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Bacterial Bacterial Meningitis 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 Presentation

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Page 1: Bacterial Meningitis

Bacterial MeningitisBacterial Meningitis

Page 2: Bacterial 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

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What is meningitis ?What is meningitis ?

MeningitisMeningitis

EncephalitisEncephalitis

MeningoencephalitisMeningoencephalitis

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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

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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%

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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 )

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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)

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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’

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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

Page 10: Bacterial Meningitis

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.

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Kernig’s signKernig’s sign

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Brudzinski’s signBrudzinski’s sign

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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.

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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

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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

Page 16: Bacterial Meningitis

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

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Abnormal PostureAbnormal Posture

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PapilloedemaPapilloedema

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ManagementManagement

AirwayAirway

BreathingBreathing

CirculationCirculation

DrugsDrugs

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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

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AntibioticsAntibiotics

Choice depends on Choice depends on Causative PathogenCausative Pathogen Resistance of Local pathogensResistance of Local pathogens Penetrance of CSFPenetrance of CSF

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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

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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

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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

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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

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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

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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

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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

Page 32: Bacterial Meningitis

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.