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Evidence based Evidence based management – Pyogenic management – Pyogenic
meningitis in childrenmeningitis in children
Dr.T.KanimozhiDr.T.KanimozhiJunior resident Junior resident
Dept of pediatricsDept of pediatricsJIPMERJIPMER
IntroductionIntroduction
Definition: Inflammation of meninges – Definition: Inflammation of meninges – pia, arachnoid and subarachnoid pia, arachnoid and subarachnoid space space
Medical emergencyMedical emergency Important cause of mortality and Important cause of mortality and
morbidity world widemorbidity world wide Mortality of untreated bacterial Mortality of untreated bacterial
meningitis- 100% ;even among meningitis- 100% ;even among treated 16- 32% in Indiatreated 16- 32% in India
Incidence Incidence
Commonest in infancyCommonest in infancy
95% cases 1month- 5yrs95% cases 1month- 5yrs
Males > femalesMales > females
EpidemiologyEpidemiology After the introduction of After the introduction of
the the Haemophilus influenzaeHaemophilus influenzae type b (Hib) type b (Hib) and pneumococcal conjugate vaccines, and pneumococcal conjugate vaccines, incidence of bacterial meningitis incidence of bacterial meningitis declined in all age groups except declined in all age groups except children younger than two months children younger than two months
The median age shifted from <5 years The median age shifted from <5 years to 42 years to 42 years
The peak incidence continues to occur The peak incidence continues to occur in children younger than two monthsin children younger than two months
Etiology Etiology Age Causative organism
0- 3 months Group B streptococcus, gram negative bacilli, staph. Aureus, listeria monocytogenes
3months – 3 yrs N.meningitidis, H.influenza, S.pneumoniae
> 3 yrs S.pneumoniae, N.meningitidis
Precipitating factors Causative organisms
Defects of complement system (C5-8) and properdin
Meningococcus
Splenic dysfunction H.Influenza B, pneumococcus
T-lymphocyte defects Listeria monocytogenes
CSF leaks and cochlear implants
Pneumococcus
CSF shunts CONS, Staph. Aureus
Lumbosacral dermal sinus and meningocoele
Staph. Aureus, gram negative enteric bacilli
Bacterial profile in a tertiary Bacterial profile in a tertiary care centre in south india care centre in south india
( 10 yr retrospective study)( 10 yr retrospective study)Gram positive Gram negative
S. Pneumoniae (mc) K. Pneumoniae (mc)
S.pyogenes P.aeruginosa
CONS Acinetobacter
S.aureus E.coli
Enterococci sps H.influenza
Enterobacter sps
Journal of Scientific and Innovative Research Journal of Scientific and Innovative Research 2013 2013
Clinical featuresClinical features
depend on the age of the patient and depend on the age of the patient and duration of diseaseduration of disease
Onset of acute BM has two formsOnset of acute BM has two forms
1. sudden onset- rapidly progressive 1. sudden onset- rapidly progressive shock, purpura , DIC, reduced level of shock, purpura , DIC, reduced level of consciousness leading to death in consciousness leading to death in 24hrs24hrs
2.Common form with Non specific 2.Common form with Non specific findings - fever(84%) findings - fever(84%)
headache(76%)headache(76%)
vomiting(70%)vomiting(70%)
anorexia(19%) anorexia(19%)
poor feedingpoor feeding
symptoms of URTIsymptoms of URTI
myalgia , arthralgia myalgia , arthralgia
petechiae , rash etcpetechiae , rash etc
Alteration in mental status (5%)Alteration in mental status (5%) Seizures (20 -30%)Seizures (20 -30%) Bulging fontanelle (esp in neonates)Bulging fontanelle (esp in neonates) Signs of meningeal irritation(59%) - Signs of meningeal irritation(59%) -
neck stiffness(65%), kernigs neck stiffness(65%), kernigs sign(27%) and brudzinski sign(51%)sign(27%) and brudzinski sign(51%)
Focal neurological deficitFocal neurological deficit
Classical signs often absent in infants Classical signs often absent in infants with meningitiswith meningitis
Hence, high index of suspicion is Hence, high index of suspicion is necessarynecessary
Initial managementInitial management
Resuscitation Resuscitation
AAirway & irway & BBreathing- give supplemental reathing- give supplemental oxygen and intubate ,if necessaryoxygen and intubate ,if necessary
CCirculation – treat shock with rapid irculation – treat shock with rapid fluid infusion and vasopressorsfluid infusion and vasopressors
DDisability-if signs of cerebral edema + isability-if signs of cerebral edema + -give mannitol-give mannitol
EExposure- rash- meningococcal xposure- rash- meningococcal sepsis; regulation of temperature is sepsis; regulation of temperature is importantimportant
FFluids- fluid restriction not necessary luids- fluid restriction not necessary unlesss there is SIADH or raised ICP unlesss there is SIADH or raised ICP
GGlucose – checked early and lucose – checked early and corrected if necessarycorrected if necessary
SSeizures: IV diazepam or lorazepam eizures: IV diazepam or lorazepam f/b phenytoin (15-20mg/kg loading; f/b phenytoin (15-20mg/kg loading; 5mg/kg/day maintainence) to reduce 5mg/kg/day maintainence) to reduce the likelyhood of recurrencethe likelyhood of recurrence
Management algorithmManagement algorithm
IDSA guidelines.2004IDSA guidelines.2004
Routine investigationsRoutine investigations CBC :Neutrophilia s/o bacterial infection CBC :Neutrophilia s/o bacterial infection Serum glucose: Often low; allows Serum glucose: Often low; allows
interpretation of CSF glucoseinterpretation of CSF glucose Electrolytes, urea, and creatinine :To assess Electrolytes, urea, and creatinine :To assess
for complications and fluid managementfor complications and fluid management Coagulation studies: To assess for Coagulation studies: To assess for
complicationscomplications Blood cultures : Positive in 40–90% Blood cultures : Positive in 40–90%
depending on the organismdepending on the organism
Lumbar punctureLumbar puncture
Gold standard for establishing Gold standard for establishing diagnosis- diagnosis- isolation of bacteria from isolation of bacteria from CSFCSF
Do LP once stablisedDo LP once stablised If LP delayed and bacterial meningitis If LP delayed and bacterial meningitis
is clinically suspected , antibiotics is clinically suspected , antibiotics should be given prior to LP should be given prior to LP
Indications to delay LPIndications to delay LP
Indications of CT prior to LPIndications of CT prior to LP Signs of ↑ICT (e.g. papilloedema )Signs of ↑ICT (e.g. papilloedema ) Suspecting malignancy( focal Suspecting malignancy( focal
neurological deficits)neurological deficits) Deteriorating neurological statusDeteriorating neurological status Previous neurosurgical procedure or Previous neurosurgical procedure or
traumatrauma Immunocompromised Immunocompromised
Normal CT scan does not exclude the risk Normal CT scan does not exclude the risk of raised ICTof raised ICT
Interpreting CSFInterpreting CSF
No single CSF parameter distinguishes No single CSF parameter distinguishes bacterial from non bacterial meningitisbacterial from non bacterial meningitis
< 3% instances CSF normal< 3% instances CSF normal When clinical indicators of meningitisWhen clinical indicators of meningitis
are present but initial CSF examinationare present but initial CSF examination
is normal - repeat LP at 24-48 hoursis normal - repeat LP at 24-48 hours
may be indicatedmay be indicated
Typical CSF findingsTypical CSF findings
CSF parameter
Normal Bacterial meningitis
Viral meningitis
PMN 0 100-10000 <100
Mononuclear cells
< 5 (<20 in neonates)
<100 10-1000
Protein (g/L) < 0.4 >1 0.4 - 1
Glucose (mmol/L)
<2.5 Usually decreased
Usually normal
Glucose ( CSF : Blood ratio)
> 0.6 <0.4 Usually normal
GRAM STAIN GRAM STAIN Best single test for rapid diagnosis of Best single test for rapid diagnosis of
bacterial meningitisbacterial meningitis Sensitivity- 60- 90%Sensitivity- 60- 90% Specificity- > 97%Specificity- > 97% positive Gram stain – bacterial count positive Gram stain – bacterial count
> 1×103 cells per mL in CSF> 1×103 cells per mL in CSF Positive in 90% pneumococcal, 86% Positive in 90% pneumococcal, 86%
Hib, 75% meningococcal, 50% gram Hib, 75% meningococcal, 50% gram neg and 33% listeria meningitisneg and 33% listeria meningitis
Interpretation of traumatic Interpretation of traumatic CSFCSF
1WBC : 500 RBC is acceptable; but 1WBC : 500 RBC is acceptable; but dependant on peripheral countsdependant on peripheral counts
Protein levels may be elevatedProtein levels may be elevated 0.01- 0.015 g/L increase in protein 0.01- 0.015 g/L increase in protein
levels for every 1000 RBC ‘ s in levels for every 1000 RBC ‘ s in uncentrifuged CSFuncentrifuged CSF
Peripheral WBC/RBC count× CSF RBC count = Peripheral WBC/RBC count× CSF RBC count =
CSF WBC countCSF WBC count
Interpretation of CSF in Interpretation of CSF in those with prior use of those with prior use of
antibioticsantibiotics rate of positive CSF culture and Gram rate of positive CSF culture and Gram
stain recovery decreases stain recovery decreases Complete sterilisation within 2 hr in Complete sterilisation within 2 hr in
N.meningitidis and within 4 hr in N.meningitidis and within 4 hr in pneumococcal meningitispneumococcal meningitis**
Cell count and biochemistry are not Cell count and biochemistry are not significantly influencedsignificantly influenced
Kanegaye JT et al. Pediatrics 2001Kanegaye JT et al. Pediatrics 2001
what investigations help in early what investigations help in early diagnosisdiagnosis??
Latex agglutinationLatex agglutination commercially available antisera directed commercially available antisera directed
against the capsular polysaccharides of against the capsular polysaccharides of meningeal pathogensmeningeal pathogens
Rapid results <15 minRapid results <15 min a positive CSF antigen test result did not a positive CSF antigen test result did not
affect clinical therapy or hospital courseaffect clinical therapy or hospital course** Culture negative meningitis, CSF latex Culture negative meningitis, CSF latex
agglutination had a sensitivity of only 7% in agglutination had a sensitivity of only 7% in one studyone study##
*Maxson et al. J Pediatr.1994*Maxson et al. J Pediatr.1994
#Tarafdar k et al.clin Infect Dis.2001#Tarafdar k et al.clin Infect Dis.2001
may be most useful for the patient may be most useful for the patient who has been pretreated with who has been pretreated with antimicrobial therapy and whose antimicrobial therapy and whose Gram stain and CSF culture results Gram stain and CSF culture results are negative are negative (B-III)(B-III)
Limulus lysate assayLimulus lysate assay positive test result suggests the positive test result suggests the
presence of endotoxin presence of endotoxin detect ∼103 gram-negative bacteria/mL detect ∼103 gram-negative bacteria/mL
of CSF and as little as 0.1 ng/mL of of CSF and as little as 0.1 ng/mL of endotoxinendotoxin
negative test does not rule out negative test does not rule out diagnosis of gram neg meningitis & diagnosis of gram neg meningitis & results rarely influence patient treatmentresults rarely influence patient treatment
Not routinely recommended Not routinely recommended (D II)(D II)
PCRPCR amplify DNA amplify DNA Broad based PCR - sensitivity 100%, a Broad based PCR - sensitivity 100%, a
specificity 98.2%, PPV 98.2%, and NPV specificity 98.2%, PPV 98.2%, and NPV 100%100%**
Appears to be promising for etiological Appears to be promising for etiological diagnosisdiagnosis
May be useful in gram stain negative May be useful in gram stain negative meningitis meningitis (B II)(B II)
*Saravolatz LD et al.Clin Infect Dis 2003*Saravolatz LD et al.Clin Infect Dis 2003
What Laboratory Testing What Laboratory Testing May Be Helpful in Distinguishing May Be Helpful in Distinguishing Bacterial from Viral Meningitis ?Bacterial from Viral Meningitis ?
Determination of lactate Determination of lactate concentrationconcentration
Generally non specific ; despite high Generally non specific ; despite high sensitivity and PPVsensitivity and PPV
CSF lactate was found to be superior to CSF lactate was found to be superior to CSF :blood glucose in postoperative CSF :blood glucose in postoperative neurosurgical patientsneurosurgical patients**
CSF concentration of 4.0 mmol/ L was CSF concentration of 4.0 mmol/ L was used as a cutoff value for the diagnosisused as a cutoff value for the diagnosis
*Leib SL et al.Clin Infect Dis. 1999*Leib SL et al.Clin Infect Dis. 1999
Determination of C-reactive protein Determination of C-reactive protein (CRP) concentration(CRP) concentration
Sensitivity - 18% to 100%, and specificity Sensitivity - 18% to 100%, and specificity
75% to 100%75% to 100%**in differentiating bacterial and in differentiating bacterial and viral meningitisviral meningitis
Sen -96%, spe 93%, NPV-99% in Sen -96%, spe 93%, NPV-99% in distinguishing gram negative meningitisdistinguishing gram negative meningitis
normal CRP has a high negative predictivenormal CRP has a high negative predictive
value in the diagnosis of bacterial meningitis value in the diagnosis of bacterial meningitis (BII)(BII)
*Gerdes at al.Scan J Clin Lab*Gerdes at al.Scan J Clin Lab
Determination of procalcitonin Determination of procalcitonin concentrationconcentration
Sensitivity 94%, specificity- 100% Sensitivity 94%, specificity- 100% using cut off >5mcg/L using cut off >5mcg/L **
Not routinely available. so no Not routinely available. so no recommendations as of nowrecommendations as of now
*Gendrel et al.Clin Infect Dis.1997*Gendrel et al.Clin Infect Dis.1997
How Quickly Should How Quickly Should Antimicrobial Therapy Be Antimicrobial Therapy Be Administered to Patients with Administered to Patients with Suspected Bacterial Meningitis?Suspected Bacterial Meningitis?
As soon as bacterial meningitis As soon as bacterial meningitis is is
suspected suspected
If LP delayed and bacterial If LP delayed and bacterial meningitis is clinically suspected , meningitis is clinically suspected , antibiotics should be given prior to LP antibiotics should be given prior to LP
Retrospective study –outcome based on Retrospective study –outcome based on nature of presentationnature of presentation
nonspecific illness nonspecific illness - a short delay (3–5 days) - a short delay (3–5 days) did not appear to alter the risk of sequelae did not appear to alter the risk of sequelae or deathor death
fulminant meningitisfulminant meningitis-delay in the initiation -delay in the initiation of antibiotics seemed to be unconnected to of antibiotics seemed to be unconnected to outcomeoutcome
clinically overt meningitis - clinically overt meningitis - inappropriate inappropriate delay incrementally increased the risk of delay incrementally increased the risk of permanent injurypermanent injury
Radetsky et al.Pediatr Infect Dis J.1992Radetsky et al.Pediatr Infect Dis J.1992
What Specific Antimicrobial What Specific Antimicrobial Agents Should Be Used in Agents Should Be Used in Patients with Suspected or Patients with Suspected or Proven Bacterial Meningitis?Proven Bacterial Meningitis?
Appropriate empirical regimen Appropriate empirical regimen i.e one that covers resistant i.e one that covers resistant S.pneumoniae , N.meningitidis and S.pneumoniae , N.meningitidis and H.influenza B- H.influenza B-
Third generation cephalosporin + Third generation cephalosporin + vancomycin vancomycin
IDSA guidelines. 2004IDSA guidelines. 2004
NIMHANS study: NIMHANS study:
Streptococcus pneumoniae Streptococcus pneumoniae remains remains the major aetiological agent of CAABMthe major aetiological agent of CAABM
No penicillin resistance was detected No penicillin resistance was detected among the isolatesamong the isolates
R mani et al.Indian J Med Microbiol.2007R mani et al.Indian J Med Microbiol.2007
Third generation Third generation cephalosporinscephalosporins
drugs of choice for empirical therapy drugs of choice for empirical therapy for for H. influenzae meningitisH. influenzae meningitis
recommended in pneumococcal and recommended in pneumococcal and meningococcal meningitis caused by meningococcal meningitis caused by strains that are not susceptible to strains that are not susceptible to penicillin penicillin (AIII)(AIII)
Cefepime also has greater in vitroCefepime also has greater in vitro
activity than the third-generation activity than the third-generation cephalosporins against cephalosporins against EnterobacterEnterobacter
species and species and Pseudomonas Pseudomonas aeruginosaaeruginosa**
Kaplan SL.Clin Infect Dis J.Kaplan SL.Clin Infect Dis J.
VancomycinVancomycin
Even in patients with meningitis caused Even in patients with meningitis caused by highly penicillin and cephalosporin by highly penicillin and cephalosporin resistant strains, vancomycin should be resistant strains, vancomycin should be combined with a thirdgeneration combined with a thirdgeneration cephalosporin cephalosporin (A-III) (A-III) and should not be and should not be used as a single agentused as a single agent
Kaplan SL.Clin Microbio RevKaplan SL.Clin Microbio Rev
Meropenam Meropenam
Broad in vitrio activityBroad in vitrio activity Useful as alternative to third Useful as alternative to third
generation cephalosporin generation cephalosporin (AIII)(AIII) Useful in gram negative meningitis Useful in gram negative meningitis
resistant to standard therapyresistant to standard therapy**
Buckingham SC.South Med J.2002Buckingham SC.South Med J.2002
Rifampin Rifampin
Good CSF penetration and in vitrio activityGood CSF penetration and in vitrio activity Resistance develops rapidly when used Resistance develops rapidly when used
alonealone combine with a third-generation combine with a third-generation
cephalosporin +/- vancomycin, cephalosporin +/- vancomycin, pneumococcal meningitis caused by pneumococcal meningitis caused by highly penicillin- or cephalosporin highly penicillin- or cephalosporin resistant strainsresistant strains**
Kaplan SL.Pedr Infect Dis J.2002Kaplan SL.Pedr Infect Dis J.2002
What Is the Role of Adjunctive What Is the Role of Adjunctive Dexamethasone Therapy in Dexamethasone Therapy in Patients with Bacterial Patients with Bacterial Meningitis?Meningitis?
RationaleRationale subarachnoid space inflammatory subarachnoid space inflammatory
response - major factor contributing response - major factor contributing to morbidity and mortalityto morbidity and mortality
Attenuation of this inflammatory Attenuation of this inflammatory response- decrease cerebral edema, response- decrease cerebral edema, increased ICP, altered cerebral blood increased ICP, altered cerebral blood flow, cerebral vasculitis, and flow, cerebral vasculitis, and neuronal injury, as mediated by neuronal injury, as mediated by proinflammatory cytokine expressionproinflammatory cytokine expression
Hib meningitis - Hib meningitis - reduced hearing reduced hearing impairment overall ; whereas inimpairment overall ; whereas in
pneumococcal meningitis - only pneumococcal meningitis - only suggested protection for severe suggested protection for severe hearing loss if given earlyhearing loss if given early**
2007 Cochrane review2007 Cochrane review- lower case - lower case mortality, and lower rates of severe mortality, and lower rates of severe hearing loss and long-term hearing loss and long-term neurological sequelaeneurological sequelae
*McIntyre PB et al.meta analysis. JAMA*McIntyre PB et al.meta analysis. JAMA
Committee on Infectious Diseases of Committee on Infectious Diseases of the AAP the AAP ::
““For infants and children 6 weeks of age For infants and children 6 weeks of age and older, adjunctive therapy with and older, adjunctive therapy with dexamethasone may be considered dexamethasone may be considered after weighing the potential benefits after weighing the potential benefits and possible risks. Experts vary in and possible risks. Experts vary in recommending the use of recommending the use of corticosteroids in pneumococcal corticosteroids in pneumococcal meningitis; data are not sufficient to meningitis; data are not sufficient to demonstrate clear benefit in children “demonstrate clear benefit in children “
Recommendation Recommendation
Steroids are recommended Steroids are recommended early in early in children ≥3 months of age just children ≥3 months of age just before or at the time of antibioticsbefore or at the time of antibiotics, , provided that they have not been provided that they have not been pre-treated with parenteral pre-treated with parenteral antibioticsantibiotics
dosing regimen is dosing regimen is 0.15 mg/kg/dose 0.15 mg/kg/dose IV, every 6 hours for 2-4 daysIV, every 6 hours for 2-4 days
Management of Raised ICP in Management of Raised ICP in meningitis meningitis
General measuresGeneral measures Head end elevation 15–30°Head end elevation 15–30° Maintenance fluids – isotonic fluids to Maintenance fluids – isotonic fluids to
maintain MAP ; if this fails vasopressors maintain MAP ; if this fails vasopressors can be initiatedcan be initiated
Agressively treat fever- antipyretics/ Agressively treat fever- antipyretics/ cooling blanketscooling blankets
Adequate sedation and analgesiaAdequate sedation and analgesia Maintain euvolemia/euglycemiaMaintain euvolemia/euglycemia Prevention and treatment of seizuresPrevention and treatment of seizures
Specific measuresSpecific measures
Mannitol: Initial bolus: 0.25–1 g/kg, Mannitol: Initial bolus: 0.25–1 g/kg, then 0.25–0.5 g/kg, q 2–6 h as per then 0.25–0.5 g/kg, q 2–6 h as per requirement, up to 48 hrsrequirement, up to 48 hrs
Hypertonic Saline: Preferable in Hypertonic Saline: Preferable in presence of Hypotension, Hypovolemia, presence of Hypotension, Hypovolemia, Serum osmolality >320 mOsm/kg, Serum osmolality >320 mOsm/kg, Renal failure, Dose: 0.1–1 ml/kg/hr Renal failure, Dose: 0.1–1 ml/kg/hr infusion, Target Na+−145–155 meq/Linfusion, Target Na+−145–155 meq/L
Mannitol vs hypertonic Mannitol vs hypertonic salinesaline
Recent meta analysis: Recent meta analysis: Evidence is Evidence is non-definitive regarding any non-definitive regarding any advantages to treating ICP with advantages to treating ICP with hypertonic saline over Mannitolhypertonic saline over Mannitol
Kamel H et al. Crit care Med 2011Kamel H et al. Crit care Med 2011..
HyperventilationHyperventilation — Target PaCo2 — Target PaCo2 30-35 mmHg ( reserved for episodes 30-35 mmHg ( reserved for episodes of acute brain herniation or ICP of acute brain herniation or ICP elevation )elevation )
Refractory raised ICP- hypothermia, Refractory raised ICP- hypothermia, barbiturate coma, decompressive barbiturate coma, decompressive craniectomycraniectomy
what is the duration of what is the duration of antimicrobial therapy based on antimicrobial therapy based on isolated pathogenisolated pathogen??
Organism Duration of therapy (days)
Group B streptococcus 14
Gram negative rods 21
Listeria monocytogenes 21
Neiserria meningitidis 7
Hemophilus influenza 7-10
Streptococcus pneumoniae 14
Culture negative meningitis 7
What Are the Indications What Are the Indications for Repeated Lumbar Puncture in for Repeated Lumbar Puncture in Patients with Bacterial Patients with Bacterial Meningitis?Meningitis?
any patient who has not responded any patient who has not responded clinically after 48 h of appropriate clinically after 48 h of appropriate antimicrobial therapy antimicrobial therapy
In neonates with gram negative In neonates with gram negative
meningitis to document sterilisationmeningitis to document sterilisation
Prognostic factors?Prognostic factors?
GCS- independent predictor of death or GCS- independent predictor of death or neurological sequeleneurological sequele
EtiologyEtiology Mortality and neurologic sequelae are Mortality and neurologic sequelae are
higher with pneumococcal meningitis higher with pneumococcal meningitis Hearing loss -30 % in pneumococcal Hearing loss -30 % in pneumococcal
meningitis, 10 % in meningococcal meningitis, 10 % in meningococcal meningitis, and 5-20 % in Hib meningitismeningitis, and 5-20 % in Hib meningitis**
Nelson textbook of pediatricsNelson textbook of pediatrics
CSF glucose concentration (<20mg/ CSF glucose concentration (<20mg/ dL ) – associated with hearing lossdL ) – associated with hearing loss
Time to sterilization of CSF after Time to sterilization of CSF after start of therapy (16 to 18 hours after start of therapy (16 to 18 hours after the initiation of therapy)the initiation of therapy)
Malnutrition :increased morbidity and Malnutrition :increased morbidity and mortalitymortality
Seizures > 72 hours after initiation of Seizures > 72 hours after initiation of appropriate antimicrobial therapy -appropriate antimicrobial therapy -increased risk of neurologic sequelae increased risk of neurologic sequelae
Follow up?Follow up?
Neurological sequele in Neurological sequele in survivorssurvivors
Hearing /visual deficitHearing /visual deficit Seizure disorderSeizure disorder Cranial nerve palsyCranial nerve palsy ParesisParesis Cognitive impairmentCognitive impairment hydrocephalushydrocephalus
Hearing assessment should be Hearing assessment should be done at dischage or within 6-8 wks done at dischage or within 6-8 wks by PTA/BERA. If normal then by PTA/BERA. If normal then reassessed at 3months, 6 months reassessed at 3months, 6 months and 1 yrand 1 yr
severe sequele not discovered at severe sequele not discovered at discharge do not appear laterdischarge do not appear later
Children who appear well have more Children who appear well have more non-specific symptoms like headache, non-specific symptoms like headache, and inattention, hyperactivity and and inattention, hyperactivity and impulsiveness than their siblingsimpulsiveness than their siblings
Berq et al.Eur J Ped.2002Berq et al.Eur J Ped.2002
Preventive measures?Preventive measures?
Immunisation Immunisation
Immunisation is the most effective Immunisation is the most effective means of prevention BM in childrenmeans of prevention BM in children
IAP recommends routine use of Hib IAP recommends routine use of Hib vaccine in children vaccine in children with efficacy rate with efficacy rate against invasive infection ranges from 70-against invasive infection ranges from 70-100%100%
IAP recommends IAP recommends pnemococcal and pnemococcal and meningococcal vaccination for high risk meningococcal vaccination for high risk childrenchildren as vaccines under special as vaccines under special circumstances.circumstances.
Meningococcal vaccineMeningococcal vaccine
MCV-4 (A,C, Y, W-135)MCV-4 (A,C, Y, W-135) Minimal age- 2 yrsMinimal age- 2 yrs Revaccination only once after 3yrs Revaccination only once after 3yrs
in those at continued high riskin those at continued high risk
Pneumococcal vaccinePneumococcal vaccine
Minimum age - 6wks for Minimum age - 6wks for pnemococcal conjugate vaccine(PCV) pnemococcal conjugate vaccine(PCV) and 2yrs for polysaccharide and 2yrs for polysaccharide vaccine(PPSV)vaccine(PPSV)
PCV must be offered to premature PCV must be offered to premature and low birth weight infantsand low birth weight infants
Functional/anatomic asplenia and Functional/anatomic asplenia and immunodeficient individuals- high immunodeficient individuals- high riskrisk
Chemoprophylaxis Chemoprophylaxis --to household contacts to household contacts
Neiserria meningitidis Rifampin 10mg/kg/dose q12h for 2 days
H.influenza Rifampin 20mg/kg/24 hr for 4 days
Thank youThank you