Acute bacterial (Pyogenic) meningitis - Dr. S. Srinivasan, Professor of Pediatrics
-
Upload
pediatricsmgmcri -
Category
Healthcare
-
view
970 -
download
3
Transcript of Acute bacterial (Pyogenic) meningitis - Dr. S. Srinivasan, Professor of Pediatrics
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