Download - Bacterial Meningitis
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
THANK YOUBy Extern ณัชชา