Morning Report

Morning ReportDecember 7, 2010

MeningitisThe morbidity and mortality in the child that has bacterial meningitis has not changed in the last 15 years despite the availability of newer antibiotics and preventative strategies.

A variety of infections cause meningits, including bacteria, viruses, fungi and mycobacteria. These are the most common which tend to vary by age group. 95% of cases worldwide are causes by meningo and pneumococcus.4Common Bacterial PathogensStreptococcus pneumoniaeNP colonization, subsequent bacteremia with seeding of choroid plexus7 serotypes14, 6B, 19F, 18C, 23F, 4, 9VVaccination has decreased incidence by 75%Emergence of nonvaccine serotypes

The leading pathogen in infants and young children5Common Bacterial PathogensNeisseria meningitidisFulminant presentationHigh fatality rateAt riskFlu AAsplenia, terminal complement deficiency, lab exposure, travel to epidemic regions (Saudi Arabia or sub-Saharan Africa)Does occur in healthy98% sporadicA, B, C, W-135

Although mostly sporadic, outbreaks do occur6Less Common Bacterial PathogensNon-neonatal Gram-negative bacilliMycobacterium tuberculosisBorrelia burgdorferiRickettsia rickettsii

TB most common cause in sub-Saharan Africa bc of HIV, in US children less than 5y, anyone who is immunosuppressedLyme not common in this areaRMSF seasonal just like entero and borrelia May through august7Aseptic MeningitisInfectiousEnterovirusCoxsackie and Echo1/4 an etiology is identifiedHSV, arboviruses, EBV, Rabies, HHV-6NoninfectiousDrug-inducedNSAIDs, IVIG, OKT3, BactrimVasculitisKD or Lupus

Aseptic no bacterial pathogens have been identified8HistoryInfantsFeverLethargyIrritabilityAMSVomitingSeizures

Older ChildrenMalaiseMyalgiaHAPhotophobiaNeck stiffnessAnorexiaNausea Infants are generally nonspecific and you need to have a high index of suspicion. And dont forget anyone can present in fulminant sepsis9

Risk factors for different types of meningitis. Recent infections otitis, sinusitis or mastoiditis10Physical ExamABCs!!!NeuroAMSPapilledemaCranial nerve palsiesPoorly reactive pupilsFontanelle Focal deficits

Warning signs of increased ICP11Physical ExamNeckMeningismusKernigBrudzinski

SkinExanthems

Meningismus not present in infantsKernig lies supine and the thigh is flexed at a right angle to the trunk. Knee extention elicits painBrudinski lies supine and flextion at the neck. Flexion of the lower extremities

12

Signs of increased ICPDefer until CTMass, hemorrhage, midline shift, effacement of basilar cisterns or sulciNormal findings do not exclude increased ICP

14

Remember to look at age specific values. The values can often give clues to etiology. The gram stain findings should never be used to narrow the spectrum of empiric coverage. 15Work UpElectrolytesSIADHCBCLeukopenia, thrombocytopeniaHigh WBCCoagsBlood CultureCSF CultureConsider other CSF studiesCan also send other tests on CSF if suspecting a viral or other cause such as TB or Lyme16The Traumatic LPFrankly bloody CSF should not be used to make clinical decisions

Reattempt

Do not recommend using formulas to correct!TreatmentGoalsPrompt initiationUse of appropriate antimicrobial with correct dosing and durationAttention to anticipated complicationsAppropriate follow-upTreatmentChildren older than 2 monthsVancomycin (60mg/kg/day div q 6) PLUSCeftriaxone (100mg/kg/day) ORCefotaxime (200-300mg/kg/day div q 6)

Only adjust after culture and susceptibility data are availableTreatmentDurationDepends on organism and degree of complicationsF/U CSF in some childrenID specialist involved if questionable

Gram-negativeLonger course minimum 21 daysWhat about steroids??Well studied in adultsReduce rates of mortality, severe hearing loss and neuro sequelaeChildrenMay be beneficial for Hib meningitisMay be considered in pneumococcal meningitis

Dexamethasone (0.6mg/kg/d div q 6) x 4dComplicationsShockSeizuresIncreased ICPSubdural effusionsFocal neuro deficitsCerebral edemaSIADHSeizures 20-30% of cases of bacterial meningitis and within 72 hoursSubdural effusions 10-40% with bacterial meningitisFocal deficits vascular injurySIADH unclear rates, VS, UOP, lytes and osmolality should be monitored closely, fluid restriction22Meningitis ExposureMeningococcalHousehold contactsHigh-risk contactsDay care or nursery schoolIntimate contact contact with secretions or slept or eaten in same dwelling in last 7 daysPassengers on airline sitting next to patient for >8hRifampinCeftriaxone or ciproRedbook for dosing and durationMeningitis ExposureHibUnimmunized or underimmunized children