S. aureus wasisolated from the cerebrospinal fluid.S. aureus was responsible for 21(3%) of the 710 cases of acutebacterial meningitis. Therapy withcloxacillin or methicillin, or both,with or without other agents, wassuccessful in 14 of the 21 patients.Three of the 14 patients withoutventricular shunts died, 2 with fulmi-nating septicemia and 1 with a post-operative brain abscess treated withcloxacillin. Following shunt removaland antibiotic therapy all seven pa-tients with ventricular shunts sur-vived the infection. Shunt removalmay therefore be essential in appro-priate cases.
On a etudi. les dossiers de tous lespatients hospitalis.s au VancouverGeneral Hospital entre 1956 et 1981souffrant de m&ningite . Staphylo-coccus aureus. Tous les patientsoffraient les caract&istiques cliniqueet de laboratoire d'une m&ningite. etdans tous les cas S. aureus fut isol.du liquide c.phalo-rachidien. S.aureus .tait responsable de 21(3%)des 710 cas de m.ningite bact&ienneaigue. Le traitement .i la cloxacillineon i. la m&hicilline, on au deux, avecon sans autres m.dicaments, aentrain. la gu.rison de 14 des 21From the division of microbiology, VancouverGeneral HospitalPresented in part at the Canadian Congressof Laboratory Medicine, Vancouver, June19-23, 1982Reprint requests to: Dr. Frederick J. Roberts,Division of medical microbiology, VancouverGeneral Hospital, 855 W 12th Ave.,Vancouver, BC V5Z M9
patients. Trois des 14 patients quin avaient pas de derivation ventricu-laire sont d.c.d.s, 2 d'une septicemiefulminante et 1 d'un abc.s cerebralpostoperatoire traite . la cloxacil-line. Les sept patients porteurs d'uned&ivation ventriculaire ont surv&u .l'infection apr.s l'enl.vement de lad&ivation. Dans les cas appropri.s,l'enkvement de la derivation pentdonc .tre essentiel.
Meningitis caused by Staphylococ-cus aureus has not been reviewed inthe English literature since 1964,' 6and all large reviews predate the useof cloxacillin. Also, previous reportsdid not make a clear distinctionbetween patients with ventricularshunts and those without. We there-fore decided to do an updated reviewof patients with S. aureus meningi-tis presenting at a large referralhospital.
Patients and methods
We studied all the patients withS. aureus meningitis who had beenadmitted to Vancouver GeneralHospital, a university-affiliated hos-pital with 1500 beds, between 1956and 1981. The patients were identi-fied from laboratory records, andtheir charts were retrieved from themedical records department. Wealso searched for patients coded ashaving staphylococcal meningitiswho might have been overlooked inthe review of laboratory records.
S.2 aureus meningitis was diag-nosed if the clinical and laboratoryfeatures were compatible with men-ingitis and if S. aureus had beenisolated in pure culture from at leastone sample of cerebrospinal fluid. Inone patient S. aureus meningitis wasdiagnosed at autopsy when the or-
ganism was isolated in pure culturefrom purulent meninges that showedgross and microscopic evidence ofacute bacterial meningitis.
For the purpose of analysis thepatients were classified into twogroups: those with ventricular shuntsand those without.
Cerebrospinal fluid was routinelycentrifuged, and the sediment wasGram-stained and then cultured onblood agar, on chocolate agar and intrypticase soy broth. The cultureswere incubated in 5% carbon dioxidefor 48 hours. Uncentrifuged aliquotswere analysed separately for leuko-cyte count and serum glucose andprotein levels. S. aureus was identi-fied by its colonial and microscopicmorphologic features, catalase reac-tion and coagulase production. Sus-ceptibility testing by agar discdiffusion was done with standardmethods.78The proportions of patients with
S. aureus meningitis and with othertypes of bacterial meningitis weredetermined from the laboratory re-cords.
Results
During the study period therewere 710 cases of acute bacterialmeningitis, 21 (3%) of which weredue to S. aureus. There had been anincrease in the incidence of thisdisease, from 1.7% in the first5-year period to 4.3% in the mostrecent 5-year period.
All of the patients, except for onepremature infant, had had a temper-ature greater than 380C sometimebefore treatment. Nuchal rigiditywas found in 5 of the 7 patients withventricular shunts .and in 12 of the14 without ventricular shunts. Men-tal disturbances, ranging from con-
1418 CAN MED ASSOC J, VOL. 128, JUNE 15, 1983
fusion to an obtunded state, werenoted in 4 and 11 of the patients inthe two groups respectively.
All 17 staphylococcal isolatestested were sensitive to methicillin,and 3 of 21 were sensitive to penicil-lin.The ventricular shunts in the
seven patients, five children and twoadults, had been in place for periodsfrom 2 weeks to 3 years. One childhad a malignant glioma. Six pa-tients were given cloxacillin (4 to 6g/d) or methicillin or both, with orwithout gentamicin (in two pa-tients). The seventh patient wastreated in 1958 with seven antimi-crobial agents. The shunts were re-moved in all seven patients, includ-ing the two in whom treatment withantibiotics alone had failed. Follow-ing shunt removal and antibiotictherapy all seven patients survivedthe infection.Of the 14 patients without ven-
tricular shunts 6 had undergoneneurosurgical procedures (for men-ingioma in 1, schwannoma in 1,pituitary adenoma associated withCushing's syndrome in 1, astro-cytoma in 2 and trauma in 1). Inseven of the remaining eight patientsa source of S. aureus was identifiedoutside the central nervous system:two patients had endocarditis, onehad pyelonephritis, one (a prema-ture infant) had a scalp abscess, onehad diabetes and endophthalmitis,one had pneumonia and one hadosteomyelitis.
Three of the 14 patients died. Intwo patients - one with endocardi-tis who had been treated with clox-acillin, and another with penicillin-resistant S. aureus pneumonia whohad been treated with ampicillin -death occurred within 24 hours of
admission to hospital. The third pa-tient died following treatment withcloxacillin for staphylococcal menin-gitis and a brain abscess, the latterresulting from surgery and radio-therapy for an astrocytoma.
In one patient, in whom staphylo-coccal meningitis had developed fol-lowing craniotomy for a meningi-oma, a brain abscess developed dur-ing therapy with erythromycin. Thispatient was subsequently successful-ly treated with penicillin and sulfa-diazine; methicillin was not yetavailable. Eight patients were suc-cessfully treated with cloxacillin (6to 8 g/d) or methicillin or both, withor without gentamicin or chloram-phenicol. The remaining two pa-tients were treated with penicillinand streptomycin since 3-lactamase-resistant penicillins were not yetavailable.
Table I summarizes the results oflaboratory studies of the cerebrospi-nal fluid for the two groups ofpatients. Although the numbers aretoo small for statistical testing, therewere less striking abnormalities inthe patients with ventricular shunts.
Discussion
Our finding that 3% of the casesof laboratory-confirmed bacterialmeningitis were caused by S. aureusis compatible with the 1% to 8%quoted by others.'3 We also con-firmed the fact that there has been arecent increase in the incidence of S.aureus meningitis,2'9 an increase thatparallels the increasing role of neuro-surgery in modern medical prac-tice. The greater leukocyte countsand protein levels in the cerebrospi-nal fluid and the more striking clini-cal features in the patients without
ventricular shunts suggests that themeningitis was more serious in thisgroup. This observation is consistentwith those in previous reports,'0-'3and is further substantiated by thefacts that there were no deaths andthat lower dosages of cloxacillinwere required in the patients withventricular shunts.
Cloxacillin and methicillin, aloneor in combination, were used mostoften in treating the patients with S.aureus meningitis; they were some-times given along with an amino-glycoside or chloramphenicol. Threepatients died, two with coexistingfulminating staphylococcal diseaseoriginating outside the central ner-vous system and one with a brainabscess. The variations in dosageand in combinations of drugs usedprecludes any statistical analysis ofthe value of treatment with cloxacil-lin or methicillin. Other penicilli-nase-resistant penicillins may alsobe of value.'4 However, our reviewpoints strongly to the usefulness ofcloxacillin and methicillin, alone orin combination with other antibiot-ics, along with shunt removal, whenindicated. Vancomycin has beenused successfully in penicillin-aller-gic patients.'5"6References
1. WELLMAN WE, SENFT RA: Bacterialmeningitis. Ill. Infections caused by Sta-phylococcus aureus. Mayo Clin Proc1964; 39: 263-269
6. FLOYD RF, FEDERSPIEL CF, SCHAFFNERW: Bacterial meningitis in urban andrural Tennessee. Am J Epidemiol 1974;99: 395-407
7. BAUER AW, KIRBY WMM, SHERRIS JC,TURCK M: Antibiotic susceptibility test-ing by a standardized single disk method.Am J Clin Pathol 1966; 45: 493-496
8. National Committee for Clinical Labora-tory Standards, subcommittee on antimi-crobial susceptibility testing: Perfor-mance Standards for Antimicrobial DiscSusceptibility Tests. Approved Stan-
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dard, ASM-2, National Committee forClinical Laboratory Standards, Vil-lanova, Pa, 1979
9. FINLAND M, JONES WF JR, BARNESMW: Occurrence of serious bacterialinfections since the introduction of an-tibacterial agents. JAMA 1959; 170:2188-2197
12. SCIIIMKE RT, BLACK PH, MARK VH,SWARTZ MN: Indolent Staphylococcusalbus or aureus bacteremia after ven-triculoatriostomy: role of foreign body inits initiation and perpetuation. N Engl JMed 1961; 264: 264-272
14. KANE JG, PARKER RH, JORDAN GW,HOEPRICHi PD: Nafcillin concentration incerebrospinal fluid during treatment ofstaphylococcal infections. Ann InternMed 1977; 87: 309-3 11
15. HAWLEY HB, GuMP DW: Vancomycintherapy of bacterial meningitis. Am J DisChild 1973; 126: 261-264
16. GARVY G: Endovascular and prostheticimplant infections. In GRIECO MH (ed):Infections in the Abnorrmal Host, YorkeMed, New York, 1980: 693-745
Empyema caused byClostridium perfringens
WING C. KWAN, MDSTEPHEN C. LAM, MD, FRCP[C]ANTHONY W. CHOW, MD, FRCP[C]MICHAEL LEPAWSKI, MD, CCFPMONTE M. GLANZBERG, MD, CCFP
Trauma, chest surgery or other inva-sive procedures and underlying lungdisease are often found to precedeclostridial empyema. A case is des-cribed in which empyema caused byClostridium perfrinkens was not as-sociated with any of these factors.
L'empyeme clostridien est souventprecede d'un traumatisme, d'une chi-rurgie thoracique ou d'un autre pro-cede avec effraction tissulaire, oud'une maladie pulmonaire sous-jacente. On decrit ici un cas ou unempyeme cause par Clostridiumperfringens n'a ete relie 'a aucun deces facteurs.
Anaerobic bacteria are recognizedas important pathogens in pleuro-pulmonary infections; however, clos-tridial infection of the pleural spaceis rarely encountered in the absenceof trauma or chest surgery. Previ-ously reported cases of primary clos-tridial empyema have occurred inpatients with underlying lung dis-ease or in those who had recentlyundergone an invasive procedureinto the pleural space.'5 We describe
From the departments of medicine and familypractice, University of British Columbia,Vancouver, and Vancouver General Hospital
Reprint requests to: Dr. Stephen C. Lam,UBC respiratory clinic, Ground floor, 2775Heather St., Vancouver, BC V5Z 3J5
a case of empyema caused by Clos-tridium perfringens in a previouslyhealthy young woman.
Case report
A 19-year-old woman was admit-
ted to hospital with a 1-week historyof progressive pleuritic chest pain,malaise and night sweats. She de-nied cough, sputum production, he-moptysis, dyspnea and loss of con-sciousness. She had been healthyand had had no recent illness or
