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.