Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.Name of the Candidate and Address : DR JAGADEVI
# 7/5 F VINODA NILAYA 2ND FLOOR,
3RD MAIN 9TH CROSS,
CHAMRAJPET,
BANGALORE-560018.
2.Name of Institution : KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES,
BANGALORE-560070.
.
3.Course of the study and subject : M.D MICROBIOLOGY
4.Date of admission to the course : 31st MAY 2011
5.Title of the Dissertation :
EVALUATION OF CONVENTIONAL CULTURE METHOD WITH LATEX
AGGLUTINATION TEST FOR DIAGNOSIS OF BACTERIAL MENINGITIS
AMONG PEDIATRIC AGE GROUP.
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6.
6.1
BRIEF RESUME OF THE INTENDED WORK
NEED FOR THE STUDY
Acute bacterial meningitis is one of the most sever infectious disease in infants and children. It is
associated with high rate of mortality and morbidity in pediatric population.1
As acute bacterial meningitis is a medical emergency, early and accurate etiologic diagnosis and
appropriate antimicrobial treatment remains the cornerstone in the management of patients and helps in
improving the outcome of the disease.
Cerebrospinal fluid (CSF) culture is considered to be gold standard for diagnosis of bacterial
meningitis, but it is time consuming (24-48 hours) and can give false negative results if the sample is not
properly collected, transported and processed. Although CSF Gram’s stain may provide immediate
information about causative microorganisms, it depends on factors like the number of organisms , prior use
of antibiotics, technique and observer’s skill.2 Hence there is a definite need for rapid ,sensitive and specific
method for accurate identification of bacteria causing meningitis to help in diagnosis.
6.2 REVIEW OF LITERATURE
Bacterial meningitis is an inflammatory reaction of pia and arachnoid membranes surrounding the brain
and spinal cord with a definitive or presumptive evidence of bacteria and inflammatory cells in the CSF.
Most common route of spread being haematogenous from distant site infection such as, lower respiratory
tract infection, osteomyelitis, pyoderma. contagious spread occurs from otitis media, infections of paranasal
sinuses. Direct spread from compound fracture of skull is the less common route.
The advent and widespread use of antibacterial agents in the treatment of meningitis have drastically
reduced the mortality caused by this disease. However, untreated and inappropriately treated bacterial meningitis
is highly fatal and leaving serious neurologic sequel in survivors.3
MICROBIOLOGY
Etiology of bacterial meningitis may vary in different parts of the world and common pathogens of
bacterial meningitis also vary with different age.4
Neonate (0-28 days) – Group B streptococci, Escherichia coli, Listeria monocytogenes,
Klebsiella and Enterococcus species.
4-12 weeks –
Haemophilus influengae, streptococcus pneumoniae,
Group B streptococci and Listeria monocytogenes.
12 weeks and older - Neisseria meningitidis , streptococcus pneumonia and
Haemophilus influenae.
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Alteration of host defence due to immune deficits or anatomical defects also increase the risk of
bacterial meningitis from less common pathogens such as, Staphylococcus aureua , Coagulase negative
staphylococci,Pseudomonas, Proteus and Salmonella species.5
EPIDEMIOLOGY
Bacterial meningitis is much more common in developing countries than developed.3 It occurs in both
epidemic and sporadic patterns. The exact incidence is not known. 4 The average incidence in India works out to
be 1% of the total admissions to pediatric ward and 0.8% of the total number of new pediatric cases seen in all
out patient departments.6 More than two third of cases meningitis occur in first two years of life owing to
decreased immunity and high vascularity of the brain.7
PATHOGENESIS
The subarachnoid space and its CSF are relatively defenseless in stopping invasion by bacterial pathogens
because of the CSF’s paucity of phagocytic cells and low concentration of complement and immunoglobulin. 3
Inflammation of meninges is initiated by the presence of bacterial lipopolysaccharide, teichoic acid and/or
other bacterial cell wall components in subarachnoid space. The bacterial antigens stimulate monocytes to
produce the cytokine interleukin-1 and stimulate macrophages, astrocytes, microglial cells, ependymal cells and
endothelial cells in the central nervous system to produce the tumor necrosis factor. Interleukin-1and tumor
necrosis factor probably act synergistically to elicit inflammatory responses which manifest clinically as
meningitis.3
sequence of such responses are structural changes in blood brain barrier; cytotoxic parancymal edema;
increased intracranial pressure; decreased intracranial perfusion; cerebral infarction; and focal or diffuse brain
damage.
6.3 OBJECTIVE OF THE STUDY
1. To compare the sensitivity and specificity of CSF culture, Gram’s stain and latex agglutination test.
2. To evaluate the diagnostic technique for early diagnosis of the cases.
3. To determine the antibiotic sensitivity pattern of pathogens isolated in bacterial meningitis
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7. MATERIALS AND METHOD
7.1 SOURCE OF DATA
The study will comprise of clinically suspected cases of meningitis attending inpatient and outpatient
Department of Pediatrics KIMS, Bangalore.
PERIOD OF STUDY: 1 year 6 months
SAMPLE SIZE: Around 60
INCLUSION CRITERIA
Clinically suspected meningitis patients with the fallowing altered parameters in CSF :
Protein - >80 mg/dl
Glucose -< 40 mg/dl
Leucocyte neutrophils - >5cells.cumm
EXCLUSION CRITERIA :
1. No alteration of CSF parameters in clinically suspected meningitis patients.
2. Consent refusal.
STUDY DESIGN
Comparative study.
SAMPLE DESIGN
Purposive sampling.
METHODOLOGY
The data for the study will be collected from all those who fulfill the inclusion and exclusion criteria by
purposing sampling.
STATISTICAL ANALYSIS
Data collected will be analyzed statistically by computing percentage, mean, Standard deviation.
Appropriate tests will be employed for categorical, parametric or nonparametric data. Wherever necessary the
results will be depicted in the form of graphs and percentage.
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7.2 METHOD OF COLLECTION OF DATA
SPECIMEN COLLECTION
CSF samples will be collected from suspected meningitis patients under aseptic precautions. A sterile
lumbar puncture needle is introduced into subarachnoid space between the third and fourth lumbar vertebrae and
the sample is collected into a sterile container and transported to the laboratory immediately for processing.
PROCEDURE
CSF collected from the patients is first analyzed for cell count and type, protein and glucose. The same
sample is subjected to centrifugation at 1500rpm for 15minutes.sediment is used for Gram’s stain and culture and
the supernatant is used for antigen detection.
Microscopic examination – comprising of Gram’s staining. Two drops of sediment is placed on glass slide, air
dried, heat fixed and used for gram staining.
Culture – 1-2 drops of sediment is added on to Blood Agar, Chocolate Agar, Mac Conkey Agar and Brain heart
infusion (BHI)Broth. The solid media are streaked. The Blood Agar and Chocolate Agar are incubated in carbon
dioxide jar at 37⁰C for 48 hours. The Mac Conkey Agar is incubated at 37⁰C for 48 hours. BHI Broth is
incubated at 37⁰C for 7days. The Agar plates and Broth are examined after every 24 hours, any growth present is
identified appropriately and processed further by biochemical tests and antibiotic sensitivity.
Antigen detection – By using WELLCOGEN bacterial antigen kit ,a latex agglutination test to detect antigens of
5 organisms; Ecoli k1,N.meningitidis ABCYW135,Streptococcus pneumoniae, group B streptococcus and
H.influenzae type b is performed according to the manufacturer’s instructions.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE
CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?IF SO,PLEASE DISCRIBE
BRIEFLY.
The study involves investigating CSF samples from suspected meningitis cases . The study does not involve
animal experiments.
7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITTION IN CASE OF
7.3?
yes.
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8. LIST OF REFERENCES (ABOUT 4-6)
1. Das BK, Gurubacharya RL, Mohapatra M, Mishra OP. Bacterial
antigen detection test in Meningitis. Indian Journal of Pediatrics
2003;70(10):799-801.
2.Surinder K, Bineeta K, Megha M. Latex particle agglutination test as an adjunct to the
diagnosis of bacterial
meningitis. Indian J Med Microbiol 2007;25:395-7.
3.Larry D. Gray and Daniel P. Fedorko. Laboratory Diagnosis of Bacterial Meningitis.Clinical
Microbiology
Review,Apr.1992.p.130-145.
4. Nandhita Chinchankar, Meenakshi Mane, Sheila Bhave, Swate Bapat, Ashish Bavdekar, Anand Pandit et al.
Diagnosis and outcome of Acute Bacterial Meningitis in early
childhood. Indian pediatrics 2002; 39: 914-921.
5. Prober CG.Central nervous system infections.In:Nelson Textbook of Pediatrics,18th ed. In : Kliegman, Behrman ,
Jenson. 2007.p.2512-2521.`
6. Athavale.V.B .Pyogenic meningitis.In:Textbook of Pediatrics,Vol 3, Rev 1ST ed. Udani PM,
Nelson
Waleto E, Koko.W. 1998.p.2107-2116.
7. Xavier Saez-Llorens and George H. Mc cracken Jr. Infectious
disease of children. 11th ed. Philadelphia: Mosby publications;
2004.
9. SIGNATURE OF CANDIDATE
10. REMARKS OF GUIDE
:
: Bacterial meningitis is commonly seen in
Pediatric age group and more than two third of
meningitis cases occurs in first 2 years of life due to
decreased immunity, and also carries high
mortality and morbidity .Hence this study is taken
up to early and specific diagnosis and to reduce the
complications.
11. NAME AND DESIGNATION OF
(In block letters)
11.1 GUIDE
: DR.JAGADEESH,
PROFESSOR,
DEPARTMENT OF MICROBIOLOGY,
KEMPEGOWDA INSTITUTE OF MEDICAL
SCIENCES, BENGALURU.
SIGNATURE
:
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11.2 CO GUIDE
: DR.YASHODA. H.T ,
PROFESSOR,
DEPARTMENT OF PEDIATRICS,
KEMPEGOWDA INSTITUTE OF MEDICAL
SCIENCES, BENGALURU.
SIGNATURE
:
11.3 HEAD OF DEPARTMENT : DR.K.L.RAVIKUMAR,
PROFESSOR& HEAD,
DEPARTMENT OF MICROBIOLOGY,
KEMPEGOWDA INSTITUTE OF MEDICAL
SCIENCES, BENGALURU.
SIGNATURE
:
12. REMARKS OF CHAIRMAN AND PRINCIPAL:
SIGNATURE
:
.
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