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 - PowerPoint PPT PresentationTRANSCRIPT
Bacterial MeningitisBacterial Meningitis
ObjectivesObjectives
To define bacterial meningitisTo define bacterial meningitis To discuss the causative pathogensTo discuss the causative pathogens To discuss clinical presentationTo discuss clinical presentation To discuss diagnosis and lumbar punctureTo discuss diagnosis and lumbar puncture To discuss management including To discuss management including
antibiotics and dexamethasoneantibiotics and dexamethasone To discuss outcomes and follow upTo discuss outcomes and follow up To discuss Meningococcal diseaseTo discuss Meningococcal disease To discuss preventionTo discuss prevention
What is meningitis ?What is meningitis ?
MeningitisMeningitis
EncephalitisEncephalitis
MeningoencephalitisMeningoencephalitis
Bacterial PathogensBacterial Pathogens
Depends on AgeDepends on Age
Depends on underlying conditionsDepends on underlying conditions
Depends on vaccination statusDepends on vaccination status
Depends on Geographical locationDepends on Geographical location
Bacterial PathogensBacterial Pathogens
Neonatal periodNeonatal period Group B Strep. 49%Group B Strep. 49% E.Coli 18%E.Coli 18% Listeria 7%Listeria 7% Misc. Gram. Neg. 10%Misc. Gram. Neg. 10% Misc. Gram. Pos. 10%Misc. Gram. Pos. 10%
Bacterial PathogensBacterial Pathogens
Older than 1 monthOlder than 1 month Neiserria Meningitidis(Meningcoccus)Neiserria Meningitidis(Meningcoccus) Strep. Pneumoniae (Pneumococcus)Strep. Pneumoniae (Pneumococcus) H.influenzae ( Now rare )H.influenzae ( Now rare )
Bacterial PathogensBacterial Pathogens
V-P ShuntV-P Shunt Staph. EpidermidisStaph. Epidermidis Staph. AureusStaph. Aureus ColiformsColiforms
Post Head injuryPost Head injury Strep. Pneumoniae most common if CSF Strep. Pneumoniae most common if CSF
leak ( Consider s.aureus/Pseudomonas)leak ( Consider s.aureus/Pseudomonas)
Symptoms of MeningitisSymptoms of Meningitis
Depends on AgeDepends on Age
Older ChildOlder Child Fever, Chills, vomiting, photophobiaFever, Chills, vomiting, photophobia & severe headache& severe headache SeizuresSeizures
Younger ChildYounger Child More subtle – poor feeding, drowsy, quiet, More subtle – poor feeding, drowsy, quiet,
‘Not herself’‘Not herself’
Clinical Signs of MeningitisClinical Signs of Meningitis
Signs of infection: Signs of infection: Fever, pallor.Fever, pallor.
Raised ICP:Raised ICP: Elevated BP with decreased Heart rate. Elevated BP with decreased Heart rate.
Papilloedema Papilloedema
Nuchal Rigidity:Nuchal Rigidity: Neck Neck stiffnessstiffness – not soreness – not soreness
Clinical Signs of MeningitisClinical Signs of Meningitis
Kernigs: Kernigs: “ “If one attempts to extend the patient’s knees If one attempts to extend the patient’s knees
one will succeed only to an angle of one will succeed only to an angle of approximately 135approximately 135°°. In cases in which the . In cases in which the phenomenon is very pronounced the angle may phenomenon is very pronounced the angle may even remain 90even remain 90°°.”.”
Brudzinskis:Brudzinskis: With the patient lying on the back: if the neck is With the patient lying on the back: if the neck is
forcibly bended forward, there occurs a reflexive forcibly bended forward, there occurs a reflexive flexion of the knees. flexion of the knees.
Kernig’s signKernig’s sign
Brudzinski’s signBrudzinski’s sign
Role of Lumbar Puncture (LP)Role of Lumbar Puncture (LP)
CSF analysis and culture is the CSF analysis and culture is the definitive method of diagnosisdefinitive method of diagnosis
Identifying pathogen allows Identifying pathogen allows rationalisation of antibiotic treatment rationalisation of antibiotic treatment and collection of epidemiological and collection of epidemiological informationinformation
Definitive diagnosis allows better Definitive diagnosis allows better outcome prediction.outcome prediction.
Role of Lumbar PunctureRole of Lumbar Puncture
When to LP?When to LP? When meningitis is suspectedWhen meningitis is suspected When its safe !When its safe ! ? Role of CT? Role of CT Sterilisation of CSF after antibioticsSterilisation of CSF after antibiotics Molecular techniquesMolecular techniques
Interpretation of CSF findingsInterpretation of CSF findingsNormalNormal BacteriaBacteria
l l ViralViral
GlucoseGlucose Not less Not less than 2/3 than 2/3 of Bloodof Blood
Normal Normal or lowor low
elevatedelevated
ProteinProtein
gm/Lgm/L0.3-2.00.3-2.0 elevatedelevated 0-1.50-1.5
WBCWBC 5-155-15
No PMNNo PMN10-100010-1000 10-100010-1000
BacteriaBacteria May be May be seenseen
Contraindications to Lumbar Contraindications to Lumbar PuncturePuncture
Signs of cerebral herniationSigns of cerebral herniation GCS < 8GCS < 8 Abnormal pupillary signsAbnormal pupillary signs Abnormal tone / postureAbnormal tone / posture PapilloedemaPapilloedemaFocal neurological signsFocal neurological signsCardiorespiratory compromise Cardiorespiratory compromise Obvious signs of MeningococcaemiaObvious signs of Meningococcaemia
Abnormal PostureAbnormal Posture
PapilloedemaPapilloedema
ManagementManagement
AirwayAirway
BreathingBreathing
CirculationCirculation
DrugsDrugs
CirculationCirculation
How much fluid?How much fluid? Fluid restriction no longer recommended in Fluid restriction no longer recommended in
meningitismeningitis Consider SIADH in later managementConsider SIADH in later management Massive fluid resuscitation may be Massive fluid resuscitation may be
required for meningococcal required for meningococcal sepsissepsis
AntibioticsAntibiotics
Choice depends on Choice depends on Causative PathogenCausative Pathogen Resistance of Local pathogensResistance of Local pathogens Penetrance of CSFPenetrance of CSF
Empiric Antibiotics for MeningitisEmpiric Antibiotics for MeningitisPatient GroupPatient Group Likely Likely
PathogensPathogensEmpiric Empiric AntibioticsAntibiotics
Neonatal Neonatal (Early)(Early)
Group B Strep. Group B Strep.
E.ColiE.Coli
ListeriaListeria
Ampicillin & Ampicillin & CefotaximeCefotaxime
Neonatal Neonatal (Late)(Late)
AboveAbove
Staph. AureusStaph. AureusCefotaxime & Cefotaxime & fluclox. or vanc.fluclox. or vanc.
1 to 3 months1 to 3 months MeningcoccalMeningcoccal
PneumococcusPneumococcus
H.influenzaeH.influenzae
CefotaximeCefotaxime
+/- Vancomycin+/- Vancomycin
Older than Older than 3 months 3 months
MeningcoccalMeningcoccal
PneumococcusPneumococcusCefotaxime +/- Cefotaxime +/- VancomycinVancomycin
The role of SteroidsThe role of Steroids
Dexamethasone now recommended Dexamethasone now recommended for all types of bacterial meningitis.for all types of bacterial meningitis.
Improved neurological outcome – Improved neurological outcome – especially hearing.especially hearing.
Must be given early – with initial Must be given early – with initial antibiotics.antibiotics.
Some concern over use with resistant Some concern over use with resistant pneumococcuspneumococcus
ComplicationsComplications
Early & Late includeEarly & Late include
Circulatory collapse – not just meningococcalCirculatory collapse – not just meningococcal Focal neurological abnormalitiesFocal neurological abnormalities HydrocephalusHydrocephalus Brain abscessBrain abscess SeizuresSeizures
Outcome from Bacterial MeningitisOutcome from Bacterial Meningitis
Mortality - Less than 10%Mortality - Less than 10% Reports of less than 2% in infants and childrenReports of less than 2% in infants and children Reports of up to 30% in Neonates and AdultsReports of up to 30% in Neonates and Adults
Morbidity – 15% (10-30%)Morbidity – 15% (10-30%) HearingHearing SeizuresSeizures Learning problemsLearning problems Lower IQ when compared with sibsLower IQ when compared with sibs
Meningococcal DiseaseMeningococcal Disease May present as meningitis or as sepsis May present as meningitis or as sepsis
(Meningococcaemia) or both.(Meningococcaemia) or both. Significant differences in management Significant differences in management
depending on presentation.depending on presentation. Endotoxins trigger “Sepsis Syndrome”Endotoxins trigger “Sepsis Syndrome” Meningococcaemia may cause profound shock Meningococcaemia may cause profound shock
and may require significant fluid resuscitation. and may require significant fluid resuscitation. Also associated with Disseminated intravascular Also associated with Disseminated intravascular
coagulation (DIC).coagulation (DIC). Mortality reduced by early recognition and Mortality reduced by early recognition and
administration of IM Penicillinadministration of IM Penicillin
Prevention of Bacterial MeningitisPrevention of Bacterial Meningitis
VaccinationVaccination H.Influenzae – incidence decreased by > 99%H.Influenzae – incidence decreased by > 99% Meningococcal A & C – Problems with BMeningococcal A & C – Problems with B Polyvalent pneumococcalPolyvalent pneumococcal New vaccinesNew vaccines
Perinatal ScreeningPerinatal Screening HVS for Group B Strep.HVS for Group B Strep. Antepartum penicillin Antepartum penicillin
ChemoprophylaxisChemoprophylaxis House hold contacts of children with meningococcus or H. influenzaHouse hold contacts of children with meningococcus or H. influenza Usual treatment Rifampicin for 2/7Usual treatment Rifampicin for 2/7
ConclusionsConclusions
Significant infectionSignificant infection Pathogen usually depends on age of Pathogen usually depends on age of
the childthe child Choice of antibiotic is based on the Choice of antibiotic is based on the
likely pathogenlikely pathogen Meningococcal disease may manifest Meningococcal disease may manifest
as meningitis or sepsis – separately as meningitis or sepsis – separately or combinedor combined
Prevention is still better than curePrevention is still better than cure
ReferencesReferences
Bacterial meningitis in children
Xavier Sáez-Llorens, George H McCracken Jr
The Lancet. Volume 361 Issue 9375 Page 2139
Diagnosis and treatment of bacterial meningitisH El Bashir, M Laundy, and R BooyArch. Dis. Child., Jul 2003; 88: 615 - 620.