Discussion and conclusions
Nosocomial meningitis following spinal anaesthesia remains a rare but
serious event and can involve the patient’s vital or functional
prognosis. As far as we know, our case may be the first case of
nosocomial meningitis following spinal anaesthesia withPseudomonas treated with cefoperazone and ciprofloxacin. The
outcome was favorable despite the absence of the reference treatment.
The mortality rate of a NM with Pseudomonas remains high even
with the recommended reference antibiotic therapy [5] [6].Pseudomonas was identified as the causative agent of the
meningitis in our case, whereas the germs usually encountered are
Gram-positive Cocci. This bacterium is more isolated in nosocomial
infections, but it is rarely responsible for meningitis.Pseudomonas aeroginosa infections are formidable because of their
capacity for native or acquired resistance to antibiotics [7]
[8] [9]. Its management has become a major challenge because of
this ability to resist most of the antibiotics currently available
[10].
Kamath et al. reported a case of Pseudomonas NM, which was
treated with meropenem and levofloxacin with a favorable outcome
[11]. Rodríguez-Lucas C et al reported series of cases of NM withPseudomonas that were treated with ceftazidime or colistin with a
mortality rate that remains high [5]. None of the molecules
recommended as first-line treatment is available in Madagascar. Instead,
cefoperazone, recently introduced in the country in its combined form
with sulbactam, is a third-generation broad-spectrum cephalosporin that
is little known in Europe and the United States but is widely used in
Asian countries. Cefoperazone has a good meningeal diffusion and this
diffusion increases in case of breached blood-brain barrier as in the
case of bacterial meningitis [12]. It will therefore be useful to
test the sensitivity of cefoperazone in the case of identification ofPseudomonas on a bacteriological examination in order to help
clinicians, especially in the case of Madagascar where the availability
of antibacterial molecules is limited. However, it needs to be confirmed
by further large-scale studies. Indeed, with the problem of antibiotic
resistance to this bacterium, a further in-depth study would thus be
interesting to serve as scientific evidence to confirm the efficacy of
cefoperazone in the management of Pseudomonas nosocomial
meningitis. Ciprofloxacin is the most active antipyocyanic quinolone
against this bacterium, which has a good meningeal diffusion but must be
used at a high dose to reach the minimal inhibitory concentration ofPseudomonas aeroginosa and especially under the condition of a
sensitivity verified on the antibiogram.
It is essential to recognize early the situations that lead to evoke the
diagnosis of meningitis, whether nosocomial or community-acquired, to
reduce the delay between the first symptoms and the treatment, which is
an essential condition to improve the prognosis. Cytological,
biochemical and Gram stain results should be also available to the
medical team in charge of the patient within hours after the lumbar
puncture to ensure adapted treatment in order to improve the prognosis,
which is not always the case in everyday practice of hospitals in
low-income countries. In addition, it is necessary to follow rigorously
and systematically the recommendations of skin antisepsis, during
invasive procedures such as lumbar punctures, in order to prevent and
reduce the risk of nosocomial meningitis.
Pseudomonas aeoginosa is known to be responsible for severe
nosocomial infections including meningitis, especially since it has both
natural and acquired resistance capabilities. Cefoperazone could be a
therapeutic alternative in combination with ciprofloxacin, to treat
nosocomial Pseudomonas aeoginosa meningitis, in countries with
limited resources where reference treatment is unavailable.This case is an avenue for further study to evaluate the real efficacy
of cefoperazone in the management of nosocomial Pseudomonasmeningitis.
-Funding: None
-Competing interests: The authors declare that they have no
competing interests.
-Acknowledgements: We thank the team of the Infectious Diseases
Department Befelatanana, Antananarivo Madagascar for the care of the
patient. We also thank the patient for accepting the publication of her
case.
-Authors’ contributions: Dr Johary Andriamizaka
Andriamamonjisoa, Dr Etienne Rakotomijoro, Dr Volatiana Andriananja :
Patient management, data collection and literature review and manuscript
drafting. Dr Mamy Jean de Dieu Randria : Manuscript revision
All authors approved the final manuscript.
Availability of data and material: all datasets are available
from the corresponding author.
Ethical approval and consent to participate: not applicable.
Consent for publication : The patient was informed about the
case report, why the case was peculiar and the authors’ interest in
publishing his case. The patient willingly gave informed consent to
allow the authors to use every image needed for this case report. The
patient’s anonymity is well respected.
Our patient signed a written consent for publication of his clinical
information and scan image.