Challenges in the management of multidrug-resistant Gram-negative bacterial meningitis in children: a decade of clinical insights

Background: Clinical characteristics, microbiology, treatment and outcomes of Gram-negative bacterial (GNB) meningitis with/without ventriculitis in children are limited. Methods: All hospitalized patients with GNB meningitis in a tertiary care university hospital between January 2012 and December 2022 were retrospectively recorded. Results: During the 10-year study period, 55 GNB meningitis were identified. The median age was 28 months. The majority were male (65.5%), while 29.1% had a history of prematurity, and 25.5% were primarily diagnosed with malignancy. Acinetobacter spp. (22%) and Pseudomonas spp. (20%) were the leading causative agents of meningitis, followed by Klebsiella spp. (18%) and Escherichia coli. (16%). Neurosurgical operation history in the last month (71%) appears to be one of the most common contributing factors and time from previous neurosurgery to meningitis episode was median 12 days. Both ventriculoperitoneal shunt or external ventricular drainage were present in 45 (82%) cases. While the combination of meropenem and ciprofloxacin was the most commonly used intravenous treatment, colistin was mostly used in five episodes (4/5 survived) intraventricular/intrathecal way. Infection-related mortality was 13% and deaths were commonly seen in cases infected with Acinetobacter spp., Klebsiella spp. and Escherichia coli. Conclusion: Managing GNB meningitis is challenging due to poor CSF penetration of many antibiotics and rising multidrug resistance. Given the evolving resistance patterns, particularly the persistence of penicillin resistance and the emergence of carbapenem resistance, continuous surveillance of antimicrobial susceptibility profiles is essential. This allows for timely adaptation of empiric therapy protocols and supports effective infection control strategies. Although surgical procedures and catheter use were not significantly associated with mortality in our cohort, these remain key risk factors for the development of Gram-negative meningitis and ventriculitis. Therefore, strict adherence to aseptic technique is essential for prevention.