Bacterial
Meningitis in
Pediatrics
Shihab Idris
M4
Ross Universoty school of Medicine
Objectives
1.
Define meningitis within the context of pediatrics and
discuss its epidemiology and predisposing factors
2.
Review the classic signs and symptoms associated with
meningitis.
3.
Discuss the specific signs and symptoms of acute bacterial
meningitis caused by the following bacteria:
Streptococcus agalactiae = Group B Streptococcus,
Haemophilus influenzae type b, Streptococcus
pneumoniae (pneumococcal meningitis), Neisseria
meningitidis (meningococcal meningitis), and Listeria
monocytogenes (listeriosis).
4.
Discuss important pointers and distinctions that are helpful
to identify the causative agent.
5.
Review the proper process of diagnosis, management and,
treatment of meningitis caused by the aforementioned
bacteria.
Clinical description
Meningitis is a disease caused by the inflammation of the protective
membranes covering the brain and spinal cord known as the meninges.
Meningitis can be life-threatening because of the inflammation's proximity to
the brain and spinal cord; therefore the condition is classified as amedical
emergency.
Suspected bacterial meningitis is a medical emergency, and immediate
diagnostic steps must be taken to establish the specific cause so that
appropriate antimicrobial therapy can be initiated. The mortality rate of
untreated bacterial meningitis approaches 100 percent
Epidemiology
Introduction of the Haemophilus influenzae type b (Hib) and
pneumococcal a declined incidence of bacterial meningitis in
all age groups except children younger than two months .
The median age shifted from <5 years to 42 years .
The peak incidence continues to occur in children younger than
two months.
In population-based surveillance (2006 to 2007), the incidence of
bacterial meningitis in United States children varied with age :
<2 months 80.69 per 100,000 population
2 through 23 months 6.91 per 100,000 population
2 through 10 years 0.56 per 100,000 population
11 through 17 years 0.43 per 100,000 population
Relative frequency of pathogens
Age group
Pathogens
1 month and
<3 months
Group B
streptococcus
(39 percent)
Gram-negative
bacilli (32
percent)
Streptococcus
pneumoniae
(14 percent)
Neisseria
meningitidis
(12 percent)
3 months and
<3 years
S. pneumoniae
(45 percent)
3 years and
<10 years
S. pneumoniae
(47 percent)
N. meningitidis N. meningitidis
(34 percent)
(32 percent)
Group B
streptococcus
(11 percent)
Gram-negative
bacilli (9
percent)
10 years and
<19 years
N. meningitidis
(55 percent)
Predisposing Factors
Recent exposure to someone with meningococcal or Hib
meningitis
Recent infection (especially respiratory or otic infection)
Recent travel to areas with endemic meningococcal
disease, such as sub-Saharan Africa
Penetrating head trauma
Cerebrospinal fluid (CSF) otorrhea (including congenital
defects, such as Mondini dysplasia) or CSF rhinorrhea
Cochlear implant devices, particularly those with a
positioner Anatomic defects or urinary tract anomaly)
or recent neurosurgical procedure
Clinical Features of CNS
Infections
Classic symptoms in a non-specific
prodrome:
1.
1.
Fever
2.
Headache
3. + Nuchal rigidity (i.e., neck
stiffness)
Pathognomonic sign of
meningeal irritation
Kernigs sign
Brudzinskis sign
Kernigs sign - is assessed with the patient lyingsupine, with the
hip and knee flexed to 90degrees. In a patient with a positive Kernig's
sign, pain limits passive extension of the knee.
Brudzinski signs -A positive Brudzinski's sign occurs when
flexion of the neck causes involuntary flexion of the knee and hip.
Clinical Features of CNS Infections
4. Other signs and symptoms (more
common as intracranial pressure increases)
Altered mental status
Focal neurologic signs
Seizures
Bulging fontanelle
Skin manifestations (e.g., rash)
Papilledema
Blurring of the edges
of the optic disc
Indicates increased
intracranial
pressure
Sign of impending
herniation
Lumbar puncture is
contraindicated!
Normal optic
disc
CT scan needed
prior to
performing the
12
Skin findings: Nonspecific blanching, erythematous, maculopapular
rash to a petechial or purpuric rash.
**Approximately 6% of affected infants and children
show signs of disseminated intravascular coagulopathy
and endotoxic shock. These signs are indicative of a poor
prognosis.
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Most Important
Bacterial Etiologies
Haemophilus influenzae Meningitis
Occurs mostly in children
Gram-negative aerobic bacteria, normal throat flora
(nasopharynx)
Capsule antigen type b : serotype b capsule composed
of polyribitol phosphate (PRP)
Reduction in [Link] meningitis due to development of
Hib vaccine
Leading cause of pediatric meningitis in U.S. PRIOR to
introduction of Hib vaccine in 1990
Infection was common because maternal antibodies that
passed transplacentally would decrease after 6 months
of age
Vaccine has reduced incidence by >90% in immunized children
CDC reported 469 cases of invasive disease (<5 y.o.) in
2010
Only 23 cases caused by serotype b
Transmitted by respiratory droplets
Predisposing risk factors:
Non-vaccinated children
Children in day care centers
Individuals of Native American or Eskimo descent
Complement deficiencies (esp. C3)
Decreased antibody levels
Asplenia (anatomic/functional)
Prevention
Vaccine!
Chemoprophylaxis:
rifampin
- Secreted in saliva
reduces transmission
-
- Close contacts
-
- NOT in pregnant women
Neisseria Meningitis,
(Meningococcal Meningitis)
Gram-negative aerobic cocci, capsule
Epidemiology
2nd MCC of bacterial
meningitis in persons
>1 month of age
Transmission by respiratory
droplets
Associated with living in
close quarters
schools, day care
centers, residential
facilities
Petechiae
Purpura
Purpura
Waterhouse-Friderichsen
Syndrome
Prevention
Streptococcus pneumoniae Meningitis,
Pneumococcal Meningitis
Gram-positive diplococci
Transient member of the URT
flora
Colonize nasopharynx
of up to 40% of
healthy adults and
children
Most common in children (1
month to 4 years)
Mortality: 30% in children, 80%
in elderly
Prevented by vaccination
No soft cheeses for pregnant
women! Why?
Listeria Monocytogenes
Epidemiology
Found in GI tract of a variety of mammals and
other animals in soil and water and on
vegetation
In U.S. mostly associated with unpasteurized soft
cheeses
Can cross the placenta
Fetal loss (abortion, stillbirth)
- Neonatal meningitis
Clinical Disease
Fetal loss abortion or stillbirth
Neonatal disease
Transmission across the placenta
OR during delivery
Early-onset (in utero)
Disseminated abscesses and
granulomas
Late-onset (24 weeks after birth)
Meningitis
Meningoencephalitis
Treatment of Acute
Bacterial Meningitis
Antimicrobial agents (minimum of 2 IV
drugs)
Administer promptly (preferably after
LP)
Bactericidal properties
Good CSF penetration necessary
3rd/4th generation cephalosporins
Ceftazidime (3rd generation antipseudomonal)
Ampicillin / Vancomycin
Relieve intracranial pressure (ICP)
NOT by removing fluid
Dexamethasone concomitant with or
just prior to 1st dose of antimicrobial
attenuates inflammatory response
following antimicrobial-induced
lysis
Symptoms can be the same for
Viral and Bacterial
COMPLICATIONS
Brain damage
Buildup of fluid between the skull
and brain (subdural effusion)
Hearing loss
Hydrocephalus
Seizures
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References :
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NE, et al. Bacterial meningitis in the United States, 1998-200
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A, Robinson K, Wenger JD, et al. Bacterial meningitis in the
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R, Bacterial Meningitis Study Group of the Pediatric Emergen
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Academy of Pediatrics. Children with bacterial meningitis p
resenting to the emergency department during the pneumococca
AcadEmergMed
2008;
l conjugate vaccine
era.15:522.
4. Geiseler PJ, Nelson KE. Bacterial meningitis without clinical sig
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signs of meningeal irritation. South Med J 1982; 75:448.
6. TeeleDW,DashefskyB,Rakusan
T, Klein JO. Meningitis after lumbar puncture in childre
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J, et al. Influence of admission findings on death and neu
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8.
THANK YOU
