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Klebsiella Meningitis Report of Nine Cases Journal of Neurology, Neurosurgery, and Psychiatry, 1972, 35, 903-908 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.903 on 1 December 1972. Downloaded from Klebsiella meningitis report of nine cases D. J. E. PRICE' AND J. D. SLEIGH From the Institute of Neurological Sciences, Killearn Hospital, Glasgow SUMMARY During a serious epidemic of chest and urinary infections due to Klebsiella aerogenes in a neurosurgical unit, several patients developed klebsiella meningitis after trauma or surgery. Despite all attempts to control the epidemic and treat the meningitis with antibiotics, eight of the nine patients died. It was not until all antibiotics used to treat respiratory and urinary infections had been totally withdrawn that no further patients developed klebsiella meningitis. Recent advances in antibiotic therapy have re- Lancet, 1970). Such outbreaks in neurosurgical sulted in a great reduction in mortality from units may result in patients developing menin- many infections and pyogenic meningitis is no gitis or serious wound infections which may en- exception. Klebsiella species are an uncommon danger life (Ayliffe, Lowbury, Hamilton, Small, cause of pyogenic meningitis, but this infection Asheshov, and Parker, 1965). still carries a high mortality. This paper reports Until 1971, the Glasgow Institute of Neuro- guest. Protected by copyright. nine patients in a neurosurgical unit who devel- logical Sciences was situated at Killearn Hospi- oped this form of meningitis within one year. tal, some 16 miles from Glasgow, and during Only one patient survived. the winter of 1967-68, antibiotic-resistant coli- In recent years an increasing number of hos- form organisms producing mucoid colonies, later pital epidemics due to antibiotic-resistant Gram- identified as Klebsiella aerogenes, were isolated negative bacilli have been reported (Lancet, 1966; from sputum and urine specimens in increasing numbers. By July 1968, this organism 1 Reprints from Mr. D. J. E. Price, Department of Neurosurgery, could be General Infirmary, Leeds. recovered from the sputum of 12% of the % PATIENTS WITH KLEBSIELLA ORGANISMS IN SPUTUM 30 25 FIGURE Occurrence of http://jnnp.bmj.com/ 20 meningitis in relationz to isolation of klebsiella 15 organisms from sputum. 10 5 on September 24, 2021 by 903 904 D. J. E. Price and J. D. Sleigh J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.903 on 1 December 1972. Downloaded from patients in the intensive care ward (Figure). Full .3 --, Li .E. xo 0 ur 0 0 O realization of the seriousness of the problem Q _) en .- :13 4.1 came with the death from klebsiella meningitis ccn '-, of a 12 year old boy admitted with cerebrospinal fluid (CSF) rhinorrhoea after a moderately severe + + head injury. >. >X O E ea L 0. 4) PATIENTS c .2 0 00 There were six male and three female patients; two were children, one a young adult and the remaining + ++ + + six adults aged from 45 to 60 years (Table). Three patients (cases 1, 2, and 8) had sustained serious head injuries with compound fractures of the skull involv- + 4- ing sphenoidal or frontal air sinuses. Two patients (cases 7 and 9) had undergone aneurysm surgery and at both procedures mucosa was breached during the +) approach: the frontal sinus at frontotemporal + craniotomy for a middle cerebral aneurysm and the pharyngeal mucosa at a transcervical approach to a + + + + + basilar aneurysm. Two patients (cases 3 and 5) (A developed meningitis after operations for benign z intracranial tumours-an acoustic neuroma and a guest. Protected by copyright. pituitary adenoma. The remaining two patients 0. (cases 4 and 6) had relatively minor procedures-a z 0 : . e. m m 0 0 ventriculoperitoneal shunt for hydrocephalus and [,L Z stereotaxic surgery for Parkinsonism. Three patients (cases 3, 4, and 5) had localized Ov 0 0 ~ wound infections at the operative site in addition to w -1 the meningitis. Klebsiella was persistently isolated 0 0 O from the sputum and throat of one patient (case 9) 0 t O ^ m O~~~~4O during the period of four weeks between operation z and development of meningitis, but it was only o 8 8 °>~~~4 ° °o 4 0n 0 found in the sputum or throat of five patients and en also the urine of two of these patients only in the 48 hours preceding clinical recognition of the menin- gitis. Blood cultures were taken from three patients during the 48 hours after meningitis was diagnosed. One (from case 9) was sterile but from the other two 40 C4. (from cases 3 and 4), KI. aerogenes was isolated. > > > > 4> 4.-S. 1 L. &.4- .0 4 4 . o 4) 4) a 40 4). C http://jnnp.bmj.com/ 0 U4. 04 0 DEVELOPMENT OF MENINGITIS -'A0. 0. 0 0. L. In all but one patient, persistent pyrexia of 39-40' C ~ 0 developed within the 24 hours before recognition of o4o meningitis: the remaining patient (case 8), however, ).044 -C had an intermittent fever for a week. The time between 1 the presumed penetration of the dural defect (at injury or surgery) by Kl. aerogenes and the develop- ment of meningitis varied from three to 10 days in all on September 24, 2021 by but one patient. In this exception (case 9) the period was four weeks. Only five patients had neck stiffness or Kernig's sign before the diagnosis was proven at lumbar puncture. The clinical presentation was in Kiebsiella meningitis-report ofnine cases 905 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.903 on 1 December 1972. Downloaded from fact as varied as any other purulent meningitis in Gentamicin: 2 mg Twice neurosurgical patients, and we concur with Thomp- daily son, Williams, Williams, and Anderson (1952) that Intrathecaln for two days the clinical features of klebsiella meningitis are Ifollowedfolwdbby indistinguishable from any other type. Colistin: 50,000 units once daily When the diagnosis was substantiated by examina- (half of the dosage into a ventricle and half into the tion of the CSF, the initial white cell counts ranged lumbar theca). from 1,300 to 7,000 cells per cu.mm. Sugar deter- minations were made on the CSF of six of the RESULTS OF patients and results were all low, and, in fact, sugar TREATMENT was absent in four. Ventricular taps confirmed ven- Only five patients were treated. Of the remaining triculitis in all six patients who had this examination four, three were diagnosed only within a few and ventricular CSF white cell counts ranged from hours of death so that no more than one dose of 90 to 25,000 cells per cu.mm. Gram-stained films colistin and could be showed large numbers of polymorphs and Gram- gentamicin given and in the negative bacilli. Culture yielded a heavy growth of other case (case 6) the diagnosis was made only lactose fermenting coliform organisms which pro- at necropsy. duced mucoid colonies. Full biochemical investiga- Three of the patients who were treated died tion proved that they were Ki. aerogenes. In one five, 30, and 19 days after isolation of the organ- patient (case 6) there was an increasing CSF leuco- ism from the CSF (cases 3, 4, and 5). In these cytosis but organisms were not seen in the smears patients, the CSF became sterile within four days nor were they isolated in culture until necropsy. but it remained purulent. In the other two treated patients (cases 1 and 9) lumbar and ventricular CSF rapidly became sterile and the cell counts guest. Protected by copyright. CHEMOTHERAPY steadily fell to below 20 cells per cu.mm. One of these PROPHYLACTIC At the time of this epidemic, no patients recovered (case 9) but the other defined policy restricting the use of antibiotics had finally died of pneumonia while remaining un- been formulated. It was common practice to pre- conscious a month after the meningitis had scribe routinely broad-spectrum antibiotics to pa- subsided. tients thought to be at high risk of meningeal infec- Necropsy was performed on six of the eight tion after suspected dural breaches at the site of patients who died. All had florid meningitis with compound fractures or when the upper respiratory tenacious pus in the subarachnoid space over the tract mucosa was opened at craniotomy. The most convexities and filling the basal cisterns. In addi- commonly used antibiotic regime was the combina- tion, four of them had evidence of tion of ampicillin and cloxacillin. Of the seven persisting patients ventriculitis, two had subdural abscesses, and given prophylactic chemotherapy, two were one had given additional intramuscular colistin and despite encephalitis. Three of the patients had the fact that all strains ofKl. aerogenes were sensitive herniation of the unci or cerebellar tonsils indi- in vitro to this drug, both patients developed menin- cating raised intracranial pressure. gitis after eight days of administration at normal dosage. DISCUSSION THERAPEUTIC Although the strains of Ki. aerogenes INCIDENCE Klebsiella species have been re- http://jnnp.bmj.com/ isolated differed in their sensitivity to many anti- ported as an uncommon cause of purulent biotics, all proved to be sensitive to both gentamicin meningitis in several series. Ransmeyer and and colistin. The therapy for adults who were treated Major (1943) investigating the literature found was standardized as follows: that this was the causal organism of only three Gentamicin: patients out of a total of 3,714 cases of purulent 40 mg twice daily* meningitis. In reviews of published cases, kleb- on September 24, 2021 by Systemic siella meningitis was twice as common in men as in women. It usually affected infants or adults Colistin: 1 mega unit 4-hourly and was most uncommon between the ages of 3 * and 20 years (Ransmeyer The recommended dose of gentamicin is now 80 mg three times a and Major, 1943; day.
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