ACUTE BAKTERIAL ACUTE BAKTERIAL MENINGITIS IN INFANT MENINGITIS IN INFANT

AND CHILDRENAND CHILDREN

DR. DR. Dr. H. Ruslan Muhyi, Sp. A (K)Dr. H. Ruslan Muhyi, Sp. A (K)

SMF/Bagian Ilmu Kesehatan AnakSMF/Bagian Ilmu Kesehatan AnakRSUD Ulin-FK UNLAMRSUD Ulin-FK UNLAM

BanjarmasinBanjarmasin

BACTERIAL MENINGITISBACTERIAL MENINGITIS Is an acute purulent infection in the Is an acute purulent infection in the

subarachnoid space that is associated with subarachnoid space that is associated with inflammation reaction in the brain and cerebral inflammation reaction in the brain and cerebral blood vessels that cause decreased blood vessels that cause decreased conciuosness, seizure, raised intracranial conciuosness, seizure, raised intracranial pressure, and stroke.pressure, and stroke.

Is inflammation of the meningens caused by a Is inflammation of the meningens caused by a bacterial pathogen.bacterial pathogen.

INCIDENCEINCIDENCE In Asia, there is increasing incidence of In Asia, there is increasing incidence of H influenzae H influenzae

type b (Hib)type b (Hib). Previously, . Previously, SalmonellaSalmonella, , S pneumoniaeS pneumoniae and and M tuberculosisM tuberculosis..

In USA, 2.5 to 3.5 cases per 100,000 population.In USA, 2.5 to 3.5 cases per 100,000 population.

H influenzae type bH influenzae type b declined 421 cases 1987 to 0.7 declined 421 cases 1987 to 0.7 per 100,000 in 1997.per 100,000 in 1997.

Today the most common bacterial: Today the most common bacterial: Streptococcus Streptococcus pneumoniaepneumoniae, , N meningitidisN meningitidis, and , and H influenzaeH influenzae..

MENINGITISMENINGITIS Classified into two syndromes :Classified into two syndromes :

Septic or purulent meningitis is caused by bacterial Septic or purulent meningitis is caused by bacterial or fungal organism.or fungal organism.

Aseptic meningitis is caused by viral, neoplastic, Aseptic meningitis is caused by viral, neoplastic, protozoal, spirochetal or other non septic causes.protozoal, spirochetal or other non septic causes.

Pooled information from 1853 case of meningitisPooled information from 1853 case of meningitis

Fig. Distribution of the most common causes of neonatal maningitisFig. Distribution of the most common causes of neonatal maningitis

3

2

3

2

3

1

4.5

4

8

6

30

34

Others

Meningococcus

Pseudomonas spp

Haemophilus

Pneumococcus

Salmonella spp

Staphylococci

Other streptococci

Other gram negative

Listeria spp

Group B strep

E. coli

TABLE. Estimated age-specifik incidence of TABLE. Estimated age-specifik incidence of bacterial meningitis (cases per 100,000 bacterial meningitis (cases per 100,000

population), United States, 1995population), United States, 1995

Adapted from Schuchat A, Robinson K, Wenger JD, et al. Adapted from Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. N Engl J Bacterial meningitis in the United States in 1995. N Engl J

Med 1997;337;970Med 1997;337;970

Age groupAge group Haemophilus Haemophilus influenzaeinfluenzae

Streptococcus Streptococcus pneumoniaepneumoniae

Neiseria Neiseria meningitismeningitis

Group B Group B StreptococcusStreptococcus

ListeriaListeria

< 1 mo< 1 mo 00 15.715.7 00 125.0125.0 39.239.2

1-23 mo1-23 mo 0.70.7 6.66.6 4.54.5 2.82.8 00

1-29 yr1-29 yr 0.10.1 0.50.5 1.11.1 0.10.1 0.040.04

CLINICAL PRESENTATIONCLINICAL PRESENTATIONThere are two patterns of presentation :There are two patterns of presentation :

The first is more insidious and develops over one The first is more insidious and develops over one or several day.or several day.

The other is more acute and fulminant. Usually The other is more acute and fulminant. Usually with severe brain edema and herniationwith severe brain edema and herniation

Signs and Symptoms of Bacterial Signs and Symptoms of Bacterial MeningitisMeningitis

FeverFeverDepression of consciousnessDepression of consciousnessFull fontanelFull fontanelIrritabilityIrritabilitySeizuresSeizuresHeadacheHeadacheFocal neurologic deficitsFocal neurologic deficitsPetechial skin rashPetechial skin rash

Table 3. Clinical signs of neonatal Table 3. Clinical signs of neonatal bacterial meningitisbacterial meningitis

Source :Source : Frequencies from Klein & Marey (1995)Frequencies from Klein & Marey (1995)

SymptomsSymptoms PercentagePercentage SignsSigns PercentagePercentage

LethargyLethargy 5050 Fever or hypothermiaFever or hypothermia 6161

AnorexiaAnorexia Respiratory distressRespiratory distress 4747

VomitingVomiting 4949 IrritabilityIrritability 3232

DiarrheaDiarrhea JaundiceJaundice 2828

ConvulsionsConvulsions 4040 Full/bulging fontanelleFull/bulging fontanelle 2828

ApneaApnea 77 Neck stiffnessNeck stiffness 1515

Altered sleep patternAltered sleep pattern HipotoniaHipotonia

High-pitched cryHigh-pitched cry PetechiaePetechiae

Hypotension, shockHypotension, shock

BradycardiaBradycardia

Table 1. INCIDENCE AND MORTALITY RATES IN Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL MENINGITISACUTE BACTERIAL MENINGITIS

NA = not availableNA = not available

OrganismOrganismChildrenChildren

Incidence (%)Incidence (%) Mortality rate (%)Mortality rate (%)

S. pneumoniaeS. pneumoniae 10-2010-20 88

N. meningitidisN. meningitidis 25-4025-40 1515

H. influenzaeH. influenzae 40-6040-60 44

Gram negative bacilliGram negative bacilli 1-21-2 NANA

S. aureusS. aureus 1-21-2 NANA

StreptococciStreptococci 2-42-4 NANA

L. monocytogenesL. monocytogenes 1-21-2 8-508-50

AnaerobesAnaerobes 1-21-2 NANA

EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITISEVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS

BACTERIAL CELL WALL COMPONENTSBACTERIAL CELL WALL COMPONENTS

Endotelial CellsEndotelial Cells CNS-Macrophages CNS-Macrophages Endotoxin Shock Endotoxin Shock

TNF, IL-1, PAFTNF, IL-1, PAFIL-1IL-1PGEPGE22

TrombosisTrombosis ↑ ↑ CSF pleocytosisCSF pleocytosis

Impaired BBBImpaired BBB InfarctionInfarction HydrocephalusHydrocephalus ↓↓ PerfusionPerfusion

EdemaEdema

↑↑ ICPICP ↑↑ CBFCBF Microcirculatory Failure Microcirculatory Failure

CSF Examination in Suspected Bacterial CSF Examination in Suspected Bacterial MeningitisMeningitis

Routin testRoutin testGramGram’’s Stain (60-90%)s Stain (60-90%)Bacterial culture and sensitivities (70-85%)Bacterial culture and sensitivities (70-85%)Cell count and differentialCell count and differentialGlucouseGlucouseProteinProteinBacterial antigen (50-100%)Bacterial antigen (50-100%)

Special testSpecial testCulture for tuberculosis, fungus,virusCulture for tuberculosis, fungus,virusAdditional bacterial antigen studiesAdditional bacterial antigen studiesSerologySerologyCryptococcus antigenCryptococcus antigenIndia inkIndia inkCoccidioidoruycosisCoccidioidoruycosisPolymerase chain reactionPolymerase chain reaction

Tabel 3. CEREBROSPINAL FLUID FINDINGS IN Tabel 3. CEREBROSPINAL FLUID FINDINGS IN BACTERIAL BACTERIAL MENINGITISMENINGITIS

CSF : Cerebrospinal FluidCSF : Cerebrospinal Fluid

NormalNormal Bacterial meningitisBacterial meningitis

Opening pressureOpening pressure 50-195 mm CSF50-195 mm CSF(3.8-15 mm Hg)(3.8-15 mm Hg)

>200 mmCSF>200 mmCSF

Cell countCell count <5 cells/mm<5 cells/mm33

(15% neutrophils)(15% neutrophils)100-10,000 cells/mm100-10,000 cells/mm33

(86% neutrophils)(86% neutrophils)

ProteinProtein 15-50 mg/dL15-50 mg/dL 100 to 500 mg/dL100 to 500 mg/dL

GlucoseGlucose 45-80 mg/dL45-80 mg/dL usually <20-40 mg/dLusually <20-40 mg/dL

CSF Glucose RatioCSF Glucose Ratio >0.5>0.5 <0.4<0.4

TREATMENTTREATMENTTwo critical decisions must be consider :Two critical decisions must be consider :

The first concern the choice of antibiotic The first concern the choice of antibiotic therapy.therapy.The second, the benefits versus the risk of The second, the benefits versus the risk of doing a lumbar puncture.doing a lumbar puncture.

EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITISEVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS

MildMild-Irritability-Irritability-Lethargy-Lethargy-Headache-Headache-Vomiting-Vomiting-Nurchal rigidity-Nurchal rigidity

ModerateModerate-Seizures-Seizures-Focal deficit-Focal deficit-Consciousness-Consciousness-Papilledema-Papilledema

SevereSevere-Status epilepticus-Status epilepticus-Persistent deficit-Persistent deficit-Coma-Coma-Herniation-Herniation

Lumbar Lumbar Puncture;Puncture;

Start Start Antibiotics Antibiotics

And SteroidsAnd Steroids

Start Start Antibiotics Antibiotics

And Steroids And Steroids And Do CT or And Do CT or

MRI ScanMRI Scan

↑ ↑ ICPICP

NL ICPNL ICP

Lumbar Lumbar PuncturPuncturee

CT or MRI Scan and Treat

Observe

↑ ICP

NL ICP

Treat

Observe

DELAYED LPDELAYED LP Intravenous antibiotics used for 2 to 3 days Intravenous antibiotics used for 2 to 3 days

prior to lumbar puncture do not alter the CSF prior to lumbar puncture do not alter the CSF cells count, or protein or glucose cells count, or protein or glucose concentrations.concentrations.

Substantially decrease the chance of Substantially decrease the chance of demonstrating bacteria on Gram stain or demonstrating bacteria on Gram stain or culture.culture.

TABLE 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN TABLE 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN PATIENTS WITH BACTERIAL MENINGITISPATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIATYPE BACTERIA CHOICE OF ANTIBIOTICCHOICE OF ANTIBIOTIC

On Gram’s stainingOn Gram’s staining

CocciCocci

Gram-positiveGram-positive Gram-negativeGram-negative

Vancomycin plus broad-spectrum cephalosporinVancomycin plus broad-spectrum cephalosporinPenicillin GPenicillin G

BacilliBacilli

Gram-positiveGram-positive Gram-negativeGram-negative

Ampicillin (or Penicillin G) plus aminoglycosideAmpicillin (or Penicillin G) plus aminoglycosideBroad-spectrum cephalosporin plus aminoglycosideBroad-spectrum cephalosporin plus aminoglycoside

Table 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN Table 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN PATIENTS WITH BACTERIAL MENINGITISPATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIATYPE BACTERIA CHOICE OF ANTIBIOTICCHOICE OF ANTIBIOTIC

On cultureOn culture

S. pneumoniaeS. pneumoniae Vancomycin plus broad-spectrum cephalosporinVancomycin plus broad-spectrum cephalosporin

H. influenzaeH. influenzae CeftriaxoneCeftriaxone

N. meningitidisN. meningitidis Penicillin GPenicillin G

L. monocytogenesL. monocytogenes Ampicillin plus gentamicinAmpicillin plus gentamicin

S. agalactiaeS. agalactiae Penicillin GPenicillin G

EnterobactericeaeEnterobactericeae Broad-spectrum cephalosporin plus aminoglycosideBroad-spectrum cephalosporin plus aminoglycoside

Pseudomonas aeruginosaPseudomonas aeruginosa, , acinetobacteracinetobacter

Ceftazidime plus aminoglycosideCeftazidime plus aminoglycoside

The American Academic of The American Academic of Pediatrics recommendedPediatrics recommended

Dexamethasone, 0.6 mg/kg per day in four Dexamethasone, 0.6 mg/kg per day in four divided doses for the first two days of divided doses for the first two days of antibiotic treatment.antibiotic treatment.

The first dose should be given at the time of, The first dose should be given at the time of, or shortly before the first dose of antibiotic.or shortly before the first dose of antibiotic.

Empiric therapy for acute bacterial Empiric therapy for acute bacterial meningitis in neonatusmeningitis in neonatus

0-7 days0-7 days Ampicillin 150 mg/kg/d divided dose every 8 hours IV plus Ampicillin 150 mg/kg/d divided dose every 8 hours IV plus cefotaxime 100 mg/kg/d divided dose every 12 hours IVcefotaxime 100 mg/kg/d divided dose every 12 hours IV

ororCeftriaxone 50 mg/kg/d every 24 hours IVCeftriaxone 50 mg/kg/d every 24 hours IVororAmpicillin 150 mg/kg/d divided dose every 8 hours IV plus Ampicillin 150 mg/kg/d divided dose every 8 hours IV plus

gentamicin 5 mg/kg/d divided dose every 12 hours IVgentamicin 5 mg/kg/d divided dose every 12 hours IV

Empiric therapy for acute bacterial Empiric therapy for acute bacterial meningitis in neonatusmeningitis in neonatus

> 7 days> 7 days Ampicillin 200 mg/kg/d divided dose every 6 hours Ampicillin 200 mg/kg/d divided dose every 6 hours IVIV

ANDANDCefotaxime 150 mg/kg/d divided dose every 8 hours Cefotaxime 150 mg/kg/d divided dose every 8 hours

IVIVororCeftriaxone 75 mg/kg/d every 24 hours IVCeftriaxone 75 mg/kg/d every 24 hours IV

Table 2. Empiric therapy for acute bacterial Table 2. Empiric therapy for acute bacterial meningitismeningitis

1-3 months1-3 months Ampicillin 200-400 mg/kg/d divided dose every 6 Ampicillin 200-400 mg/kg/d divided dose every 6 hours IV hours IV ANDAND

Cefotaxime 200 mg/kg/d divided dose every 6 hours Cefotaxime 200 mg/kg/d divided dose every 6 hours IV IV oror

Ceftriaxone 100 mg/kg/d divided dose every 12 Ceftriaxone 100 mg/kg/d divided dose every 12 hours IV or 80 mg/kg daily IV/IMhours IV or 80 mg/kg daily IV/IM

Add vancomicyn 60 mg/kg/d IV divided dose every Add vancomicyn 60 mg/kg/d IV divided dose every 6 hours IV if penicillin-resistant 6 hours IV if penicillin-resistant S pneumococcusS pneumococcus suspectedsuspected

Table 2. Empiric therapy for acute bacterial Table 2. Empiric therapy for acute bacterial meningitismeningitis

> 3 months> 3 months Cefotaxime 200 mg/kg/d divided dose every 6-8 Cefotaxime 200 mg/kg/d divided dose every 6-8 hours IV hours IV ororCeftriaxone 100 mg/kg/d divided dose every 12 Ceftriaxone 100 mg/kg/d divided dose every 12 hours IV or 80 mg/kg daily IV/IM hours IV or 80 mg/kg daily IV/IM ororAmpicillin 200 mg/kg/d divided dose every 6 hours Ampicillin 200 mg/kg/d divided dose every 6 hours IV IV PLUSPLUSChloramphenicol 100 mg/kg/ d divided dose every 6 Chloramphenicol 100 mg/kg/ d divided dose every 6 hours IV;hours IV;Add vancomicyn 60 mg/kg/d IV divided dose every Add vancomicyn 60 mg/kg/d IV divided dose every 6 hours IV if penicillin-resistant 6 hours IV if penicillin-resistant S pneumococcusS pneumococcus suspectedsuspected

TABLE 4. GUIDELINES FOR THE DURATION TABLE 4. GUIDELINES FOR THE DURATION OF ANTIBIOTIC THERAPYOF ANTIBIOTIC THERAPY

PATHOGENPATHOGEN SUGGESTED DURATION SUGGESTED DURATION OF THERAPY (DAYS)OF THERAPY (DAYS)

H. influenzaeH. influenzae --

N. meningitidisN. meningitidis --

S. pneumoniaeS. pneumoniae 10-1410-14

L. monocytogenesL. monocytogenes 14-2114-21

Group B streptococcusGroup B streptococcus 14-2114-21

Gram negative bacilli (other than Gram negative bacilli (other than H. influenzaeH. influenzae))

2121

Complications during Acute Bacterial MeningitisComplications during Acute Bacterial Meningitis

CommonCommonIncreased intracranial pressureIncreased intracranial pressureSIADHSIADHVentriculomegalyVentriculomegalySeizuresSeizuresExtra-axial fluid collectionExtra-axial fluid collectionInfarction and necrosisInfarction and necrosisCranial nerve involvement (deafness)Cranial nerve involvement (deafness)Disseminated intravascular coagulationDisseminated intravascular coagulation

UncommonUncommonSubdural empyemaSubdural empyemaBrain abscessBrain abscessCranial nerve deficits other than VIIICranial nerve deficits other than VIII

Table. Treatment of the Seriously III Patient with MeningitisTable. Treatment of the Seriously III Patient with Meningitis

SCAN RESULTSSCAN RESULTS

INTRACRANIAL PRESSURE MEASUREMENTINTRACRANIAL PRESSURE MEASUREMENT

INCREASEDINCREASED

NormalNormal Hyperventilate to reduce increased cerebral blood volumeHyperventilate to reduce increased cerebral blood volume

EdemaEdema Do not hyperventilate; use furosemid or mannitol restrict fluidsDo not hyperventilate; use furosemid or mannitol restrict fluids

Acute ventriculomegaly, Acute ventriculomegaly, hydrocephalus or enlarged hydrocephalus or enlarged subarachnoid spacessubarachnoid spaces

Remove CSF by ventricular tap or drain; decrease CSF Remove CSF by ventricular tap or drain; decrease CSF production (Diamox or digoxin); increase CSF production (Diamox or digoxin); increase CSF reabsorption (steroids)reabsorption (steroids)

Subdural effusionsSubdural effusions Subdural drainageSubdural drainage

InfarctsInfarcts Steroids to reduce peri-infarct edemaSteroids to reduce peri-infarct edema

Fundamental principles to the Fundamental principles to the management of meningitismanagement of meningitis

Antibiotic therapy should be prompt and Antibiotic therapy should be prompt and appropiateappropiate

Cerebral metabolisme should be protectedCerebral metabolisme should be protected Increased intracranial pressure should be Increased intracranial pressure should be

monitormonitor Seizure should be prevented or controlledSeizure should be prevented or controlled Fluid managementFluid management Hyperpyrexia should be controlledHyperpyrexia should be controlled

Penetration of antibacterials into CNSPenetration of antibacterials into CNS

Sources : Infectious Disease in Emergency Medicine. Judith C. Sources : Infectious Disease in Emergency Medicine. Judith C. Brillman & RonaldBrillman & Ronald

AntibioticsAntibiotics Normal meningesNormal meninges MeningitisMeningitis

PenicillinsPenicillins

Penicillins GPenicillins G PoorPoor Fair-goodFair-good

AmpicillinAmpicillin PoorPoor Fair-goodFair-good

MethicillinMethicillin PoorPoor --

NafcillinNafcillin -- FairFair

CephalosporinsCephalosporins

CefazolinCefazolin PoorPoor Fair-goodFair-good

CefotaximesCefotaximes GoodGood GoodGood

CeftriaxoneCeftriaxone GoodGood GoodGood

CeftazidimeCeftazidime GoodGood GoodGood

TetracyclinesTetracyclines

TetracyclineTetracycline -- FairFair

OxytetracyclineOxytetracycline -- FairFair

ChlortetracyclineChlortetracycline -- FairFair

Penetration of antibacterials into CNSPenetration of antibacterials into CNS

Sources : Infectious Disease in Emergency Medicine. Judith C. Sources : Infectious Disease in Emergency Medicine. Judith C. Brillman & RonaldBrillman & Ronald

AntibioticsAntibiotics Normal meningesNormal meninges MeningitisMeningitis

AminoglycosidesAminoglycosides

GentamycinGentamycin PoorPoor FairFair

AmikasinAmikasin -- PoorPoor

RifampinRifampin FairFair GoodGood

CyproofloxacinCyproofloxacin FairFair FairFair

Miscellaneus antibacterialsMiscellaneus antibacterials

ChloramphenicolChloramphenicol GoodGood GoodGood

ClindamycinClindamycin PoorPoor FairFair

MetronidazoleMetronidazole -- GoodGood

TrimetrophinTrimetrophin GoodGood GoodGood

VancomycinVancomycin PoorPoor GoodGood

Table. Complications and outcome of patient with Table. Complications and outcome of patient with acute acute bacterial meningitis bacterial meningitis

ChildrenChildren(%)(%)

ComplicationsComplications

Acute suizuresAcute suizures 3131

Cranial nerve palsiesCranial nerve palsies 3-53-5

DeafnessDeafness 1010

Focal neurologic defisitsFocal neurologic defisits 4-154-15

HydrocephalusHydrocephalus 2-202-20

Cerebrovascular involvementCerebrovascular involvement 2-122-12

Cerebral edemaCerebral edema 2-82-8

Cerebral nervous system hemorrhageCerebral nervous system hemorrhage 22

HerniationHerniation 2-62-6

Mental retardationMental retardation 4-64-6

EpilepsyEpilepsy 4-74-7

OutcomeOutcome

Good recovery/mild disabilityGood recovery/mild disability 84-8884-88

Severe/moderate disabilitySevere/moderate disability 8-148-14

Persistent vegetatif statePersistent vegetatif state 1-21-2

DeadDead 2-52-5

Guidelines for acceptable CSF Guidelines for acceptable CSF values At the end of therapyvalues At the end of therapy

1.1. The percentage of polymorphonuclear The percentage of polymorphonuclear leucocytes (PMNs) in the CSF is more leucocytes (PMNs) in the CSF is more important than the absolute white blood important than the absolute white blood cell (WBC) count and is usually 5 cell (WBC) count and is usually 5 percent, but should not exceed 25-30 percent, but should not exceed 25-30 percent of the total WBC.percent of the total WBC.

2.2. The CSF glucose concentration should The CSF glucose concentration should exceed 20 mg/dl and be more than 20 exceed 20 mg/dl and be more than 20 percent of a concomitantly obtained percent of a concomitantly obtained serum glucose.serum glucose.

Table 1. INCIDENCE AND MORTALITY RATES IN Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL MENINGITISACUTE BACTERIAL MENINGITIS

NA = not availableNA = not available

OrganismOrganismChildrenChildren

Incidence (%)Incidence (%) Mortality rate (%)Mortality rate (%)

S. pneumoniaeS. pneumoniae 10-2010-20 88

N. meningitidisN. meningitidis 25-4025-40 1515

H. influenzaeH. influenzae 40-6040-60 44

Gram negative bacilliGram negative bacilli 1-21-2 NANA

S. aureusS. aureus 1-21-2 NANA

StreptococciStreptococci 2-42-4 NANA

L. monocytogenesL. monocytogenes 1-21-2 8-508-50

AnaerobesAnaerobes 1-21-2 NANA

Figure 33.1 Pathophysiology of bacterial meningitisFigure 33.1 Pathophysiology of bacterial meningitisHypoxia

Lactate Blood flow

↓ Glucose

↑ Intracranial Pressure

Immunemodulators

Edema

BacteriaPeptidoglycanTeichoic acid

Endotoxin

↑ Permeabilityblood-brain

barier

Cell damage

Lethal to infantsLethal to infants Meningitis infects the membranes Meningitis infects the membranes

covering the brain, and it is always covering the brain, and it is always treated as a medical emergencytreated as a medical emergency

National Health and Medical Research National Health and Medical Research Council (AUS) suggest that doctors Council (AUS) suggest that doctors should give the first doses of antibiotic should give the first doses of antibiotic before a child goes to hospitalbefore a child goes to hospital

Important to be a ware of the sign of Important to be a ware of the sign of meningitis and act quicklymeningitis and act quickly

Acute bacterial meningitisAcute bacterial meningitis A high index of suspicion is required A high index of suspicion is required

to diagnose this condition which, if to diagnose this condition which, if undetected and untreated, can lead undetected and untreated, can lead to significant morbidity or death.to significant morbidity or death.

Table 33.3 Clinical signs of bacterial Table 33.3 Clinical signs of bacterial meningitismeningitis

Source :Source : Frequencies from Klein & Marey (1995)Frequencies from Klein & Marey (1995)

SymptomsSymptoms PercentagePercentage SignsSigns PercentagePercentage

LethargyLethargy 5050 Fever or hypothermiaFever or hypothermia 6161

AnorexiaAnorexia Respiratory distressRespiratory distress 4747

VomitingVomiting 4949 IrritabilityIrritability 3232

DiarrheaDiarrhea JaundiceJaundice 2828

ConvulsionsConvulsions 4040 Full/bulging fontanelleFull/bulging fontanelle 2828

ApneaApnea 77 Neck stiffnessNeck stiffness 1515

Altered sleep patternAltered sleep pattern HipotoniaHipotonia

High-pitched cryHigh-pitched cry PetechiaePetechiae

Hypotension, shockHypotension, shock

BradycardiaBradycardia

Table 1. Complications and Outcome In Acute Bacterial MeningitisTable 1. Complications and Outcome In Acute Bacterial Meningitis

ChildrenChildren(%)(%)

ComplicationsComplications

Acute suizuresAcute suizures 3131

Cranial nerve palsiesCranial nerve palsies 3-53-5

DeafnessDeafness 1010

Focal neurologic defisitsFocal neurologic defisits 4-154-15

HydrocephalusHydrocephalus 2-202-20

Cerebrovascular involvementCerebrovascular involvement 2-122-12

Cerebral edemaCerebral edema 2-82-8

Cerebral nervous system hemorrhageCerebral nervous system hemorrhage 22

HerniationHerniation 2-62-6

Mental retardationMental retardation 4-64-6

EpilepsyEpilepsy 4-74-7

OutcomeOutcome

Good recovery/mild disabilityGood recovery/mild disability 84-8884-88

Severe/moderate disabilitySevere/moderate disability 8-148-14

Persistent vegetatif statePersistent vegetatif state 1-21-2

DeadDead 2-52-5

TABLE 1. Chronic complications of TABLE 1. Chronic complications of bacterial meningitisbacterial meningitis

Hearing lossHearing lossBehavior disordersBehavior disordersMental retardationMental retardationNeuropsychiatric dysfunctionNeuropsychiatric dysfunctionSeizuresSeizuresAuditory disfunctionAuditory disfunctionSpasticity, paresisSpasticity, paresisDiabetes insipidusDiabetes insipidusHydrocephalusHydrocephalusTransverse myelitisTransverse myelitisBlindnessBlindnessPolyarteritisPolyarteritis

Table 2. Antibiotics Recommended for Empirical Therapy in Table 2. Antibiotics Recommended for Empirical Therapy in Patients With Suspected Bacterial Meningitis Who Have A Patients With Suspected Bacterial Meningitis Who Have A

Nondiagnostic Gram’s Stain of Cerebrospinal FluidNondiagnostic Gram’s Stain of Cerebrospinal Fluid

Group of PatientsGroup of Patients Likely PathogenLikely Pathogen Choice of AntibioticChoice of Antibiotic

ImmunocomperentImmunocomperent Age, < 3 moAge, < 3 mo Age, 3 mo to <18 yrAge, 3 mo to <18 yr

S. agalactiae, E. coliS. agalactiae, E. coli or or L. L. monocytogenesmonocytogenes

N. meningitidis, S. pneumoniae, N. meningitidis, S. pneumoniae, H. influenzaeH. influenzae

Ampicillin plus broad-Ampicillin plus broad-spectrum cephalosporinspectrum cephalosporin

Broad-spectrum cephalosporinBroad-spectrum cephalosporin

With impired cellularWith impired cellular L. monocytogenesL. monocytogenes or gram- or gram-negative bacillinegative bacilli

Ampicillin plus ceftazidineAmpicillin plus ceftazidine

With head trauma, With head trauma, neurosurgery, or neurosurgery, or cerebrospinal fluid cerebrospinal fluid shuntshunt

Staphylococci, gram-negative Staphylococci, gram-negative bacilli, or bacilli, or S. pneumoniaeS. pneumoniae

Vancomycin and ceftazidineVancomycin and ceftazidine

The American Academy of Pediatrics The American Academy of Pediatrics (AAP) recommended in 1997 :(AAP) recommended in 1997 :

Vancomycin plus Cefotaxim or Vancomycin plus Cefotaxim or Ceftriaxone should be administered Ceftriaxone should be administered initially to all children older than 1 initially to all children older than 1 month with definite or probable month with definite or probable bacterial meningitis.bacterial meningitis.