MENINGITIS

Presented by: Bijaya Rai

Roll no-12

B.Sc nursing (II year)

CONTENT Definition Incidence Causative agent Pathophysiology Classification Bacterial meningitis

Causes Predisposing factors Sign and symptoms Investigation Nursing management Treatment Complication Outcome. Prevention

Summary

Meningitis

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as meninges.

Inflammation may be caused by infection with viruses, bacteria, or other micro-organism and less commonly by certain drugs.

It is classified as Medical emergency.

Incidence:

Kids of any age can get meningitis, but because it can be easily spread between people living in close quarters, teens, college students, and boarding-school students.

Causative agent:

Type Pathogen (most Common)

Bacterial Strep pneumoniae, E-coli, Neisseria meningitis

Viral infection Coxsackie Virus, Echovirus, Enterovirus, Arbovirus, HIV, HSV-2

TB meningitis M. Tuberculosis

Protozoal Infection

Toxoplasma Gondii (toxoplasmosis)

Fungal infection Cryptococcus neoformans (cryptococcal meningitis)

Vasculitis of cerebral vessels

Ischemia, cytotoxic edema

Immune Response from Astrocytes+Microglia,

Cytokin Release

Immune Response from Astrocytes+Microglia,

Cytokin Release

Inc. BBB permeabilty Inc. no. of WBC in CSF

Fluid leakage from vessels Inflammation of Meninges Dec. cerebral blood flow

Vasogenic edema Interstitial edema (Inc. ECF)

Cerebral EdemaCerebral Edema

Subarachnoid Space

Microorganisms

Via BloodDirect to CSF

PATHO PHYSIOLOGYPATHO PHYSIOLOGY

Dec. Cerebral blood flow, Ischemia, apoptosis (Brain Death)

Classification:

Acute pyogenic (bacterial) meningitis Acute aseptic (viral) meningitis Chronic bacterial infection (tuberculosis).

Causes/ Pathogens: In neonatal period- Escherichia coli, Streptococcus

pneumonae,Salmonella species,Pseudomonas aeruginosa,Streptococcus fecalis and Staphylococcus aureus.

3 months to 3 years: Hemophilus influenza, S.pnemoniae and meningococci(Neisseria meningitidis).

Beyond 3 years: S.pnemoniae and Neisseria meningitis.

Other: Accidental wound infection and iatrogenic cause.

Mode Of Transmission: The bacteria are spread by direct close contact with the discharges from the nose or throat of an infected person.

Predisposing Factor:

Prematurity Low birth weight baby Complicated labor Prolonged rupture of membrane Maternal sepsis Babies in artificial respiration or intensive

care.

BACTERIAL MENINGITIS

Inflammation of meninges caused by bacteria.

Should be taken seriously. Can be life –threatening if not treated right

away.

Sign and Symptoms:

The sign and symptoms of meningitis vary and depend both on the age of the child and on the cause of the infection. Because the flu-like symptoms can be similar in both types of meningitis, particularly in the early stages, and bacterial meningitis can be very serious, it's important to quickly diagnose an infection.

The first symptoms of bacterial or viral meningitis can come on quickly or surface several days after a child has had a cold and runny nose, diarrhea and vomiting, or other signs of an infection. Common symptoms include:

fever lethargy (decreased consciousness) irritability headache photophobia (eye sensitivity to light) stiff neck skin rashes seizures

In newborns and infants, the typical symptoms of fever, headache, and neck stiffness may be hard to detect. Other signs in babies might be inactivity, irritability, vomiting, and poor feeding.

symptoms of meningitis in infants can include: jaundice (a yellowish tint to the skin) stiffness of the body and neck (neck rigidity) fever or lower-than-normal temperature poor feeding a weak suck a high-pitched cry bulging fontanelles (the soft spot at the top/front of the baby's

skull) Viral meningitis tends to cause flu-like symptoms, such as fever

and runny nose, and may be so mild that the illness goes undiagnosed. Most cases of viral meningitis resolve completely within 7 to 10 days, without any complications or need for treatment.

1) Acute Pyogenic Bacterial Meningitis

Investigation: Physical Examination:

Brudzinski’s & Kernig’s sign Nuchal rigidity

Laboratory Investigation:

Specimen: CSF Chemistry - glucose and protein. Cytology – WBC and %PMN Gram stain or Rapid diagnostic tests Polymerase chain reaction: (N.meningitidis, S. pneumoniae, H.

influenzae, S. agalactiae, L. monocytogenes & enteroviruses). Non- specific tests: including C-reative protein, lactic dehydrogenase,

and CSF lactic acid level . Culture for pathogens.

Blood, Urine, & Sputum Cultures

CSF Detail Report:

Changes in CSF Normal Pyogenic (Bacterial)

Appearance Crystal-clear Turbid/purulent

WBC < 5 mm3 > 1000 mm3

Mononuclear cells < 5 mm3 <50 mm3

Polymorph cells Nil 200-300/ mm3

Protein 0.2- 0.4 g/L 0.5-2.0 g/L

Glucose 40-80 mg/dl <40 mg/dl

Nursing management:

Vital signs are obtained and monitored frequently depending on child’s condition.

In infant, the nurses should monitor the fontanel and maintain a record of the daily head circumference.

Input/ output charting should be done. Daily weight of child should should be taken. Positioning should be maintained every 4

hourly.

Empirical Therapy For ABMAge Common Pathogen Anti microbial

< 1 month Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species

Ampicillin plus cefotaxime or ampicillin plus an aminoglycoside

4-12 weeks Streptococcus pneumoniae, Haemophilus influenzae, Group B streptococcus,Listeria monocytogenes.

Ampicillin plus either cefotaxime or ceftriaxone.

12 weeks and older

H. influenza, N. meningitidis, S. pneumoniae Ceftriaxone or cefotaxime or ampicillin plus chloramphenical.

Microorganism Duration of therapy, days

Neisseria meningitidis 7

Haemophilus influenzae 7

Streptococcus pneumoniae 10-14

Streptococcus agalactiae 14-21

Aerobic gram-negative bacillia 21

Listeria monocytogenes >21

Duration of Antimicrobial Therapy for Bacterial Meningitis Based on Isolated Pathogen (A-III)a Duration in the neonate is 2 weeks beyond the first sterile CSF culture or >3 weeks, whichever is longer.

Duration OF Therapy For ABM

• Dexamethasone is given in a dose 0.5 mg/kg/6hourly for 4 days .The dose should be administered intravenously 15 minutes before first parenteral antibiotic dose.

• Adjunctive dexamethasone should not be given to the patients who have already received antimicrobial therapy, because administration of dexamethasone in this circumstance is unlikely to improve patient outcome

Adjunct Steroid Therapy for Infants, Children

Complication:

Subdural effusion or empyema Ventriculities Arachnoiditis Brain abscess Hydrocephalous Hemiplegia Aphasia Ocular palsies Hemianopsia Blindness Deafness Mental retardation Shock Status epilepticus

Outcome:

The majority of children recover without permanent deficits.

Subdural hematomas develop in approximately 50% of children under 18 months, but most resolve without treatment. Headaches may persists for varying period of time.

15-20% of children may develop auditory nerve deficit.

Even when children have defects,many children have no evidence of the defects 2 years after discharge.

Prevention: Vaccines -- There are vaccines against Hib, some strains of Neisseria

meningitidis, and many types of Streptococcus pneumoniae.

The vaccines against Hib are very safe and highly effective. By age 6 months of age, every infant should receive at least three doses of an Hib vaccine. A fourth dose (booster) should be given to children between 12 and 18 months of age.

The vaccine against Neisseria meningitidis (meningococcal vaccine) is not routinely used in civilians in the United States and is relatively ineffective in children under age 2 years. The vaccine is sometimes used to control outbreaks of some types of meningococcal meningitis in the United States. New meningococcal vaccines are under development.

The vaccine against Streptococcal pneumoniae (pneumococcal vaccine) is not effective in persons under age 2 years but is recommended for all persons over age 65 and younger persons with certain medical problems. New pneumococcal vaccines are under development.

Disease reporting -- Cases of bacterial meningitis should be reported to state or local health authorities so that they can follow and treat close contacts of patients and recognize outbreaks.

Treatment of close contacts -- People who are identified as close contacts of a person with meningitis caused by Neisseria meningitidis can be given antibiotics to prevent them from getting the disease. Antibiotics for contacts of a person with Hib disease are no longer recommended if all contacts 4 years of age or younger are fully vaccinated.

Travel precautions -- Although large epidemics of bacterial meningitis do not occur in the United States, some countries experience large, periodic epidemics of meningococcal disease. Overseas travelers should check to see if meningococcal vaccine is recommended for their destination. Travelers should receive the vaccine at least 1 week before departure, if possible.

 

Summary:

Acute bacterial meningitis, a major cause of morbidity and mortality in young children, occurs both in epidemic and sporadic pattern.

It is commoner in neonates and infants than in older children because their immune mechanism and phagocytic functions are not fully matured.

It is life threatening situation and nursing care is very important.

Treatment is possible but may develop auditory and neurological defects.

Reference:

Ghai O.P.; Essential Pediatrics; 6th edition 2005;CBS Publishers and distributors ,New Delhi : Page no:517-20

Parthasarathy A, “ IAP Textbook of Pediatrics” ; 3rd Edition, Jaypee Brothers Medical Publishers (P) Ltd; Page no: 336-40.

Dorothy R. Marlow, Barbara A. Redding, “Textbook of Pediatric Nursing”, 6th Edition, 2009, ELSEVIER

Retrieved on google.com on 7th and 24th July 2009.