Hamid Khizar, Hamza Muhammad, Naim Touba, Shahid Mahum, Hsu Jennifer L
Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota.
Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota.
S D Med. 2022 Aug;75(8):357-360.
Proteus mirabilis, a gram-negative bacterium commonly known for causing urinary tract infections (UTI) can rarely present with central nervous system (CNS) infections. Proteus mirabilis CNS infections are usually encountered in the neonatal and infantile period and occasionally cause brain abscesses. It is an uncommon cause of adult CNS infection. We report the first case of a community-acquired Proteus mirabilis meningitis (PMM) in a patient with Proteus mirabilis UTI, urolithiasis, and bacteremia. Risk factors for gram-negative bacillary meningitis (GNBM) include extremes of age, cancer history, diabetes mellitus, UTI, and nosocomial exposure, with the latter being a more prominent cause of PMM. Compromise of the anatomical defense against CNS infections whether accidental or neurosurgical is another important cause, and approximately two-thirds of reported cases of PMM have occurred after neurosurgical procedures. PMM patients develop fever, altered consciousness, and have an acute clinical course. Antimicrobials that can be used for treatment include third-generation cephalosporins, ciprofloxacin, imipenem/ cilastatin, aztreonam, and intraventricular aminoglycosides. Despite appropriate antibiotic therapy outcomes are poor with severe neurological deficit and death commonly resulting. Nosocomial infections can be drug-resistant and multiple antibiotics should be started while awaiting culture results. Literature review reveals that treatment with intraventricular aminoglycosides when attempted has shown bacteriological cure indicating this can be an important treatment approach. Due to the acute clinical course and high morbidity and mortality, we recommend starting multiple antibiotics with different mechanisms of action as soon as the disease is suspected. Our patient was initially started on ceftriaxone, vancomycin, acyclovir, and ampicillin for UTI and meningoencephalitis. The antibiotics were later consolidated to cefepime based on blood, urine and, cerebrospinal fluid cultures growing pan-sensitive Proteus mirabilis. Her clinical condition continued to worsen and ciprofloxacin was added. However, due to the progressive decline in her condition, the family elected for inpatient hospice care and intraventricular aminoglycosides were not attempted.
奇异变形杆菌是一种革兰氏阴性菌，通常因引起尿路感染（UTI）而为人所知，很少会引发中枢神经系统（CNS）感染。奇异变形杆菌中枢神经系统感染通常发生在新生儿和婴儿期，偶尔会导致脑脓肿。它是成人中枢神经系统感染的罕见病因。我们报告了首例社区获得性奇异变形杆菌脑膜炎（PMM）病例，该患者同时患有奇异变形杆菌尿路感染、尿路结石和菌血症。革兰氏阴性杆菌脑膜炎（GNBM）的危险因素包括年龄极端情况、癌症病史、糖尿病、尿路感染和医院暴露，后者是PMM更突出的病因。无论是意外还是神经外科手术导致的针对中枢神经系统感染的解剖学防御受损是另一个重要原因，并且报告的PMM病例中约三分之二发生在神经外科手术后。PMM患者会出现发热、意识改变，且临床病程急性。可用于治疗的抗菌药物包括第三代头孢菌素、环丙沙星、亚胺培南/西司他丁、氨曲南和脑室内氨基糖苷类药物。尽管进行了适当的抗生素治疗，但结果不佳，通常会导致严重的神经功能缺损和死亡。医院感染可能具有耐药性，在等待培养结果时应开始使用多种抗生素。文献综述显示，尝试使用脑室内氨基糖苷类药物治疗已显示出细菌学治愈，表明这可能是一种重要的治疗方法。由于临床病程急性且发病率和死亡率高，我们建议一旦怀疑该病，应尽快开始使用多种作用机制不同的抗生素。我们的患者最初因尿路感染和脑膜脑炎开始使用头孢曲松、万古霉素、阿昔洛韦和氨苄西林。后来根据血液、尿液和脑脊液培养出对所有药物敏感的奇异变形杆菌，抗生素改为头孢吡肟。她的临床状况持续恶化，于是加用了环丙沙星。然而，由于她的病情逐渐恶化，家属选择了住院临终关怀护理，未尝试使用脑室内氨基糖苷类药物。
