1. Prof. Rai Muhammad Asghar Head of Pediatric Department RMC Rawalpindi

2. Bacterial Meningitis

3. Bacterial Meningitis. -Acute Inflammation of meninges
Bacterial Meningitis -Acute Inflammation of meninges - It is associated with acute complications and chronic morbidity - Pattern and treatment of meningitis is different in neonates and older infants - Mortality 5-10% - Long term neurological impairment – % survivors

4. Pathophysiology:. Bacterial infection of meninges follows. bacteraemia
Pathophysiology: * Bacterial infection of meninges follows bacteraemia * Damage is due to host response to infection, not from organism itself - Inflammatory mediators - Activated leucocytes - Endothelial damage * Cerebral edema * Raised intracranial pressure * Decreased cerebral blood flow

5. Causative Organisms:. Neonatal -3 months:. - E- Coli & coliforms
Causative Organisms: Neonatal -3 months: - E- Coli & coliforms - Staphylococcus aureus Pseudomonas aeroginosa - Group B streptococcus - Listeria monocytogenes

6. 3 months – 6 years:. - Haemophilus influenzae
3 months – 6 years: - Haemophilus influenzae - Streptococcus pneumoniae Neisseria meningitidis > 6 years - Neisseria meningitidis - Streptococcus pneumoniae

7. Risk Factors:. - Otitis media. - Sinusitis. - Pneumonia
Risk Factors: - Otitis media - Sinusitis - Pneumonia - CSF rhinorrhea - Splenectomy - Anatomic defects - Immune deficiency - Crowding - Absence of breast feeding for infants 2-5 months

8. Risk Factors:. Defects of Complement & Properdin. system
Risk Factors: Defects of Complement & Properdin system Meningococcal meningitis Splenic dysfunction Pneumococcal & H. Influenzae meningitis T lymphocyte defect L. monocytogens

9. CSF leak across a mucocutaneous. barrier. Pneumococcal meningitis
CSF leak across a mucocutaneous barrier Pneumococcal meningitis Lumbosacral dermal sinus & meningomyelocele Staphlococcal & E – coli meningitis

10. Clinical Features:. Neonates:. -Nonspecific symptoms
Clinical Features: Neonates: -Nonspecific symptoms -Fever / hypothermia -Poor feeding -Vomiting -Irritability -Lethargy -Drowsiness -Seizures

11. Signs. - Bulging, tense anterior fontenelle. - Signs of septicemia
Signs - Bulging, tense anterior fontenelle Signs of septicemia - Signs of meningeal irritation are not present

12. Clinical Features:. Infants / older children. Symptoms. - Fever
Clinical Features: Infants / older children Symptoms - Fever - Headache - Photophobia - Lethargy - Poor feeding / vomiting

13. - Irritability. - Drowsiness. - Loss of consciousness. - Seizures
- Irritability Drowsiness - Loss of consciousness - Seizures - Fever & fits always consider meningitis

14. Signs: - Fever - Neck stiffness - Positive Brudzinski / Kernig signs - Signs of shock - Focal neurological signs

15. - Altered conscious level. - Signs of raised intracranial pressure
- Altered conscious level - Signs of raised intracranial pressure - Papilloedema - Purpuric rash: (Purpuric rash in febrile child Meningococcal disease) - Signs of meningeal irritation are not present till 18 months of age

16. Investigations:. - Blood Culture. 80-90%
Investigations: - Blood Culture % - CSF: Routine examination & Culture - Full blood count, DLC - Blood glucose - Serum Electrolytes - CT scan / MRI – if needed - Scrapings of purpuric rash ( culture)

17. Contraindications to immediate Lumbar Puncture
Contraindications to immediate Lumbar Puncture - Signs of raised intracranial pressure - Severe cardiorespiratory instability - Local infection at site of LP - Coagulopathy - Thrombocytopenia

18. CSF findings in Bacterial meningitis:. - Appearance:. Turbid
CSF findings in Bacterial meningitis: - Appearance: Turbid - White blood cells Increased Predominant Polymorphs - Protein: - Raised ( N=25-40 mg/dl) - Glucose: - Decreased (N= > 60% of blood) - Gram staining- Positive in 70-90% of cases

19. Management:. Don’t delay treatment for investigations
Management: * Don’t delay treatment for investigations * Start with empirical treatment Ceftriaxone 100 mg/kg/24hr - Cefotaxime 200 mg/kg/24hr Benzyl penicillin chloramphenicol -Vancomycin 60 mg/kg/24hr (if resistance or staphylococcal infection is suspected)

20. Treatment:. Neonates. - Cefotaxime or Ceftriaxone +. Aminoglycoside
Treatment: * Neonates - Cefotaxime or Ceftriaxone Aminoglycoside Add ampicillin if Listeria infection is suspected * Steroids have no role

21. Duration of treatment. -S. pneumoniae. 10-14 days. -N. meningitidis
Duration of treatment -S. pneumoniae days -N. meningitidis days -H. Influenzae type b days - Neonatal meningitis 21- days

22. Immediate Complications:. - Seizures. - Raised intracranial pressure
Immediate Complications: - Seizures - Raised intracranial pressure - Cranial nerve palsied - Syndrome of inappropriate ADH secretion - Stroke - Cerebral/ cerebellar herniation - Transverse myelitis - Ataxia -Thrombosis of dural sinuses - Subdural effusions

23. Late Complications:. - Hearing loss. - Mental retardation. - Seizures
Late Complications: - Hearing loss - Mental retardation - Seizures - Hydrocephalus - Language delay - Visual impairment - Behavioral problems

24. Prevention:. - Antibiotic & Vaccination Neisseria meningitidis
Prevention: - Antibiotic & Vaccination Neisseria meningitidis - Rifampicin 10 mg/kg/dose 12 hrly for 2 days - Meningococcal vaccine- A, C, Y, W135 in children > 2 yrs age

25. Haemophilus Influenzae type b:
Haemophilus Influenzae type b: - Rifampicin 20 mg/kg/24 hr OD for 4 days - Hib vaccine 2-6 month age Streptococcus pneumoniae: - No chemoprophylaxis - Vaccination is available (splenectomized patients)

26. Remember:. -Fever with fits-always consider meningitis
Remember: -Fever with fits-always consider meningitis - Signs of meningeal irritation are not present till 18 month of age

27. Thank You