Acute bacterial (Pyogenic) meningitis - Dr. S. Srinivasan, Professor of Pediatrics
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Transcript of Acute bacterial (Pyogenic) meningitis - Dr. S. Srinivasan, Professor of Pediatrics
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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
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S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Acute Bacterial (Pyogenic) Meningitis in
Children
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• 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Symptoms & Signs
Acute Bacterial Meningitis
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• 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
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S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
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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,
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Skin in Acute Bacterial Meningitis Complications
S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
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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
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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
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S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
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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
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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
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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
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S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
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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
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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
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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
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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
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? Complication
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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
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Greatest risk for hearing loss1 Males
2 Nuchal Rigidity3 Increased ICP4 Low CSF glucose levels5 S Pneumoniae Infection6 Abnormal CT Scan Findings
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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%
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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
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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
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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
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Empiric Antibiotic Treatment in childhood Acute Bacterial Meningitis
S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
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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
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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
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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
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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
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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 )
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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
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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.,
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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
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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