Acute Bacterial (Pyogenic) Meningitis

S.SrinivasanProfessor of Paediatrics

MGMCRI, PillayarkuppamPuducherry

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in

Children

• Definition• Etiology• Predisposing

Factors• Pathogenesis• Symptoms &

Signs

Acute Bacterial (Pyogenic) Meningitis in Children

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Diagnosis

Differential Diagnosis

Complications

Prognosis

Treatment

Follow Up

Definition

Acute Inflammation of the meninges ( the protective membranes covering the

brain and spinal cord ) caused by Bacterial ( pyogenic ) organisms

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in Children

Neonatal Meningitis:Causative Bacteria

Age Most Common Bacteria

<1 month • Escherichia coli• Group B streptococci• Enterobacteria• Listeria monocytogenes•Haemophilus influenzae• Coagulase negative staphylococci (in hospital)•Streptococcus pneumoniae

Acute Bacterial (Pyogenic) Meningitis in Children

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

AGE Bacteria causing Ac.Bact.MeningitisNeonates & Infants < 2 mths

Escherichia coli, Staph.aureus, Gram Negative bacteria (hospital flora); Listeria monocytogenes, Gp.B Strep.,

2 mths – 3 to 5 years

H.influenzae, Strep. pneumoniae, Neisseria memingitides

Beyond 5 yrs

Strep. pneumoniae( 1,3,6,7), Neisseria meningitides (A,B,C), H.influenzae

Acute Bacterial Meningitis

Post-Neonatal Childhood Bacterial Meningitis

1 to 23 months

•Strep. pneumoniae•Neisseria meningitides•Group B streptococci•Haemophilus influenzae

2 to 18 years

•Neisseria meningitides•Streptococcus pneumoniae•Haemophilus influenzae

Causative Bacteria

Acute Bacterial (Pyogenic) Meningitis in Children

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Bacterial Culture positivity ratein Post Neonatal

Childhood Bacterial Meningitis

Hemophilus influenzae 40 - 70%Streptococcus pneumoniae 30 - 40%Neisseria meningitides 10 -20 %Streptococcus pyogenes <10 %Culture Negativity <20% < Varies with age of the child >

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Predisposing Risk FactorsSinusitis, Mastoiditis, Otitis. Spleen : Asplenia, Functional /

Anatomical Trauma, or Removal : Pneumococcal Bacterial Meningitis.

Compromised Immune System: HIV   

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

OthersNeurosurgeryHead Trauma, Parameningeal Infection, Anatomical Def. of cranium , Spinal cord & Meninges

Risk Factors in Neonatal Meningitis

• Maternal infections during delivery

• PROM• Prolonged,

diffcult delivery with frequent PV Exams

• Preterm babies• Neural tube

Defects –Spina Bifida Occulta, Pilonidal Sinus

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

PathogenesisInflammation of Spinal Nerves & Roots

Signs of Meningeal irritation

Adhesive thickening of Arachnoid in basal cisterns

HydrocephalusFibrosis & Obstn of Aqueduct of Sylvius &/or Foramina of Luschka &/or MagendieEndarterial & small cortical venous Thromboembolic episodes

Cerebral infarctions and atrophy

Neuronal membrane depolarization

Seizures

Transcellular Electrolyte imbalance

Pathogenesis of Ac.Bacterial Meningitis

Haematogenous ( mostly ); Spread from local site infections

Entry of bacteria through BBBarrier Ac.Bacterial Meningitis

Cellular reaction with outpouring of Polymorphs & fibrinRelease of Cytokines , Chemokines & Inflammatory Mediators

Release of cell wall & membrane debris on cell death

Meningeal Exudative Inflammation

Vascular Compromise

Inflammatory Cerebral Oedema

Increased Intracranial tension and pressure ( coning ) effects

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Symptoms & Signs

Acute Bacterial Meningitis

• Altered sensorium

• Bulging fontanelle

• Headache• Convulsions• Nuchal rigidity• Opisthotonus• Hypothermia• Coma

Symptoms in infants and children• Fever • Irritability• Excessive

fussiness• Altered Behaviour• Refusal of feeds• Lethargy• Anorexia• Nausea• Vomiting• Photophobia

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

General Physical Examination

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Breathing, Airway &Circulation : Adequate/Compromised

Altered Sensorium and Severity , Coma Scale

Vital Parameters: Temperature,Pulse,BP, Respn: Rate,Type, Regularity, CFT, Hydration Status

Skin : Mottling, Color change,of vascular compromise Purpura, Infections, Dermal sinus, & other stigma of

Spina Bifida Occulta,

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Skin in Acute Bacterial Meningitis Complications

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Examination for signs of Meningeal

Irritation

Meningismus Nuchal stiffness / rigidityKernig’s SignBrudzinski’s neck – leg signBrudzinski’s crossed leg sign

Higher Functions Cranial Nerves Motor-coordination

Neurological Signs

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Elicitation of Meningeal SignsBrudzinski’s contralateral reflex signThe childt’s hip and knee are passively flexed on one side

Contralateral leg bends in reflex response

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Investigations in Acute Bacterial Meningitis

Complete Blood CountLP: CSF Examination Microscopy- Colour, Cells, opening Pressure Biochemistry: Glucose, Proteins Gram staining Blood & CSF Culture Electrolytes; ABG in severe casesChest x-rayCT/MRI ScansEEGPCROthers

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

CONTRAINDICATIONS FOR PERFORMING LUMBAR PUNCTURE IN CHILDREN

Increased ICPPapilloedemaUnstable Child – Shock, Resp.depression, low GCS Infection in the local siteSevere Thrombocytopenia / DIC

CSF Findings in CNS Infectionsinfection Pressure WBC /µL Glucose ProteinAc Bacterial meningitis

200-300 100-5000;> 50%PMN

< 40mg/dl > 100 mg/dl

TBM 100 - 300 100 – 500Lymphocytes

Low; <40 mg/dl

Elevated; >100mg/dl

Viral meningitis 90-200 10-300; Lymphocytes

Normal or Less in Mumps /LCM

Normal or slight rise

Aseptic Meningitis

50 - 200 10 – 300Lymphocytes

Normal Normal or slight rise

Cryptococcal 100-300 <500;Lymphocytes

Low 50-200

NORMAL 80-200 <5 Lympho-cytes

50-75mg/dl 15-40mg/dl

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Non-motile Gram-negative, coccobacillary, facultatively anaerobic bacterium, and it’s Oxidase and Catalase postive

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Other Investigations

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Detects

Latex Particle Agglutination Of C.S.F

Specific Bacterial Antigen

H.influenzae,S.pneumoniae,N.memingitidis, E.coli , etc

Countercurrent ImmunoElectrophoresis

Smears from purpuric spots –Grams staining

S.pneumoniae,N.memingitidis,

DNA Sequencing Advanced centers Bacterial identification

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial Meningitis- DIFFERENTIAL DIAGNOSIS

Partially treated Meningitis Viral EncephalitisCerebral MalariaTuberculous MeningitisEnteric EncephalopathyLeptospirosisMetabolic/ Toxic EncephalopathiesDengue Haemorrhagic Fever

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Complications• Increased Intracranial tension & coning

pressure effects• Subdural Effusion• Septicaemia & Septic Shock• Seizures• SIADH• Acute Hydrocephalus• Cranial Nerve paralysis• DIC• Purpura Fulminans and Gangrene

? Complication

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Complications Commoner after bacterial meningitis than

after viral meningitis

Sensorineural hearing loss: partial or totalSeizure and Epileptic StateCognitive problems: Memory and concentration; Learning difficulties and behavioural problemsMotor Problems involving co-ordination and balance Speech problemsVisual disturbancesCerebral Palsy

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Greatest risk for hearing loss1 Males

2 Nuchal Rigidity3 Increased ICP4 Low CSF glucose levels5 S Pneumoniae Infection6 Abnormal CT Scan Findings

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S pneumoniae : 26.3-30% Hib : 7.7-10.3%;  N meningitidis : 5-10.3%.

Overall mortality for bacterial meningitis 5-10%

Neonates: 15-20%Older children: 3-10%.

Neurologic Sequelae : 30%

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Age: Neonates, PretermsOrganisms: Pneumococci> H.imfluenzae> MeningococciGm –ve Organisms, Salmonellae and EnterobacteriaceaeDICEndotoxic shockNeural tube AnomaliesImmunosuppresse individuals.

Poor Prognostic Factors

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Poor Prognosis for Bilateral Sensoryneural Hearing Loss

MalesIncreased Nuchal RigidityProlonged SezuresLow Coma Score Low CSF glucose levelsS pneumoniae infection Abnormal CT findings

4% -6% of all bacterial meningitis cases

1 in 4 survivors had : Serious and disabling sequelae Functionally important behavior disorder or neuropsychiatric problem Auditory dysfunction that impaired their performance in school

Prognosis

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Empiric Antibiotic Treatment in childhood Acute Bacterial Meningitis

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Organism Age Group Antibiotic

Unknown

Infants less than 1 month

Ampicillin Cefotaxime Gentamicin

Children over 1 month of age and Adults

Ampicillin Cefotaxime Vancomycin

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

UnidentifiedGram-negative bacilli

Children and Adults

CefazidimeGentamicin

-UnidentifiedGram positive organisms

Children and Adults

CeftriaxoneVancomycin Ampicillin

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Haemophilus influenzatype b Ceftriaxone

Meningococci Penicillin G plus ceftriaxone

STREPTOCOCCI Vancomcin Nafcillin (with or without rifampin)

LISTERIA SP Ampicillin Gentamicin Trimethoprim-sulfamethoxaxzole

ENTERIC GRAM-NEGATIVE BACTERIA(ESCHERICHIA COLI, PROTEUS SP, KLEBSIELLA SP)

Ceftriaxone Gentamicin

PSEUDOMONASCeftazidime Cefepime *These may be used with the addition of aminoglycoside

STAPHYOCOCCI Vancomycin Nafcillin *May be prescribed with or without rifampin

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in Children

Treatment of Complications 1) Convulsions: I.V.Diazepam

2) Cerebral Oedema: Mannitol ; i.v.dexamethasone

3) Drainage of Subdural Empyema

4) Surgical management of Hydrocephalus

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in Children

Supportive Treatment 1) Correction of Fluid and Electrolyte Disturbances 2) Control & Maintenance of normal body temperature 3) Control of Convulsions ( Anticonvulsant drugs) 4) Control of increased intracranial pressure and cerebral odema 5) Care of comatose /unconscious child ( Skin, Eyes, Bladder , Bowel, Lungs )

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in Children

Supportive Treatment 6) Protocol based Management of Septic Shock with Fluids, Electrolyte & Inotropes 7) Management of Disseminated Intravascular Coagulation 8) Nutritional Support 9) Monitoring of head circumference, vital parameters, Intracranial tension, response to drugs

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Acute Bacterial (Pyogenic) Meningitis in Children

Supportive Treatment

10) Treatment of Complications like hydrocephalus, subdural empyema, etc.,

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Immunization Routine Immunization with available vaccines against Haemophilus, Pneumococcus Meningococcus ( Routine or in, High Risk Children)Vaccination before travelling to endemic areas

S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

Prevention of Acute Bacterial Meningitis

Antibiotic Chemoprophylaxis with Antibiotics given to close contacts

H.influenzae type B

Rifampicin 20mg/kg/day for 4 days

N. Meningitidis

Rifampicin 20mg/kg/day or 600mg oral for 2 days in older children

Ceftriaxone single doseCiprofloxacin single dose