Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : DC01 - DC06 Full Version

Acinetobacter Meningitis: A Retrospective Study on its Incidence and Mortality Rates in Postoperative Patients at a Tertiary Care Centre in Northern India


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59248.17187
Mitra Kar, Akanksha Dubey, Romya Singh, Chinmoy Sahu, Sangram Singh Patel, Nida Fatima

1. Senior Resident, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 2. Senior Resident, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 3. Senior Resident, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 4. Additional Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 5. Associate Professor, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. 6. PhD Scholar, Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Correspondence Address :
Dr. Chinmoy Sahu,
Department of Microbiology, C-Block, Second Floor, SGPGI,
Lucknow-226012, Uttar Pradesh, India.
E-mail: csahu78@rediffmail.com

Abstract

Introduction: Acinetobacter is a non fermenting, Gram negative bacillus, a causative pathogen of hospital-acquired infections due to its inherent Multidrug-Resistant (MDR) property. It is held responsible for the majority of nosocomial meningitis in patients undergoing neurosurgical procedures.

Aim: To identify the clinical characteristics, drug-resistance and mortality rate among the patients suffering from meningitis caused by Acinetobacter baumannii.

Materials and Methods: This retrospective, single-centre study was carried out in the Bacteriology section of the Department of Microbiology at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, from February 2019 to February 2022. A total of 150 Cerebrospinal Fluid (CSF) samples from routine bacterial culture-confirmed patients were included in the study. All clinical data were extracted from the Hospital Information System (HIS). All the isolates were identified by Matrix Assisted Laser Desorption/Ionisation-Time of Flight-Mass Spectrometry (MALDI-TOF-MS) assay and antibiotic sensitivity testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines.

Results: The study included 150 (7.55%) cases of culture-proven bacterial meningitis among 1986 CSF samples collected from February 2019 to February 2022. There were 45 (30.0%) cases of Acinetobacter meningitis. Thirty-five (77.8%) patients had undergone neurosurgical procedures for the removal of space-occupying lesions from the brain parenchyma. Forty-two (93.3%) isolates were resistant to amikacin and a cumulative resistance of almost 93.3-95.6% was observed among cephalosporins. Fluoroquinolone resistance was observed in 43 (95.6%) patients and carbapenem resistance was observed in 42 (93.33%) isolates. Overall, 12 (26.7%) succumbed to their infections.

Conclusion: Acinetobacter meningitis causes delay in the recovery of the patient undergoing intracranial surgery, amounting to a delay in brain parenchyma healing in the case of neurosurgical patients.

Keywords

Bacterial meningitis, Gram negative bacilli, Mass spectrometry, Neurosurgical procedures, Nosocomial meningitis

Hospital-acquired meningitis is the most common morbidity faced by patients undergoing neurosurgical procedures (1). The causative microorganisms responsible for these nosocomially acquired infections include a wide range of Gram negative and Gram positive microorganisms but this scenario has changed over the past decade to include many polydrug-resistant microorganisms in the list of causative pathogens of nosocomial meningitis. Among all other Gram negative bacilli, Acinetobacter species have been held responsible for the majority of nosocomial meningitis in patients undergoing neurosurgical procedures and critical patients admitted to the neurosurgery ward (2).

Acinetobacter species is a non fermenting, Gram negative bacillus which is the known causative pathogen of hospital-acquired infections due to its inherent MDR property (3). It is an opportunistic pathogen that is capable of causing infection in old and debilitated patients admitted to the hospital for a prolonged period. The common array of infections caused by it includes pneumonia, meningitis, bacteraemia, and rarely wound infections (4),(5). Acinetobacter species is known as the most common pathogenic bacteria isolated from patients who have undergone craniotomy or other neurosurgical procedures (2).

The presence of Extraventricular Drain (EVD) and Ventriculo-Peritonial (VP) shunt usually after the intracranial procedure for CSF diversion deems the patient susceptible to bacterial meningitis by MDR microorganisms like Acinetobacter species (6).

The study aimed to demonstrate the incidence of Acinetobacter meningitis among known cases of bacterial meningitis and also include the propensity of the microorganism to cause infection in neurosurgical patients. An overtime increase in the incidence of Acinetobacter meningitis among the patients admitted to the study hospital prompted the authors to conduct this study to analyse the accurate incidence of Acinetobacter meningitis among all inpatients, recognise the rate of drug resistance among these isolates and identify the group of patients that were more susceptible to this infection at our centre.

Material and Methods

This retrospective, single-centre study was carried out in the Bacteriology section of the Department of Microbiology at a tertiary care centre, where data of Acinetobacter meningitis patients from February 2019 to February 2022 was extracted from the laboratory records and HIS and was analysed from March 2022 to May 2022. The study was performed under the project with Reference number 2020-100-EMP-EXP-16 which was approved by the Institutional Ethics Committee (IEC) of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

A total of 150 non repeat culture-proven bacterial meningitis samples were included in the study and all clinical data of the patients was extracted from the HIS of the institute.

Inclusion criteria: All CSF samples with culture confirmed bacterial meningitis, from the inpatient department at the centre, without any specific age group and gender were included in the study.

Exclusion criteria: Contaminated samples and samples with delay in transportation for more than two hours were excluded from the study.

Study Procedure

Processing of samples: All CSF samples were collected at a combined receiving station and sent to the bacteriology section of the Department of Microbiology for processing in laboratory according to the standard protocols. The Gram’s stain and bacterial culture were performed for each sample. The Blood agar, MacConkey agar, and Robertsons’ Cooked Meat broth (RCM) were used for the bacterial culture of the samples. The samples were incubated for 72 hours at 37º C and isolated Acinetobacter species colonies were observed on the Blood and MacConkey agar plates. After completion of the incubation period, turbidity was observed in the RCM and identification of the Acinetobacter species was facilitated using standard biochemical tests, and MALDI-TOF-MS, (Bruker Daltonics, Germany) assay (7).

Antimicrobial susceptibility testing: The Kirby-Bauer Disc Diffusion method and Epsilometeric test were used for conducting antibiotic susceptibility testing for each of the bacterial isolates, according to the CLSI 2019 guidelines (8). Antibiotic discs containing amikacin (30 μg), ceftazidime (30 μg), ceftriaxzone (30 μg), cefoperazone-sulbactam (75/10 μg), ciprofloxacin (5 μg), imipenem (10 μg), meropenem (30 μg), and colistin (0.016-256 μg) Epsilometeric test strips were obtained from bioMérieux. Standard inoculums for each bacterial isolate were prepared and set to 0.5 McFarland and a lawn culture was applied on cation-adjusted Muller-Hinton agar plates. The above mentions E-test strips and antibiotic discs were manually placed on the lawn cultured plates and incubated overnight at 37º C. The measurement of zones of inhibition for each antibiotic against each isolate was done and classified as sensitive, intermediate, and resistant according to the tables and guidelines by CLSI 2019 (Table/Fig 1) (8).

Microbiological characteristics and drug resistance patterns were analysed for all the Acinetobacter species isolated from CSF samples included in the study. The study further demonstrated the risk of isolating MDR-Acinetobacter spp, which includes microorganisms resistant to three different classes of antibiotics (9). The study also assessed the risk factors associated with Acinetobacter meningitis in patients with and without shunts.

Statistical Analysis

Quantitative variables were articulated as mean±standard deviation. While analysing of risk factors of acquiring MDR-Acinetobacter spp, the comparison between groups for categorical variables was estimated by using χ2 tests. The results were presented as 95% Confidence Intervals. Statistical analysis was facilitated by the software program International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) Statistics version 20.0 (IBM Corp., Armonk, NY, USA), with p-value <0.05 considered statistically significant.

Results

The study included 150 (7.55%) cases of culture-proven bacterial meningitis among the 1986 CSF samples collected from February 2019 to February 2022. Forty-five (30.0%) cases of Acinetobacter meningitis among the culture-positive bacterial meningitis patients were reported in this study and thus Acinetobacter spp. has been deemed the predominant microorganism among the patients suffering predominantly from nosocomial bacterial meningitis. The mean age of the patients was 26.60±18.32 years (range 1-68), and 28 (62.22%) were males. The mean length of hospitalisation was 38.98±22.13 days. The demographic characteristics, presenting complaints, and risk factors of acquiring Acinetobacter meningitis are demonstrated in (Table/Fig 2).

Among these 45 cases of Acinetobacter meningitis, 35 (77.8%) had undergone neurosurgical procedures for the removal of space-occupying lesions from the brain parenchyma. Forty (88.89%) patients used shunts where, 27 (60.0%) patients used EVD, and 13 (28.89%) used VP shunts. The mean age of the patients with shunts and without shunts was 27.08±18.02 years and 22.8±22.5 years, respectively. The demographic characteristics and risk factors in patients suffering from Acinetobacter meningitis with and without shunt are described in (Table/Fig 3). The underlying co-morbidities like intracranial space-occupying lesions needing surgery, organ transplant, chronic obstructive pulmonary disease, heart disease, and nosocomial origin of infection is highly significant in patients with shunts in comparison to those without shunts is shown in (Table/Fig 3).

Among Acinetobacter spp isolates obtained from the CSF samples, Acinetobacter baumannii was the predominant microrganism isolated from 43 (43/45, 95.6%) samples and Acinetobacter lowffii was obtained from 2 (2/45, 4.4%) samples. Overall, a high drug resistance was observed among the Acinetobacter spp isolates from CSF samples. The antibiotic resistance among the Acinetobacter spp isolates is described in (Table/Fig 4) which demonstrates the percentage resistance of the isolates to a particular isolate. Amikacin was resistant among 42 (93.3%) isolates and among the cephalosporins, a cumulative resistance of almost 93.3-95.6% was observed. Thus, the extended-spectrum beta-lactam antibiotic resistance was thus observed in about 43 patients. Ciprofloxacin was used as a representative of the fluoroquinolone group of antibiotics and was found resistant among 43 patients. Carbapenem resistance was found in 42 isolates as seen in (Table/Fig 5).

Overall, 35 (77.8%) patients were administered appropriate antibiotics while among the rest of the 10 (22.2%) patients, 5 (11.11%) left against medical advice and 5 (11.11%) died before any treatment could be administered. Overall, 12 (26.7%) succumbed to their infections and could not be saved despite all efforts.

Discussion

A rising trend of nosocomial bacterial meningitis, predominantly in patients after neurosurgical procedures has been observed and the presence of MDR complicates the recovery of infected patients (1). Among the Gram negative bacilli, Acinetobacter species are known to be the most common causative pathogen of nosocomial bacterial meningitis, especially in the case of post neurosurgical procedures and it is also a known cause of MDR infections among those admitted to neurosurgical Intensive Care Units (ICUs) (2),(10). Among the patients included in this study, all the CSF samples were sent to the Bacteriology Section of the Department of Microbiology from the Neurosurgical ward and ICU. The four year incidence of Acinetobacter meningitis among the bacterial meningitis patients included in this study was 30.0% (45/150). Acinetobacter meningitis was observed in 30% cases of bacterial meningitis and a similar incidence of Acinetobacter meningitis was observed in studies by Sipahi OR et al., and Sharma R et al., were the incidence of Acinetobacter meningitis was 30.7% and 26.18%, respectively (6),(11).

The challenge faced during the treatment of Acinetobacter meningitis includes the MDR property of the microorganism that complicates recovery among the patients. The mean age of the patients was 26.60±18.32 years which was in contrast with other studies by Sharma R et al., (6) and Tuon FF et al., (12), where the age of patients with Acinetobacter meningitis was in the range of 30-40 years of age, thus the rate of mortality was less in compared to the above-mentioned studies. The majority of patients included in the study had undergone neurosurgical procedures. Patients with hydrocephalus, intracranial bleeding and, CSF leak were managed using a shunt diversion. Thirty-five (87.5%) patients who had undergone intracranial surgeries needed shunt diversion after the procedure making them more susceptible to bacterial meningitis in agreement to a study by Sharma R et al., (6) where all the 25 (100.0%) patients with shunt diversion developed Acinetobacter meningitis.

The risk factors associated with Acinetobacter meningitis in patients with and without shunts is demonstrated in (Table/Fig 3). Presence of intracranial space occupying lesions, Chronic Obstructive Pulmonary Disease (COPD), heart disease and organ transplant had significant association with the use of shunts. The above finding of presence of intracranial space occupying lesion leading to neurosurgery corroborate with the finding of a study conducted by Sharma R et al., (6), where Acinetobacter meningitis was observed in all patients who underwent neurosurgery followed by shunt placement. Although none of the studies mentioned COPD, heart disease and organ transplant to be significant risk factor associated with Acinetobacter meningitis.

Although cefoperazone-sulbactam is universally accepted as antibiotic prophylaxis in many surgical procedures in a study by Niu T et al., (13), the present study suggested a resistance of 95.6% (43/45) to this antimicrobial agent. (Table/Fig 6) shows comparison with other similar published original articles directly or indirectly related to this study cohort (6),(11),(14),(15),(16),(17),(18),(19),(20),(21),(22),(23),(24),(25),(26),(27),(28),(29),(30),(31),(32),(33),(34),(35),(36),(37). The presence of EVD and VP shunt also increases the risk of acquiring MDR infections. The MDR temperament of Acinetobacter isolates was significantly associated with chronic kidney disease, heart disease, and COPD in this study and authors did not come across any such association among the other co-morbidities in recently published studies by Sharma R et al., and Sipahi OR et al., (6),(11). Acinetobacter species were 93.3-95.6% resistant to amikacin, ceftazidime, ceftriaxone, ciprofloxacin, cefoperazone-sulbactam, imipenem, meropenem while other studies showed only about 20-80% (6),(12). A study by Moon C et al., suggests that the isolation of carbapenem-resistant isolates was directly proportional to the rate of mortality among the patients (14). The present study shows that carbapenem resistance was as high as 93.3% (42/45) which did not show a poor prognosis, due to the fact that being a tertiary care centre availability of newer and more effective antibiotic agents facilitated better outcome in comparison to other centres. Thus, the patients showed a higher incidence of resistance in this study, and most patients were treated with colistin infusion which is the drug of last resort and poses a high cost of treatment and morbidity.

The mortality rate in the present study was 26.7% (12/45) which was in agreement with the findings by Chen CH et al., (15), Sipahi OR et al., (16) and Chen FM et al., (17) where the mortality rates were 28.57%, 30% and 20%, respectively. On the other hand, it was much less in comparison to the study conducted by Tuon FF et al., (12) which reported a mortality rate of 72.7% and by Sharma R et al., (6) who reported about 40% mortality. This can be attributed to the early diagnosis and reporting of the antimicrobial resistance at present setting along with the fact that strict hospital infection control measures and prompt treatment with compliance to the antibiotic susceptibility report were followed at this centre.

Limitations(s)

Firstly, the study depicts the incidence of Acinetobacter meningitis at a single centre and does not mention about its incidence in the geographical area. Secondly, authors did not specify the groups of patients and found the incidence and mortality among the patients as a whole and not specifically in neonates or post neurosurgical meningitis. Thirdly, this was a retrospective study which is based mainly on previous records and HIS which may not clearly signify the incidence and mortality.

Conclusion

Acinetobacter meningitis causes a delay in the recovery of the patient from the operative procedures they had undergone, amounting to a delay in brain parenchyma healing in the case of neurosurgical patients. The associated morbidity and mortality of the disease due to the MDR nature of the microorganism and the nosocomial nature of the infection call for strict compliance to the infection control practices and drug susceptibility report to inhibit the rampant use of last resort antibiotics early in the treatment.

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DOI and Others

DOI: 10.7860/JCDR/2023/59248.17187

Date of Submission: Jul 24, 2022
Date of Peer Review: Aug 20, 2022
Date of Acceptance: Sep 29, 2022
Date of Publishing: Jan 01, 2023

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

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