meningitis bakterialis.ppt...
TRANSCRIPT
Bacterial meningitis� Is an acute purulent infection in the subarachnoid space that
is associated with inflammation reaction in the brain and cerebral blood vessels that causes decreased conciuosness, seizure, raised intracranial pressure, and stroke.
� Is inflammation of the meningens caused by a bacterial pathogen.
Incidence
� In Asia, there is increasing incidence of H influenzae type b (Hib). Previously, Salmonella, S pneumoniae and M tuberculosis.
In USA, 2.5 to 3.5 cases per 100,000 population� In USA, 2.5 to 3.5 cases per 100,000 population
� H influenzae type b declined 421 cases 1987 to 0,7 per 100,000 in 1997.
� Today the most common bacterial: Streptococcus pneumoniae, N meningitidis, and H influenzae
Meningitis
� Classified into two syndromes:
� Septic or purulent meningitis is caused by bacterial or fungal organism
� Aseptic meningitis is caused by viral, neoplastic, protozoal, � Aseptic meningitis is caused by viral, neoplastic, protozoal, spirochetal or other non septic causes.
34 %
4.5 %
1 %
30 %
6 %
8 %
4%
E coli
Listeria spp
Other gram negative
Other streptococci
Staphylococci
Salmonella spp
Group B strep
Pooled information from 1853 case of meningitis
3 %
2 %
3 %
1 %
3 %
2 %
Pseudomonas spp
Haemophilus
Pneumococcus
Meningococcus
Others
Salmonella spp
Fig. Distribution of the most common causes of neonatal meningitis
TABLE . Estimated age-specifik incidence of bacterial meningitis(cases per 100,000 population), United States, 1995
Haemophilus Streptococcus Neiseria Group B
Age group influenzae pneumoniae meningitis Streptococcus Listeria
< 1 mo 0 15.7 0 125.0 39.2
1-23 mo 0.7 6.6 4.5 2.8 01-23 mo 0.7 6.6 4.5 2.8 0
1-29 yr 0.1 0.5 1.1 0.1 0.04
Adapted from Schuchat A, Robinson K, Wenger JD, et al. Bacterial
meningitis in the United States in 1995. N Engl J Med 1997;337;970
Clinical presentation
� There are two patterns of presentation:
� The first is more insidious and develops over one or several days.
� The other is more acute and fulminant. Usually with severe � The other is more acute and fulminant. Usually with severe brain edema and herniation
Signs and Symptoms of Bacterial Meningitis
Fever
Depression of consciousness
Full fontanelFull fontanel
Irritability
Stiff neck
Seizures
Headache
Focal neurologic deficits
Petechial skin rash
Table 3. Clinical signs of neonatal bacterial meningitis
Symtoms Percentage Sign Percentage
Lethargy 50 Fever or hypothermia 61
Anorexia Respiratory distress 47
Vomiting 49 Irritability 32
Diarrhea Jaundice 28Diarrhea Jaundice 28
Convulsions 40 Full/bulging fontanelle 28
Apnea 7 Neck stiffness 15
Altered sleep pattern Hipotonia
High-pitched cry Petechiae
Hypotension, shock
Bradycardia
Source : Frequencies from Klein & Marcy (1995)
Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL MENINGITIS
Children
Incidence Mortality rate
Organism (%) (%)
S. pneumoniae 10-20 8S. pneumoniae 10-20 8
N. meningitidis 25-40 15
H. influenzae 40-60 4
Gram negative bacilli 1-2 NA
S. aureus 1-2 NA
Streptococci 2-4 NA
L. monocytogenes 1-2 8-50
Anaerobes 1-2 NA
NA = not avilable
EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS
BACTERIAL CELL WALL COMPONENTS
Endothelial Cells CNS-Macrophages Endotoxin Shock
IL-1
PGE2
TNF,IL-1,
PAF
Thrombosis CSF pleocytosis
Impaired BBB Infarction Hydrocephalus Perfusion
Edema
ICP CBFMicrocirculatory
Failure
PGE2
CSF Examinations in SuspectedBacterial Meningitis
Routine testGram’s stain (60 – 90%)
Bacterial culture and sensitivities (70 – 85%)
Cell count and differential
GlucoseGlucose
Protein
Bacterial antigen (50 –100%)
Special test
Culture for tuberculosis, fungus, virus
Additional bacterial antigen studies
Serology
Cryptococcus antigen
India ink
Coccidioidomycosis antibody
Polymerase chain reaction
Table 3. CEREBROSPINAL FLUID FINDINGS IN BACTERIAL MENINGITIS
Normal Bacterial meningitis
Opening pressure 50-195 mm CSF > 200 mm CSF
(3,8-15 mm Hg)
Cell count < 5 cells/mm3 100-10,000 cells/mm3
(15% neutrophils (86% neutrophils)(15% neutrophils (86% neutrophils)
Protein 15-50 mg/dL 100 to 500 mg/dL
Glucose 45-80 mg/dL usually <20-40 mg/dL
CSF : Glucose Ratio > 0,5 < 0,4
CSF = Cerebrospinal fluid; NL = normal
Treatment
� Two critical decisions must be consider:
� The first concern the choice of antibiotic
therapytherapy
� The second, the benefits versus the risk of doing a lumbar puncture.
EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS
Mild• Irritibility
• Lethargy
• Headache
• Vomiting
• Nurchal rigidity
Moderate• Seizures
LumbarPuncture;
Start
AntibioticsAnd Steroids
ICP
NL ICP
CT or MRI Scan and Treat
Observe
• Seizures
• Focal deficit
• Consciousness
• Papilledema
Severe• Status epilepticus
• Persistent deficit
• Coma
• Herniation
Start
AntibioticsAnd Steroids
And Do
CT or MRIScan
Lumbar
Puncture
ICP
NL ICP
Treat
Observe
Delayed LP
� Intravenous antibiotics used for 2 to 3 days prior to lumbar puncture do not alter the CSF cell count, or protein or glucose concentrations
� Substantially decrease the chance of demostrating bacteria on Gram stain or culture
TABLE 3. RECOMMENDATIONS FOR ANTIBIOTIC THERAPYIN PATIENTS WITH BACTERIAL MENINGITIS
TYPE BACTERIA CHOICE OF ANTIBIOTIC
On Gram’s staining
Cocci
Gram-positive Vancomycin plus broad-spectrum cephalosporin
Gram-negative Penicilin G
Bacilli
Gram-positive Ampicillin (or penicillin G) plus aminoglycoside
Gram-negative Broad-spectrum cephalosporin plus aminoglycoside
TABLE 3. RECOMMENDATIONS FOR ANTIBIOTIC THERAPYIN PATIENTS WITH BACTERIAL MENINGITIS
TYPE BACTERIA CHOICE OF ANTIBIOTIC
On culture
S. pneumoniae Vancomycin plus broad-spectrum cephalosporinS. pneumoniae Vancomycin plus broad-spectrum cephalosporin
H. influenzae Ceftriaxone
N. meningitidis Penicillin G
L. monocytogenes Ampicillin plus gentamicin
S. agalactiae Penicillin G
Enterobacteriaceae Broad-spectrum cephalosporin plus aminoglycoside
Pseudomonas aeru- Ceftazidime plus aminoglycoside
ginosa, acineto-bacter
The American Academic of Pediatrics recommended
� Dexamethasone, 0,6 mg/kg per day in four divided doses for the first two days of antibiotic treatment.
� The first dose should be given at the time of, or shortly before the first dose of antibiotic
0-7 hari Ampisilin 150 mg/kg/hari dibagi setiap 8 jam IV plus
cefotaksim 100 mg/kg/hari setiap 12 jam IV
atau
Ceftriaxone 50 mg/kg/hari diberikan setiap 24 jam IV
atau
Empiric therapy for acute bacterial meningitis in
neonatus
atau
Ampisilin 150 mg/kg/hari dibagi setiap 8 jam IV plus
gentamisin 5 mg/kg/hari IV setiap 12 jam.
> 7 hari Ampisilin 200 mg/kg/d divided dose every 6 hours IV
AND
Cefotaxime 150 mg/kg/d divided dose every 8 hours IV
oror
Cetriaxone 75 mg/kg every 24 hours IV
Table 2. Empiric therapy for acute bacterial meningitis
1-3 months Ampicilin 200-400 mg/kg/d divided dose every
6 hours IV AND6 hours IV AND
Cefotaxime 200 mg/kg/d divided dose every 6
hours IV or
Cetriaxone 100 mg/kg/d divided dose every 12
hours IV or 80 mg/kg daily IV/IM;
Add vancomycin 60 mg/k/d IV divided dose every
penicillin-resistant S pneumococcus suspected
Table 2. Empiric therapy for acute bacterial meningitis
> 3 months Cefotaxime 200 mg/kg/d divided dose every
6-8 hours IV OR
Ceftriaxone 100 mg/kg/d divided dose every
12 hours IV or 80 mg/kg IV/IM every day OR12 hours IV or 80 mg/kg IV/IM every day OR
Ampicillin 200 mg/kg/d divided dose every 6
hours IV PLUS
Chloramphenicol 100 mg/kg/d divided dose
every 6 hours IV;
Add vancomycin 60 mg/kg/d divided dose
every 6 hours IV if penicillin-resistant S pneu-
mococcus suspected
TABLE 4. GUIDELINES FOR THE DURATION OF ANTIBIOTIC
THERAPY
PATHOGEN SUGGESTED DURATION
OF THERAPHY
(DAYS)(DAYS)
H. influenzae 7
N. meningitis 7
S. Pneumoniae 10 – 14
I. monocytogenes 14 – 21
Group B streptococci 14 – 21
Gram – negative bacilli (other than 21
H. influenzae
Complications during Acute Bacterial Meningitis
Common
Increased intracranial pressure
SIADH
Ventriculomegaly
SeizuresSeizures
Extra-axial fluid collection
Infarction and necrosis
Cranial nerve involvement (deafness)
Disseminated intravascular coagulation
Uncommon
Subdural empyema
Brain abscess
Cranial nerve deficits other than VIII
SCAN RESULTS INCREASED
Normal Hyperventilate to reduce increased cerebral
blood volume
INTRACRANIAL PRESSURE MEASUREMENT
Table Treatment of the Seriously III Patient with Meningitis
blood volume
Edema Do not hyperventilate; use furosemide or
mannitol and restrict fluids
Acute ventriculomegaly, Remove CSF by ventricular tap or drain; de
hydrocephalus or en- crease CSF production (Diamox or digo
larged subarachnoid xin); increase CSF reabsorption (stero -
spaces ids)
Subdural effusions Subdural drainage
Infarcts Steroids to reduce peri-infarct edema
Fundamental principles to the management of meningitis
� Antibiotic therapy should be prompt and appropriate
� Cerebral metabolisme should be protected
� Increased intracranial pressure should be monitor
� Seizure should be prevented or controlled
� Fluid management
� Hyperpyrexia should be controlled
Penetration of antibacterials into CNS
CSF
Antibiotics Normal meninges Meningitis
Penicillins
Penicillins G Poor Fair-good
Ampicillin Poor Fair-good
Methicillin Poor -
Nafcillin - Fair
CephalosporinsCephalosporins
Cefazolin Poor Fair-good
Cefotaximes Good Good
Ceftriaxone Good Good
Ceftazidime Good Good
Tetracyclines
Tetracycline - Fair
Oxytetracycline - Fair
Chlortetracycline - Poor
Sources : Infectious Disease in Emergency Medicine. 1998. Judith C. Brillman
& Ronald
Table. Complication and outcome of patient with acute bacterial meningitis
Children
(%)
Complications
Acute seizures 31
Cranial nerve palsies 3 – 5
Deafness 10
Focal neurologic deficits 4 – 15
Hydrocephalus 2 – 20
Cerebrovascular Involvement 2 – 12Cerebrovascular Involvement 2 – 12
Cerebral edema 2 – 8
Central nervous system hemorrhage 2
Herniation 2 – 6
Mental retardartion 4 – 6
Epilepsy 4 – 7
Outcome
Good recovery/mild disability 84 – 88
Severe/moderate disability 8 – 14
Persistent vegetative state 1 – 2
Dead 2 – 5
Penetration of antibacterials into CNS
CSF
Antibiotics Normal meninges Meningitis
Aminoglycosides
Gentamycin Poor Fair
Amikacin - Poor
Rifampin Fair Good
Cyprofloxacin Fair Fair
Miscellaneus antibacterials
Chloramphenicol Good Good
Clindamycin Poor Fair
Metronidazole - Good
Trimetrophin Good Good
Vancomycin Poor Good
Sources : Infectious Disease in Emergency Medicine. 1998. Judith C. Brillman
& Ronald
Guidelines for acceptable CSF values
At the end of therapy
1. The percentage of polymorphonuclear leukocytes
(PMNs) in the CSF is more important than the
absolute white blood cell (WBC) count and is absolute white blood cell (WBC) count and is
usually 5 percent, but should not exceed 25-30
percent of the total WBC.
2. The CSF glucose concentration should exceed
20 mg/dl and be more than 20 percent of a conco-
mitantly obtained serum glucose.
Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL
MENINGITIS
Children
Incidence Mortality rate
Organism (%) (%)
S. pneumoniae 10-20 8S. pneumoniae 10-20 8
N. meningitidis 25-40 15
H. influenzae 40-60 4
Gram negative bacilli 1-2 NA
S. aureus 1-2 NA
Streptococci 2-4 NA
L. monocytogenes 1-2 8-50
Anaerobes 1-2 NA
NA = not avilable
Cell damage
Bacteria
Peptidoglycan
Teichoic acid
Endotoxin
Immune
modulators
Permeability
blood-brain
barrier
Edema
Glucose
Lactate Blood flow
Intracranial
pressure
Hypoxia
Figure 33.1 Pathophysiology of bacterial meningitis
Lethal to infants
� Meningitis infects the membranes covering the brain, and it is always treated as a medical emergency
� National Health and Medical Research Council � National Health and Medical Research Council (AUS) suggest that doctors should give the first doses of antibiotic before a child goes to hospital
� Important to be a ware of the sign of meningitis and act quickly
Acute bacterial meningitis
� A high index of suspicion is required to diagnose this condition which, if undetected and untreated, can lead to significant morbidity and untreated, can lead to significant morbidity or death.
Table 33.3 clinical signs of bacterial meningitis
Symtoms Percentage Sign Percentage
Lethargy 50 Fever or hypothermia 61
Anorexia Respiratory distress 47
Vomiting 49 Irritability 32
Diarrhea Jaundice 28Diarrhea Jaundice 28
Convulsions 40 Full/bulging fontanelle 28
Apnea 7 Neck stiffness 15
Altered sleep pattern Hipotonia
High-pitched cry Petechiae
Hypotension, shock
Bradycardia
Source : Frequencies from Klein & Marcy (1995)
Table 1. Complication and Outcome In Acute Bacterial Meningitis
Children
(%)
Complications
Acute seizures 31
Cranial nerve palsies 3 – 5
Deafness 10
Focal neurologic deficits 4 – 15
Hydrocephalus 2 – 20
Cerebrovascular Involvement 2 – 12Cerebrovascular Involvement 2 – 12
Cerebral edema 2 – 8
Central nervous system hemorrhage 2
Herniation 2 – 6
Mental retardartion 4 – 6
Epilepsy 4 – 7
Outcome
Good recovery/mild disability 84 – 88
Severe/moderate disability 8 – 14
Persistent vegetative state 1 – 2
Dead 2 – 5
TABLE 1. chronic complications of
bacterial meningitis
Hearing loss
Behavior disorders
Mental retardation
Neuropsychiatric dysfunction
SeizuresSeizures
Auditory dysfunction
Spasticity , paresis
Diabetes insipidus
Hydrocephalus
Transverse myelitis
Blindness
Polyarteritis
Table 2. ANTIBIOTICS RECOMMENDED FOR EMPIRICAL THERAPY IN
PATIENTS WITH SUSPECTED BACTERIAL MENINGITIS WHO HAVE
A NONDIAGNOSTIC GRAM’S STAIN OF CEREBROSPINAL FLUID
GROUP OF PATIENTS LIKELY PATHOGEN CHOICE OF ANTIBIOTIC
Immunocomperent
Age, < 3 mo S. agalactiae, E. coli, or Ampicillin plus broad-spectrum
L. monocytogenesL. monocytogenes cephalosporin
Age, 3 mo to < 18 yr N. meningitidis, S. pneumoniae Broad-spectrum cephalosporin
H. influenzae
With impaired cellular L. monocytogenes or gram- Ampicillin plus ceftazidine
negative bacilli
With head trauma, neuro Staphylococci, gram-negative Vancomycin plus ceftazidime
surgery, or cerebrospi bacilli, or S pneumoniaenal fluid shunt
The American Academy of Pediatrics (AAP)
recommended in 1997 :
Vancomycin plus Cefotaxim or ceftriaxoneVancomycin plus Cefotaxim or ceftriaxone
should be administered initially to all children
older than 1 month with definite or probable
bacterial meningitis.