Morning Report: Thursday, April 5 th

 Bacterial meningitis is more common in the first month than at any other time in life  Mortality rate has declined from 50% in the 1970s to 10-15% currently  BUT, the morbidity rate is relatively unchanged  Incidence /1000 live births  Occurs in up to 15% of neonates with bacteremia

 LBW (<2500g)  Preterm birth (<37 wga)  PROM  Septic or traumatic delivery  Fetal hypoxia  Maternal peripartum infection  Galactosemia  Urinary tract abnormalities

 Early-onset infections (first 3-6 days after birth)  Reflect vertical transmission from maternal genital tract flora  Late-onset infections (after first week of life)  Suggest nosocomial or community acquisition  (Maternal flora may still be a source)

 The “bugs”  GBS  E.Coli  Other gram-negative bacilli  Other gram positive organisms constitute a higher portion of disease burden among VLBW infants  Enterococcus  Coagulase-negative staphylococci  S. aureus  L. monocytogenes  Alpha-hemolytic streptococci

 Temperature instability (60%)  Term infants: temp> 38C  Preterm infants: temp< 36C  Neurologic symptoms  Irritability/ lethargy (60%)  Poor tone  Tremors/twitching/seizures (20-50%)  Focal  More common presentation in gram-negative meningitis  Full fontanelle

 Other  Poor feeding/ vomiting (50%)  Respiratory distress (33-50%)  Apnea (10-30%)  Diarrhea (20%)

 Full septic work-up  CBC  BCx  UA/ UCx (if > 6 days of age)  LP  Glucose  Protein  Cell count and differential  Gram stain  Culture

WBCProteinGlucose Term infant>1000 WBC/microL* Neutrophils >100 mg/dL<30 mg/dL Preterm infant>1000 WBC/microL* Neutrophils >150 mg/dL<20 mg/dL PEARLS OF CSF WISDOM : 1.CSF WBC ct may be lower with gram-positive organisms 2. In 20% of patients with culture-confirmed meningitis, the gram stain will be negative (especially with L. monocytogenes) 3.Adjustment of WBC in the setting of a traumatic LP can result in loss of sensitivity with only a marginal gain in specificity

 CSF culture  Negative cultures  rely on cell count and protein  LP was delayed until after antibiotic administration  IAP

 Empiric therapy  Early-onset  Ampicillin and gentamicin OR  Ampicillin and cefotaxime OR  If Listeria and Enterococcus are unlikely  Ampicillin and gentamicin and cefotaxime  If a gram-negative organism is strongly suspected  Late-onset  Non-hospitalized neonates  Ampicillin and gentamicin OR  Ampicillin and gentamicin and cefotaxime  Hospitalized neonates  Vancomycin, gentamicin, cefotaxime  Vancomycin, ampicillin, gentamicin

 Specific therapy  GBS: Ampicillin or PCN+ Gentamicin  sterility  PCN G monotherapy  Gram-negative enterics: Ampicillin (for amp- susceptible strains), Cefotaxime+ Gentamicin  sterility  7-14 days of continued combination therapy  Cefotaxime monotherapy  Listeria: Ampicillin and Gentamicin  Coagulase-negative staphylococci: Vancomycin

 Positive CSF culture  Gram-positives (uncomplicated course): 14 days  Gram-negatives: 21 days (minimum)  Ventriculitis, abscess, multiple areas of infarction: up to 8 weeks

 Acute  Ventriculitis  Abscess  Infarction  Hydrocephalus  Subdural effusion  Chronic  Developmental delay (25%)  Late-onset seizures (20%)  CP (20%)  Hearing loss (10%)  Cortical blindness (<10%)

Noon is free!!