Bacterial Meningitis

Most common acute CNS infection

Always associated meningoencephalitis

Early detection and treatment decrease morbidity and mortality

Background

NewbornGBSE.coliOther gram negative enteric bacilliL.monocytogenes

Infants & children < 1-2 yoH.influenzae type bS.pneumoniaeN.meningitidisSalmonella

Etiology

Children > 5 yoS.pneumoniaeN.meningitidis

Etiology

สถาบนัสขุภาพเด็กแห่งชาติมหาราชนีิ

Neonatal meningitiso Enterobacteriacea

E.coli 10.4%K.pneumoniae 13%

Enterobacter 10.4%o GBS 11.7%o P.aeruginosa 16.9%

Epidermiology in THAILAND

สถาบนัสขุภาพเด็กแห่งชาติมหาราชนีิ

• Childhood meningitisพ.ศ. 2523-2533

H.influenza 42.3%S.pneumoniae 22.2%Salmonella spp. 12.4%

พ.ศ. 2543-2547H.influenza 29%S.pneumoniae 15%

Epidermiology in THAILAND

Pathophysiology Contact & aspiration of genital tract secretion

Nasopharyngeal colonized bacteria

Bloodstream invasion

Hematogenous dissemination

CSF invasion

Bacterial meningitis

Skull fracture Dermal sinus tract

Direct extension: paranasal sinus Dental root

Depend on the patient’s age

NewbornNonspecific: feeding intolerance,

lethargy ,fever, convulsion, abdominal distension, bulging fontanelle

Infancyfever, vomiting, irritability, convulsion,

bulging fontanelleDiarrhea in < 1 yr

significant associated with salmonella meningitis

Clinical presentation

Depend on the patient’s age

Childrenfever, chills, vomiting, severe headache,

photophobia, alteration of consciousness

Petechial and purpuric eruptions: Meningococcemia

Clinical presentation

Meningeal signs

significantly less frequent in neonates neonate beyond

neonate

stiff neck 22.5% 72.8% brudzinski’s sign 11.5% 74.8%

Southeast Asian J Trop Med Public Health 1994;25(1):107-15

Clinical presentation

Clinical presentation

1. Signs and symptoms 2. CSF examination

profilesG/SC/SBacterial antigens

3. Hemoculture

Diagnosis

Focal neurological deficitNew onset of convulsionSign of increase ICP

PapilledemaCN VI palsy

Hx of CNS diseaseImmunocompromised host

CT scan before LP

CSF profilesCondition Normal CSF Normal

CSF (newborn

)

Bacterial meningitis

ColorPressure (mmH2O)WBC (mm3) Protein (mg/dl)Glucose (mg/dl)

Clear 50-80

<575% L 20-30

>50, 75% BS

Clear< 2000-30 2-3% PMN

19-14932-121

Cloudy Usually

elevated> 1000

PMN> 50%> 100-500

< 40, <50%BS

Pediatr Infect Dis 1996;15:298-303.

Pediatrics in review 1998;19(3):78-84.

May seen organism 60-90%Useful for choose empirical ATB

S.pneumoniae

CSF gram stain

May seen organism 60-90%Useful for choose empirical ATB

gram negative rod

CSF gram stain

May seen organism 60-90%Useful for choose empirical ATB

N.meningitidis

CSF gram stain

Latex agglutinationGBSE.coli K1 strainS.pneumoniaeHibN.meningitidis

good sensitivityfalse positive & false negative can occuruseful in patients with prior ATB and CSF G/S, C/S negative

Bacterial antigen

Aseptic meningitisMeninigismus

AOMacute tonsillitis

Subarachnoid hemorrhageBrain abscess

Differential diagnosis

VirusEnterovirus, EBV, HSV 2, HHV6, adenovirus, arbovirus, coxakievirus, mumps

BacteriaM. pneumoniae, M. tuberculosis, leptospirosis

FungiC. neoformans, Candida species, Histoplasma capsulatum

Aseptic meningitis

• Rickettsia scrub typhus

• ParasitesGnathostoma spinigerum, Angiostrongylus cantonensis

• Parameningeal infections

• Postvaccinemumps, measles, polio, rabies

Aseptic meningitis

CSF profilesCondition Viral

meningitisTB

meningitisPressure (mm.H2O)

WBC (mm3) %PMN

Protein (mg/dl)

Glucose (mg/dl)Comments

Normal or slightly

100-500<40%

50-200

Ususally normal

Usually elevated

10-500< 10-20%

100-3,000

<50AFB almost negative

M.TB may be detected by PCR,C/S

Nelson Textbook of Pediatrics 18th ed.

Salmonella: Consider Cefotaxime + Ciprofloxacin to prevent recurrence

add ampicillin for Pt < 60 days: L.monocytogenes

Bacterial meningitisTreatment

Age ATB of choice Duration (days)

Neonate Ampicillin + Gentamicin

or Cefotaxime + Gentamicin

14-21

Infant & Children

Cefotaxime or Ceftriaxone

+/- vancomycin

Depend on organism

Treatment

IDSA guideline

ATB dosages (MKD)

Treatment

ATB 0-7 days 8-28 days Infant and children

Ampicillin 150 (q8)

200 (q6-8)

300 (q6)

Amikacin 15-20 (q12)

20-30 (q12)

20-30 (q12)

Gentamicin 5 (q12)

7.5 (q8)

7.5 (q8)

Cefotaxime 100-150 (q8-12)

150-200 (q6-8)

225-300 (q6-8)

Ceftriaxone 80-100 (q12-24)

Vancomycin 20-30 (q8-12)

30-45 (q6-8)

60 (q6)

Duration of ATB

Treatment

Organism Duration (days)N.meningitidis 7-10H.influenzae b 10-14S.pneunomiae 10-14GBS 14-21Gram negative bacilli

21

L.monocytogenes ≥21Salmonella.spp 28-42

IDSA guideline

Dexamethasone

Recommended in Hib meningitis

fewer audiologic/neurologic sequelae dose 0.15 mg/kg q 6hr for 4 days 0.4 mg/kg q 12 hr for 2 days

10-20 min prior to or concomitant with 1st dose ATB

Schadd UB, et al. Lancet 1993;342:457Syrogiannopoulos GA, et al. J Infect Dis 1994;169:853..

Treatment

Supportive care

Adequate oxygenationHydration Observe neuro signmonitor BW, head circumference, I/O Anticonvulsants : diazepam then phenobarbital

Treatment

Diagnostic purposein questionable case repeat LP within 24 hr

of treatment

Response of treatment48-72 hr after treatment in- cases with poor response- resistant organism- neonatal meningitis

I/C for repeat LP

Subdural effusions 20-30%, subdural empyema 1%

Ventriculitis SIADH 60-70%Hearing loss: S.pneumoniae 30%, N.meningitidis

& Hib 5-10% require hearing evaluation at the end of Rx

Other Neurologic complications: seizure, hydrocephalus, brain abscess

Complications

ImmunizationChemoprophylaxis

Prevention

Hib conjugated vaccineRecommended in Thai children > 2 moAt 2, 4, 6 mo

Pneumococcal conjugated vaccineRecommended in children > 2 moAt 2, 4, 6, 12 mo

Meningococcal polysaccharide vaccine Not recommended in Thai children

Immunization

HibRifampicin 20 mg/kg (max 600 mg) OD for 4 daysRecommended in

- all household contacts with at least 1 contact < 4 yo who is unimmunized/incomplete immunized

- all members of a household with a child < 12 mo

- all members of a household with an immunocompromised child

- child care center contacts when > 2 cases occurred within 60 d

- index case, if Rx other than cefotaxime/cetriaxone

Chemoprophylaxis

Redbook

N. meningitidisRifampicin 10 mg/kg (max 600mg) q 12 hr

for 2 dRecommended in

- all household contacts- childcare/nursery contact during previous

7 d- mouth-to mouth resuscitation, unprotected

ET intubation during 7 days before onset of the illness

- frequent sleeps/eat in same dwelling as index case

S. pneumoniaeNo recommendation for postexposure prophylaxis

Chemoprophylaxis

Redbook

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