Nosocomial Escherichia coli meningitis in adults: Report of four cases and literature review
A 29-year-old previously healthy Nepalese man, with no history of arterial hypertension, was admitted to our hospital complaining of headache, vomiting and left sided weakness. On examination his blood pressure was high, 220/140 mmHg. Neurological examination showed conscious, oriented patient with left sided weakness. Cranial CT showed right sided intraventricular hematoma with significant mass affect (shift of midline structure to the left). Magnetic resonance imaging (MRI) was performed and there were no vascular malformations or aneurysms. On the 7th day of admission, the intraventricular hematoma was evacuated and a right external ventricular drain (EVD) was inserted. The patient was kept in the surgical intensive unit. Two days later, the patient developed fever, headache and vomiting. Meningeal signs were absent and CSF examination revealed 190,000 leucocytes/μl predominantly neutrophils with protein of 399 mg/dl and glucose of 3.6 mg/dl. Gram stain examination of CSF showed Gram-negative rods, and cultures yielded E. coli sensitive to ceftazidime, ceftriaxone, cefepime, meropenem, piperacillin-tazobactam, ciprofloxacin and amoxi-clavulinate and resistance to ampicillin. Blood cultures were negative. Cranial CT showed parenchymal changes consistent with cerebritis. The patient was treated with meropenem, vancomycin and supportive treatment, but he died on the 14th day after admission most probably due to multiple unrelated complications.