1. Morning Report
December 7, 2010

3. Meningitis
The 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.

4. 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.

5. Common Bacterial Pathogens
Streptococcus pneumoniae
NP colonization, subsequent bacteremia with seeding of choroid plexus
7 serotypes
14, 6B, 19F, 18C, 23F, 4, 9V
Vaccination has decreased incidence by 75%
Emergence of nonvaccine serotypes
The leading pathogen in infants and young children

6. Common Bacterial Pathogens
Neisseria meningitidis
Fulminant presentation
High fatality rate
At risk
Flu A
Asplenia, terminal complement deficiency, lab exposure, travel to epidemic regions (Saudi Arabia or sub-Saharan Africa)
Does occur in healthy
98% sporadic
A, B, C, W-135
Although mostly sporadic, outbreaks do occur

7. Less Common Bacterial Pathogens
Non-neonatal Gram-negative bacilli
Mycobacterium tuberculosis
Borrelia burgdorferi
Rickettsia rickettsii
TB – most common cause in sub-Saharan Africa bc of HIV, in US children less than 5y, anyone who is immunosuppressed
Lyme – not common in this area
RMSF – seasonal just like entero and borrelia – May through august

8. Aseptic Meningitis Infectious Noninfectious Enterovirus
Coxsackie and Echo
1/4 an etiology is identified
HSV, arboviruses, EBV, Rabies, HHV-6
Noninfectious
Drug-induced
NSAIDs, IVIG, OKT3, Bactrim
Vasculitis
KD or Lupus
Aseptic – no bacterial pathogens have been identified

9. History Infants Older Children Fever Lethargy Irritability AMS
Vomiting
Seizures
Older Children
Malaise
Myalgia HA
Photophobia
Neck stiffness
Anorexia
Nausea
Infants are generally nonspecific and you need to have a high index of suspicion. And don’t forget anyone can present in fulminant sepsis

10. Risk factors for different types of meningitis
Risk factors for different types of meningitis. Recent infections – otitis, sinusitis or mastoiditis

11. Physical Exam ABCs!!! Neuro AMS Papilledema Cranial nerve palsies
Poorly reactive pupils
Fontanelle
Focal deficits
Warning signs of increased ICP

12. Physical Exam Neck Skin Meningismus Kernig Brudzinski Exanthems
Meningismus – not present in infants
Kernig – lies supine and the thigh is flexed at a right angle to the trunk. Knee extention elicits pain
Brudinski – lies supine and flextion at the neck. Flexion of the lower extremities

14. Signs of increased ICP
Defer until CT
Mass, hemorrhage, midline shift, effacement of basilar cisterns or sulci
Normal findings do not exclude increased ICP

15. Remember to look at age specific values
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.

16. Work Up Electrolytes CBC Coags Blood Culture CSF Culture SIADH
Leukopenia, thrombocytopenia
High WBC
Coags
Blood Culture
CSF Culture
Consider other CSF studies
Can also send other tests on CSF if suspecting a viral or other cause such as TB or Lyme

17. The Traumatic LP
Frankly bloody CSF should not be used to make clinical decisions
Reattempt
Do not recommend using formulas to correct!

18. Treatment Goals Prompt initiation
Use of appropriate antimicrobial with correct dosing and duration
Attention to anticipated complications
Appropriate follow-up

19. Treatment Children older than 2 months
Vancomycin (60mg/kg/day div q 6) PLUS
Ceftriaxone (100mg/kg/day) OR
Cefotaxime ( mg/kg/day div q 6)
Only adjust after culture and susceptibility data are available

20. Treatment Duration Depends on organism and degree of complications
F/U CSF in some children
ID specialist involved if questionable
Gram-negative
Longer course – minimum 21 days

21. What about steroids?? Well studied in adults Children
Reduce rates of mortality, severe hearing loss and neuro sequelae
Children
May be beneficial for Hib meningitis
May be considered in pneumococcal meningitis
Dexamethasone (0.6mg/kg/d div q 6) x 4d

22. Complications Shock Seizures Increased ICP Subdural effusions
Focal neuro deficits
Cerebral edema
SIADH
Seizures – 20-30% of cases of bacterial meningitis and within 72 hours
Subdural effusions – 10-40% with bacterial meningitis
Focal deficits – vascular injury
SIADH – unclear rates, VS, UOP, lytes and osmolality should be monitored closely, fluid restriction

23. Meningitis Exposure Meningococcal Household contacts
High-risk contacts
Day care or nursery school
Intimate contact – contact with secretions or slept or eaten in same dwelling in last 7 days
Passengers on airline sitting next to patient for >8h
Rifampin
Ceftriaxone or cipro
Redbook for dosing and duration

24. Meningitis Exposure Hib Unimmunized or underimmunized children<4y
Immunocompromised household contacts
2 or more cases in child care setting
Rifampin

25. Prognosis Bacterial Meningitis Mortality - 5-10% Intellectual deficits
Hydrocephalus
Spasticity
Blindness
Hearling loss
The neuro sequelae is highest in children with pneumococcal meningitis