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ORIGINAL ARTICLE
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 28-30  

Epidemiological study of acute bacterial meningitis in admitted children below twelve years of age in a tertiary care teaching hospital in Pune, India


1 Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune, India
2 Department of Community Medicine, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India
3 Department of Community Medicine, S. R. T. R. Medical College, Ambejogai, Maharashtra, India

Date of Web Publication20-Jun-2012

Correspondence Address:
Dhrubajyoti J Debnath
Department of Community Medicine, Smt. Kashibai Navale Medical College, Narhe, Pune - 411041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.97508

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  Abstract 

Context: The community incidence of acute bacterial meningitis in India is not known. There is a need for a periodic review of bacterial meningitis worldwide, since the pathogens responsible for the infection vary with time, geography, and patient age. Aims: To study some epidemiological factors of acute meningitis. Setting and Design: Hospital based cross sectional study. Materials and Methods: Detailed clinical examination of all clinically suspected cases of meningitis was done. Blood and cerebro spinal fluid culture was done. Statistical Analysis Used: Fisher exact test, P < 0.05 was considered as statistically significant. Results: There were 79 suspected cases of meningitis, majority of cases (74.7%) were under-fives. The case fatality rate (CFR) was 13.9% with a confidence interval ranging from 5.9 to 21.5%. The association between the age and the mortality was not statistically significant. (Fisher's exact test, P = 1). The association between the gender and the mortality was not statistically significant (Fisher's exact test, P = 0.3). Based on the culture examination there were 16 cases of confirmed bacterial meningitis. Commonest isolate was Klebsiella pneumoniae as seen in five cases (31.2%). Neisseria meningitides, H influenzae, or Streptococcus pneumoniae were not isolated in any case. Conclusion: Acute bacterial meningitis is still an important public health problem with a high case fatality rate.

Keywords: Acute bacterial meningitis, case fatality, surveillance, under-five mortality


How to cite this article:
Debnath DJ, Wanjpe A, Kakrani V, Singru S. Epidemiological study of acute bacterial meningitis in admitted children below twelve years of age in a tertiary care teaching hospital in Pune, India. Med J DY Patil Univ 2012;5:28-30

How to cite this URL:
Debnath DJ, Wanjpe A, Kakrani V, Singru S. Epidemiological study of acute bacterial meningitis in admitted children below twelve years of age in a tertiary care teaching hospital in Pune, India. Med J DY Patil Univ [serial online] 2012 [cited 2020 Aug 15];5:28-30. Available from: http://www.mjdrdypu.org/text.asp?2012/5/1/28/97508


  Introduction Top


Bacterial meningitis is associated with significant morbidity and mortality, hence accurate information is necessary regarding the important etiological agents and populations at risk to ascertain public health measures and ensure appropriate management. [1] The community incidence of acute bacterial meningitis in India is not known. The exact etiological diagnosis is often not possible, because of poor culture facilities, prior antibiotic therapy, delay in plating for culture, non-availability of media with uniform quality, and low bacterial load. There are limited studies from India regarding the etiology and epidemiological factors associated with acute meningitis. There is a need for a periodic review of bacterial meningitis worldwide, since the pathogens responsible for the infection vary with time, geography, and patient age. [2],[3],[4] Increased awareness, availability, and usage of vaccines may also reflect as a change in the epidemiological pattern of these pathogens. We therefore conducted the study with the aim to study the various epidemiological factors of acute meningitis.


  Materials and Methods Top


This was a cross sectional study undertaken in the pediatric-indoor patient department (IPD) of a tertiary care teaching hospital in Pune, India. Ethical approval was taken from the Institutional Ethics Committee. Inclusion criteria for suspected meningitis was all the admitted cases during the study period below 12 years of age with the history of sudden onset of fever more than 38.5°C rectal or more than 38.0°C axillary and the presence of one or more of the following such as neck stiffness, altered consciousness, meningeal sign. Inclusion criteria for children below 1 year of age was fever accompanied by bulging fontanelle. The purpose of the study was explained to the parent /guardian of the child and informed consent was taken before enrolling them in the study. Parents who did not give consent for the study were excluded from the study. Information regarding vaccination and history of contact with a case of meningitis was obtained. Detailed clinical examination was done. Blood samples and cerebro spinal fluid samples were taken from the study subjects. Fisher's exact test was used to study the association and values of P < 0.05 were considered as statistically significant. The duration of the study was 1 year.


  Results Top


Based on the above mentioned criteria there were 79 suspected cases of meningitis, 37 cases (46.8%) were less than 1 year age, 22 cases (27.9%) were between 1 to 5 years age and 20 cases (25.3%) were between 5 to 12 years of age. Thus majority of cases (74.7%) were under-fives. The mean age was 2.7 years with a standard deviation of 3.2 years. The male to female ratio was 1.82:1. There were 44 (55.6%) cases from urban area and 35 (44.4%) cases from rural area. The total number of deaths among the cases were 11. The case fatality rate (CFR) was thus 13.9% with a confidence interval ranging from 5.9 to 21.5%.

As seen in [Table 1], in both the male and female cases, the age-specific mortality was highest in children below 1 year age, CFR being 25% in males and 15.4% in females. In 1.1 to 5 years age-group, the CFR in males was 7.7% and zero in females. The CFR in the age-group 5.1 to 12 years was found to be higher (14.3%) than 1.1 to 5 years age-group in males, but it was zero in females. The association between the age and the mortality was not statistically significant. (Fisher exact test, P = 1). The CFR in males (17.6%) was higher than in females (7.1%) but the difference was not statistically significant (Fisher exact test, P = 0.311).
Table 1: Age and sex-specifi c mortality in cases of meningitis

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Based on the culture examination done on blood and CSF there were 16 cases of confirmed bacterial meningitis [Table 2]. There was not a single sample with more than one isolate. There was no case who was positive in both CSF and blood culture. Commonest isolate was Klebsiella pneumoniae as seen in five cases (31.2%). Non fermenters accounted for four cases (25%).
Table 2: Laboratory diagnosis of the meningitis cases

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Not a single case had received Meningococcal vaccine, Haemophilus b vaccine (Hib), pneumococcal vaccine. As per the history given 15 cases (18.9%) gave the history of exposure to a case of meningitis. All the cases were from the low socioeconomic status.


  Discussion Top


In the present study the 37 cases (46.8%) were less than 1 year age. As per the hospital based study in India in children aged 1 month to 5 years suffering from acute bacterial meningitis, 77.7% were below the age of 1 year. [5] This higher incidence is because of the difference in age group. The male to female ratio in the present study was 1.82:1. Similar male preponderance was observed in studies conducted by B Vishnu Bhat et al.[2] wherein the male/female ratio were 1.46:1. The case fatality rate as seen in the present study was 13.9% with a confidence interval ranging from 5.9 to 21.5%. This clearly indicates the grave nature of the disease. Different studies have also quoted a case fatality rate ranging from 11.6 to 30.5%. [2],[4],[6] In the present study, out of 79 suspected cases of meningitis, only 16 cases were confirmed based on CSF culture or blood culture result. Klebsiella pneumoniae was the commonest isolate (31.3%) in the present study followed by non-fermenters (25%),  Streptococcus pyogenes Scientific Name Search ), coagulase negative staphylococci (12.5%), and E. coli, Citrobacter freundii each in 6.3% cases. In the present study the most important finding was that  Neisseria More Details meningitides, H. influenzae, or  Streptococcus pneumoniae Scientific Name Search  not isolated in any case. Reasons for non isolation could be low incidence of the above mentioned pathogen in the present study area. Etiological pathogens do differ from region to region. [4] As regards H. influenzae, some authors have reported a high incidence of H. influenzae meningitis in the pediatric age group [5] while others have experienced a low incidence. [3],[4] It appears that H. influezae and N. meningitidis are not the common pathogen responsible for acute bacterial meningitis in south east Asia when compared with the western countries. [4] Other important reason for the non isolation of the above mentioned pathogens in the present study could be the prior antibiotic usage which might have influenced the culture results. The hospital in the present study in Pune was a 1600 bedded tertiary care referral hospital. Since large number of patients are referred from the periphery they are already seen by number of doctors. Thus the child by then is likely to have received 3−4 types of antibiotics for his/her illness. Other reasons for the non isolation could also be the extremely fragile nature of meningococcus and therefore it is often not possible to isolate the organism from the CSF. [7] One important finding of the present study was five (31.2%) of Klebsiella pneumoniae, four (25%) of non fermenters, three (18.8%) of Streptococci pyogens, two (12.5%) of Coagulase negative staphylococci (CONS) and one (6.25%) each of E. coli and Citrobacter freundii. Thus as per the present study various other Gram negative pathogens are also responsible for acute bacterial meningitis. This was also noted by other investigators. [5]

In the present study, Haemophilus influenzae and Neisseria meningitides were not isolated. This was also seen in a study conducted at NIMHANS, Bangalore where Haemophilus influenzae and  Neisseria meningitidis More Details accounted for 1.8 and 1% cases, respectively. [8] Other Gram negative bacilli, Streptococcus spp., and Staphylococcus aureus were isolated from 19 (4.9%), 9 (2.3%), and 7 (1.8%) cases, respectively. [8] Few reports on the epidemiology of meningococcal disease in India indicate low incidence of endemic meningococcal disease in India except for occasional epidemics in cities of North India. [9]

There is a need of surveillance regarding isolates in acute bacterial meningitis. Such studies should be carried out on a regular basis in a tertiary care hospital where a good laboratory support is available. This will show the trend over the years and will give a picture of the causative organisms for acute bacterial meningitis from time to time.

 
  References Top

1.Brouwer MC, Tunkel AR, van de Beek D. Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. Clin Microbiol Rev 2010;23:467-92.  Back to cited text no. 1
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2.Bhat BV, Verma IC, Puri RK, Srinivasan S, Nalini P. A profile of pyogenic meningitis in children. J Indian Med Assoc 1991;89:224-7.  Back to cited text no. 2
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3.Kabra SK, Kumar P, Verma IC, Mukherjee D, Chowdhary BH, Sengupta S, et al. Bacterial meningitis in India: An IJP survey. Indian J Pediatr 1991;58:505-11.  Back to cited text no. 3
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4.Tang LM, Chen ST, Hsu WC, Lyu RK. Acute bacterial meningitis in adults: A hospital-based epidemiological study. QJM 1999;92:719-25.  Back to cited text no. 4
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5.Chinchankar N, Mane M, Bhave S, Bapat S, Bavdekar A, Pandit A, et al. Diagnosis and outcome of acute bacterial meningitis in early childhood. Indian Pediatr 2002;39:914-21.  Back to cited text no. 5
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6.Fortnum HM, Davis A C. Epidemiology of bacterial meningitis. Arch Dis Child 1993;68:763-7.   Back to cited text no. 6
    
7.Singh H, Sarkar R, Sachdev HP, Saini L. Immunological tests in acute bacterial meningitis. Indian Pediatr 1988;25:323-8.  Back to cited text no. 7
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8.Mani R, Pradhan S, Nagarathna S, Wasiulla R, Chandramuki A. Bacteriological profile of community acquired acute bacterial meningitis: A ten-year retrospective study in a tertiary neurocare centre in South India. Indian J Med Microbiol 2007;25:108-14.  Back to cited text no. 8
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9.Sinclair D, Preziosi MP, Jacob John T, Greenwood B. The epidemiology of meningococcal disease in India: Epidemiology of meningococcal disease in India. Trop Med Int Health 2010;15:1421.  Back to cited text no. 9
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    Tables

  [Table 1], [Table 2]


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