Bacterial Meningitis Objectives To define bacterial meningitis



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Bacterial Meningitis


Objectives

  • To define bacterial meningitis

  • To discuss the causative pathogens

  • To discuss clinical presentation

  • To discuss diagnosis and lumbar puncture

  • To discuss management including antibiotics and dexamethasone

  • To discuss outcomes and follow up

  • To discuss Meningococcal disease

  • To discuss prevention



What is meningitis ?

  • Meningitis

  • Encephalitis

  • Meningoencephalitis



Bacterial Pathogens

  • Depends on Age

  • Depends on underlying conditions

  • Depends on vaccination status

  • Depends on Geographical location



Bacterial Pathogens

  • Neonatal period

  • Group B Strep. 49%

  • E.Coli 18%

  • Listeria 7%

  • Misc. Gram. Neg. 10%

  • Misc. Gram. Pos. 10%



Bacterial Pathogens

  • Older than 1 month

  • Neiserria Meningitidis(Meningcoccus)

  • Strep. Pneumoniae (Pneumococcus)

  • H.influenzae ( Now rare )



Bacterial Pathogens

  • V-P Shunt

  • Staph. Epidermidis

  • Staph. Aureus

  • Coliforms

  • Post Head injury

  • Strep. Pneumoniae most common if CSF leak ( Consider s.aureus/Pseudomonas)



Symptoms of Meningitis

  • Depends on Age

  • Older Child

  • Fever, Chills, vomiting, photophobia

  • & severe headache

  • Seizures

  • Younger Child

  • More subtle – poor feeding, drowsy, quiet, ‘Not herself’



Clinical Signs of Meningitis

  • Signs of infection:

  • Fever, pallor.

  • Raised ICP:

  • Elevated BP with decreased Heart rate. Papilloedema

  • Nuchal Rigidity:

  • Neck stiffness – not soreness



Clinical Signs of Meningitis

  • Kernigs:

  • “If one attempts to extend the patient’s knees one will succeed only to an angle of approximately 135°. In cases in which the phenomenon is very pronounced the angle may even remain 90°.”

  • Brudzinskis:

  • With the patient lying on the back: if the neck is forcibly bended forward, there occurs a reflexive flexion of the knees.



Kernig’s sign



Brudzinski’s sign



Role of Lumbar Puncture (LP)

  • CSF analysis and culture is the definitive method of diagnosis

  • Identifying pathogen allows rationalisation of antibiotic treatment and collection of epidemiological information

  • Definitive diagnosis allows better outcome prediction.



Role of Lumbar Puncture

  • When to LP?

  • When meningitis is suspected

  • When its safe !

  • ? Role of CT

  • Sterilisation of CSF after antibiotics

  • Molecular techniques



Interpretation of CSF findings



Contraindications to Lumbar Puncture

  • Signs of cerebral herniation

  • GCS < 8

  • Abnormal pupillary signs

  • Abnormal tone / posture

  • Papilloedema

  • Focal neurological signs

  • Cardiorespiratory compromise

  • Obvious signs of Meningococcaemia



Abnormal Posture



Papilloedema



Management

  • Airway

  • Breathing

  • Circulation

  • Drugs



Circulation

  • How much fluid?

  • Fluid restriction no longer recommended in meningitis

  • Consider SIADH in later management

  • Massive fluid resuscitation may be required for meningococcal sepsis



Antibiotics

  • Choice depends on

  • Causative Pathogen

  • Resistance of Local pathogens

  • Penetrance of CSF



Empiric Antibiotics for Meningitis



The role of Steroids

  • Dexamethasone now recommended for all types of bacterial meningitis.

  • Improved neurological outcome – especially hearing.

  • Must be given early – with initial antibiotics.

  • Some concern over use with resistant pneumococcus



Complications

  • Early & Late include

  • Circulatory collapse – not just meningococcal

  • Focal neurological abnormalities

  • Hydrocephalus

  • Brain abscess

  • Seizures



Outcome from Bacterial Meningitis

  • Mortality - Less than 10%

  • Reports of less than 2% in infants and children

  • Reports of up to 30% in Neonates and Adults

  • Morbidity – 15% (10-30%)

  • Hearing

  • Seizures

  • Learning problems

  • Lower IQ when compared with sibs



Meningococcal Disease

  • May present as meningitis or as sepsis (Meningococcaemia) or both.

  • Significant differences in management depending on presentation.

  • Endotoxins trigger “Sepsis Syndrome”

  • Meningococcaemia may cause profound shock and may require significant fluid resuscitation.

  • Also associated with Disseminated intravascular coagulation (DIC).

  • Mortality reduced by early recognition and administration of IM Penicillin









Prevention of Bacterial Meningitis

  • Vaccination

  • H.Influenzae – incidence decreased by > 99%

  • Meningococcal A & C – Problems with B

  • Polyvalent pneumococcal

  • New vaccines

  • Perinatal Screening

  • HVS for Group B Strep.

  • Antepartum penicillin

  • Chemoprophylaxis

  • House hold contacts of children with meningococcus or H. influenza

  • Usual treatment Rifampicin for 2/7



Conclusions

  • Significant infection

  • Pathogen usually depends on age of the child

  • Choice of antibiotic is based on the likely pathogen

  • Meningococcal disease may manifest as meningitis or sepsis – separately or combined

  • Prevention is still better than cure



References

  • Bacterial meningitis in children

  • Xavier Sáez-Llorens, George H McCracken Jr

  • The Lancet. Volume 361 Issue 9375 Page 2139

  • Diagnosis and treatment of bacterial meningitis H El Bashir, M Laundy, and R Booy Arch. Dis. Child., Jul 2003; 88: 615 - 620.




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