Bacterial Meningitis Objectives To define bacterial meningitis
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
What is meningitis ?
Depends on Age
Depends on underlying conditions
Depends on vaccination status
Depends on Geographical location
Group B Strep. 49%
Misc. Gram. Neg. 10%
Misc. Gram. Pos. 10%
Older than 1 month
Strep. Pneumoniae (Pneumococcus)
H.influenzae ( Now rare )
Post Head injury
Strep. Pneumoniae most common if CSF leak ( Consider s.aureus/Pseudomonas)
Symptoms of Meningitis
Depends on Age
Fever, Chills, vomiting, photophobia
& severe headache
More subtle – poor feeding, drowsy, quiet, ‘Not herself’
Signs of Meningitis
Signs of infection:
Elevated BP with decreased Heart rate. Papilloedema
– not soreness
Clinical Signs of Meningitis
“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°.”
With the patient lying on the back: if the neck is forcibly bended forward, there occurs a reflexive flexion of the knees.
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
Interpretation of CSF findings
Contraindications to Lumbar Puncture
Signs of cerebral herniation
GCS < 8
Abnormal pupillary signs
Abnormal tone / posture
Focal neurological signs
Obvious signs of Meningococcaemia
How much fluid?
Fluid restriction no longer
recommended in meningitis
Consider SIADH in later management
Massive fluid resuscitation may be required for meningococcal
Choice depends on
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
Early & Late include
Circulatory collapse – not just meningococcal
Focal neurological abnormalities
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%)
IQ when compared with sibs
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
H.Influenzae – incidence decreased by > 99%
Meningococcal A & C – Problems with B
HVS for Group B Strep.
House hold contacts of children with meningococcus or H.
Usual treatment Rifampicin for 2/7
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
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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