Prevention and Treatment of Penicillin-Resistant Streptococcus pneumoniae Meningitis After Intracraniofacial Surgery With Distraction Osteogenesis

Abstract

The prevalence of penicillin-resistant Streptococcus pneumoniae (PRSP) meningitis has increased worldwide, particularly in East Asia and the United States. We recently experienced a case of PRSP meningitis that developed during frontofacial distraction. The patient was a 7-year-old girl with Crouzon disease who was treated by frontofacial monobloc/Le Fort IV minus glabellar osteotomy with quadruple internal distraction devices. Penicillin-resistant Streptococcus pneumoniae meningitis was diagnosed after surgery and treated successfully with meropenem (a carbapenem) at 120 mg kg d every 8 hours, ceftriaxone (a third-generation cephalosporin) at 100 mg kg d every 12 hours, and vancomycin (a glycopeptide) at 45 mg kg d every 6 hours. This case indicates that severe and fatal bacterial meningitis may occur as a postoperative complication due to multidrug-resistant bacteria indigenous to the nasal cavity after simultaneous osteotomy of the cranium and facial bone in intracraniofacial surgery, such as that for syndromic craniosynostosis and hypertelorbitism. In such cases, preventive strategies should include preoperative administration of pneumococcal vaccine, preoperative screening of nasal bacterial flora by nasal culture test, and prior administration of a carbapenem with good cerebrospinal fluid transfer or a third- or fourth-generation cephem covering PRSP. Postoperatively, suspected meningitis may be treated with a combination of the 3 drugs used in our case, in parallel with emergency cephalic contrast computed tomography and culture tests of blood and cerebrospinal fluid. Our experience suggests that these measures will facilitate a successful outcome in frontofacial distraction osteogenesis.

Cranial vault expansion by distraction osteogenesis

“…9 Also canthopexies and scars can be addressed at this time. At each of the sites where distracter arms go through the scalp there is risk of infection for the duration of their implantation, 12,56,60 and each scalp penetration site results in a scar. These scars are in the hair-bearing scalp and, except in children who have little hair, are unlikely to present cosmetic issues; however, later hair growth patterns may make the scars more noticeable.…”

Evidence of involvement of the mannose receptor in the internalization of Streptococcus pneumoniae by Schwann cells

“…Moreover, considering that S. pneumoniae is a common commensal in the nasopharynx of healthy adults and children, any surgical procedure in this region could result in a risk of contamination. Actually, pneumococcal meningitis may occur as a postoperative complication, due to invasion of multidrug-resistant S. pneumoniae strains from the nasopharynx after simultaneous osteotomy of the cranium and facial bone in intracraniofacial surgery [ 43 ]. Similarly, other nerves of the head may also be important targets for infections, since pneumococcal meningitis is more likely in patients who received cochlear implantation through the surgical insertion technique in proximity to the auditory nerve in the inner ear (cochlea).…”

Serotype distribution and antibiotics susceptibility pattern of Streptococcus pneumonia in Iran

“…Resistance ranges to some selected antibiotic agents were shown in this study as the following: norfloxacin 85.7%, ampicillin 85.7%, erythromycin 71.4%, oxacillin 42.9%, chloramphenicol 28.6%, gentamicin 28.6%, ceftaxidine 14.3%, peflacine 14.3% (32). Results from many studies have shown that despite the control and reduction in the consumption of antibiotics, the resistance to many antibiotic agents is still increasing (33). So, for selection of an appropriate antibiotic agent with regard to the reduction in treatment cost and period of recovery, it seems essential to monitor susceptibility of S. pneumoniae for selective antibiotic agents.…”