Bacterial Meningitis

Background
Most common acute CNS infection Always associated meningoencephalitis Early detection and treatment decrease

mortality

morbidity and

Etiology
Newborn
GBS E.coli Other gram negative enteric bacilli L.monocytogenes

Infants & children < 1-2 yo

H.influenzae type b S.pneumoniae N.meningitidis Salmonella

Etiology
Children > 5 yo
S.pneumoniae N.meningitidis

Epidermiology in THAILAND
Neonatal meningitis o Enterobacteriacea E.coli 10.4% K.pneumoniae 13% Enterobacter 10.4% o GBS 11.7% o P.aeruginosa 16.9%

Epidermiology in THAILAND

Childhood meningitis
.. 2523-2533 H.influenza S.pneumoniae Salmonella spp. .. 2543-2547 H.influenza S.pneumoniae

42.3% 22.2% 12.4%

29% 15%

Pathophysiology
Contact & aspiration of genital tract secretion Nasopharyngea l colonized bacteria

Bloodstream invasion Hematogenous dissemination

Skull fracture Dermal sinus tract

CSF invasion Bacterial meningitis

Direct extension: paranasal sinus Dental root

Clinical presentation
Depend on the patients age
Newborn Nonspecific: feeding intolerance, lethargy

,fever, convulsion, abdominal distension, bulging fontanelle

Infancy fever, vomiting, irritability, convulsion,

bulging fontanelle Diarrhea in < 1 yr significant associated with salmonella meningitis

Clinical presentation
Depend on the patients age
Children fever, chills, vomiting, severe headache,

photophobia, alteration of consciousness

Petechial and purpuric eruptions: Meningococcemia

Clinical presentation
Meningeal signs
significantly less frequent in neonates

neonate stiff neck 22.5% 11.5% brudzinskis sign

beyond neonate 72.8% 74.8%

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

Clinical presentation

Diagnosis
1. Signs and symptoms 2. CSF examination profiles G/S C/S Bacterial antigens 3. Hemoculture

CT scan before LP
Focal neurological deficit New onset of convulsion Sign of increase ICP Papilledema CN VI palsy Hx of CNS disease Immunocompromised host

CSF profiles
Condition Normal CSF Normal CSF (newborn) Bacterial meningitis

Color Pressure

Clear Clear Cloudy 50-80 < 200 Usually (mmH2O) elevated <5 0-30 WBC (mm3) > 1000 75% L 2-3% PMN PMN> 50% 20-30 19-149 Protein (mg/dl) >50, 75% BS 32-121 > 100-500 Glucose (mg/dl) < 40, <50%BS Pediatr Infect Dis

1996;15:298-303.

Pediatrics in review

CSF gram stain

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

Bacterial antigen
Latex agglutination
GBS E.coli K1 strain S.pneumoniae Hib N.meningitidis
good sensitivity false positive & false negative can occur useful in patients with prior ATB and CSF G/S, C/S negative

Differential diagnosis
Aseptic meningitis Meninigismus AOM acute tonsillitis Subarachnoid hemorrhage Brain abscess

Aseptic meningitis
Virus

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

Bacteria

M. pneumoniae, M. tuberculosis, leptospirosis

Fungi

C. neoformans, Candida species, Histoplasma capsulatum

Aseptic meningitis
Rickettsia Parasites

scrub typhus

Gnathostoma spinigerum, Angiostrongylus cantonensis

Parameningeal infections Postvaccine

mumps, measles, polio, rabies

CSF profiles
Condition Pressure (mm.H2O) WBC (mm3)
%PMN

Viral meningitis TB meningitis

Normal or slightly 100-500 <40% 50-200
Ususally normal

Usually elevated 10-500 < 10-20%

Protein (mg/dl) Glucose (mg/dl) Comments

100-3,000 <50
AFB almost negative M.TB may be detected by PCR,C/S

Nelson Textbook of Pediatrics 18th ed.

Bacterial meningitis Treatment

Age Neonate ATB of choice Ampicillin + Gentamicin or Cefotaxime + Gentamicin Duration (days) 14-21

Cefotaxime or Depend on Ceftriaxone organism +/- vancomycin Salmonella: Consider Cefotaxime + Ciprofloxacin to prevent recurrence add ampicillin for Pt < 60 days: L.monocytogenes

Infant & Children

Treatment

IDSA

Treatment
ATB dosages
ATB Ampicillin Amikacin Gentamicin Cefotaxime Ceftriaxone

(MKD)
8-28 days 200 20-30 7.5 (q6-8) (q12) (q8) Infant and children 300 20-30 7.5 (q6) (q12) (q8)

0-7 days 150 (q8) 15-20 (q12) 5 (q12) 100-150 (q812)

150-200 (q6-8)

225-300 (q6-8) 80-100 24) (q12-

Treatment
Duration of ATB
Organism N.meningitidis H.influenzae b S.pneunomiae GBS Gram negative bacilli L.monocytogenes Salmonella.spp Duration (days) 7-10 10-14 10-14 14-21 21 21 28-42 IDSA guideline

Treatment
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;342:457

Treatment
Supportive care
Adequate oxygenation Hydration Observe neuro sign monitor BW, head circumference, I/O Anticonvulsants : diazepam then phenobarbital

I/C for repeat LP

Diagnostic purpose in questionable case repeat LP within 24 hr of treatment Response of treatment 48-72 hr after treatment in - cases with poor response - resistant organism - neonatal meningitis

Complications
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

Prevention
Immunization Chemoprophylaxis

Immunization
Hib conjugated vaccine
Recommended in Thai children > 2 mo At 2, 4, 6 mo

Pneumococcal conjugated vaccine

Recommended in children > 2 mo At 2, 4, 6, 12 mo

Meningococcal polysaccharide vaccine

Not recommended in Thai children

Chemoprophylaxis
Hib
Rifampicin 20 mg/kg (max 600 mg) OD for 4 days Recommended 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 Redbook cefotaxime/cetriaxone

Chemoprophylaxis
N. meningitidis Rifampicin 10 mg/kg (max 600mg) q 12 hr for 2d Recommended 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. pneumoniae Redbook No recommendation for postexposure prophylaxis

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