1. Bacterial meningitis

2. meningitis An inflammation of the leptomeninges .
bacterial meningitis is a common complication of septicemia in children and must be treated as an emergency.
Caused by :
bacteria, viruses , or rarely fungi .
viral infection of the CNS are much more common than bacterial infection

3. meningitis
Bacterial meningitis is one of the most potentially serious infection ,in infants and older children .
Associated with a high rate of acute complications and risk of long-term morbidity.
The etiology of meningitis in the neonate and the treatment are generally distinct from in older children

4. meningitis
A limited number of bacteria are associated with meningitis in normal hosts .
the principle of supportive management and the initial choice of antibiotics can be generalized.

5. Etiology of meningitis
2 month – 12yr:
S .pneumonia, N . Meningitidis ,H .influenza type b.
H .influenza type b is the most common cause of meningitis in children < 4-yr

6. Etiology and epidemiology of meningitis
2 month : maternal flora and environment .
Group B and D. streptococci
gram – negative enteric bacilli .
and listeria monocytogenes.
may be due H.Influenza type b and nonecapsulate and other pathogens

7. Etiology and epidemiology of meningitis
Lack of immunity ( IgM or igG anti capsular antibody ) to specific pathogens with young age.
recent colonization with pathogenic bacteria .
Close contact with invasive disease ( respiratory tract secration)
Crowding , poverty , black race , male .
Defect in complement (C5- C8 ) associated with recurrent meningococcal infection .

8. Etiology and epidemiology of meningitis
ventricular-peritoneal shunts:
Coagulase negative staphylococci and corynebacteria .
CSF leaks due to fracture cribriform palate or paranasal sinus ( pneumococcal ).
head trauma or neurosurgical procedures ( staphylococci )

9. Etiology and epidemiology of meningitis
Splenic disfunction (sickle cell anemia or asplenia ) increased risk of pneumococcal , H.influenza type b ,rarely meningococcal sepsis and meningitis .
Immuno-suppressed patients with T-cell defects (AIDS, and malygnancy) :
Cryptococcal and L.monocytogens.
Open neural tube defect : Meningomyelocele and lombosacral dermal sinus associated with staphylococci -Aureus and gram – negative .

10. pathogenesis Bacterial meningitis is usually hematogenous.
(endocarditis , pneumonia , or thrombophlebitis , burns , indwelling catheters )
Bacteremia precedes the condition or occur at the same time.
microorganisms leads to nasopharyngeal colonization , replication , invasion , and bacteremia .

11. pathogenesis
Bacteria entry to the CSF through the choroid plexus.and meningeal seeding , binding to specific receptors and production of local cytokines initiates inflammation.
Neutrophilic infiltration , increase vascular premeablity , alterations of blood- brain barrier , and cerebral edema .

12. pathogenesis
Meningitis rarely may be follow bacterial invasive from a contiguous focus of infection ;
Paranasal synusitis , otitis media ,mastoiditis , orbital cellulitis, cranial osteomyelitis , penetrating cranial trauma ,meningomyeloceles ,
More often brain abscesses or epidural or subdural empyema follows contiguous infection .

13. Clinical manifestation
Onset has two patterns;
The more dramatic and less common is sudden onset(< 1 day ) rapidly progressive of shock ,purpura , DIC ,and reduce level of consciousness frequntly resulting in death in 24 hr ( S.pneumoniae , or N. meningitidis )
More often is preceded by several days of upper respiratory tract symptoms or GI symptoms . Subacute 2-3day .(H. influenzae)

14. Clinical manifestation
In the young infants:
fever usually is present and irritablity ,poor feeding , restlessness,may be noted.
signs of meningeal inflammation may be minimal.
Older child :
confusion , back pain , usually Kernig and Brudzinski signs in some children particularly
age < mo are not present

15. Clinical manifestation
Increased ICP
headache , diolopia , emesis , bulging fontanel
3 or 6 nerve paralysis, hypertension with bradicardia ,apnea or hyperventilation ,stupor coma ( brain herniation )
inflammation of the meninges is associated with (headache ,nausea , vomiting , irritability , nuchal regidity , photophobia )
Arthritis ,arthralgia ,myalgia , anemia , petechia ,purpura

16. Clinical manifestation
Papilledema is uncommon .
intracranial abcess , subdural empyema or occlusion of a dural venous sinus
Focal neurologic signs are due to vascular occlusion
(10-20% )
Seizures occur in 20-30%
Seizures that occure on presentation or within the first 4 days of onset are no prognostic significance

18. Clinical manifestation
Seizures
cerebritis, infarction , electrolyte
Alteration of mental status
increased ICP,cerebritis ,hypotension

19. Clinical manifestation
Kernig sign:
Flexion of the hip 90 degrees with subsequent pain with extension of the leg .
Brudzinski sign :
Involuntary flexion of the knees and hips after passive flexion of the neck while supine.

20. diagnosis Blood culture ( reveal responsible bacteria 50-90% ) LP
analysis CSF for WBC count with diff ,protein, glucose ,Gram stain helpful in 90% , culture)
CSF leukocyte count elevated >1000 and neutrophil (75-95%)
In tramatic LP Gram stain ,culture , glucose level may not be influenced.

21. diagnosis when signs of increased ICP are present .
 LP should be performed in every child when bacterial meningitis is suspected. Except :
when signs of increased ICP are present .
Infection at the LP site.
Suspicion of a mass lesion.
Extreme patient instability.
Thrombocytopenia is a relative contraindication.

22. diagnosis Patient in the flexed lateral decubitus position .
Intervertebral space L3-L4 or L4-L5.
 Turbid CSF when CSF leukocyte count >
Pleocytosis may be absent and is a poor prognostic sign.
Pleocytosis with a lymphocytosis may be present during early stage of acute meningitis

23. Differential diagnosis
Acute viral meningoencephalytis( PMN may be prodominant)
Partial treatment of a acute bacterial meningitis .
(glucose , protein , neutrophile are not aletread)
TB ,fungal , spirochete ,,brain abcess , encephalitis bacterial endocarditis with embolism ,subdural empyema , subarachnoid hemmorhage ,
Careful examination CSF ,and additional laboratory tests are important .

24. CSF findings
pressure leukocyte proteinmg/dl glucosemg/dl
Normal mm <4 ,60-70%lymph >50 or75% blood
Bacterial , <40
Partial treat N , N
Viral N , lymph generally N
Abscess N PMN N

25. treatment
Decreasing CSF damage caused by the inflammation response with dexamethasone 0.6mg/kg/24hr for 2 days
Sterilization of CSF .
Supportive therapy :
Maintenance of adequate CNS systemic perfusion.
Treatment shock , DIC, SAIDH , seizures , ICP increased ,apnea ,arrhythmia ,coma .

26. complication Subdural effusion : in 10-30% that asymtomatic in 85-90%.
Seizure ,increased ICP ,nerves palsies ,stroke ,cerebral or cerebellar herniation ,thrombosis venous sinuses,
Subdural effusion :
in 10-30% that asymtomatic in 85-90%.
In Symptomatic patient with increased ICP depressed consciousness aspiration must be done.
Fever alone is not indication of aspiration.

27. treatment Empirical choice must cover S.pneumoniae .
Many of which are Relatively resistance to penicillin (mic0.1-1) is more common than high – level resistance .
Cefotaxime ( mg/kg/24) or ceftrixone (100mg/kg/24) plus vancomycin (60 mg/kg/24).
Cefotaxime and ceftrixone also cover N.meningitidis or H .influenza type b.
if L-monocytogenes is suspected ( infant<2 mo )
Ampicillin 200/kg/24hr plus ceftriaxone .

28. Duration of treatment S. Pneumoniae ( 10 -14 days)
N.Meningitidis ( 7days)
H.influenza (10 days)
Gram negative meningitis should be treated for 3 WK or 2 WK after CSF sterilization .
Patients with evidence of acute bacterial meningitis but no identifiable pathogen cetrixone for7-10 days.

29. repeat CSF examination
Repeat LP indicated ;
in neonate
Gram negative meningitis
In β – lactam resistance S, pneumoniae .
CSF should be sterile within hr

30. Prevention in meningococcal meningitidis
Chemoprophylaxis:
for all close contacts of patients with meningococcal meningitis.
with the rifampin 10mg/kg every 12 hr for 2 days (600mg)
Close contacts :
household,daycare ,direct exposure with oral secration ,

31. Prevention ( H, influenza)
Rifampin should be given to all close family.
20 mg/kg /24hr once each day for 4 days.

32. prognosis Mortality rate H,influenza 8% , meningococcal 15%,
for pneumococcal 25%.
35% survivors have some sequelae;
Deafness: is the most common neurologic sequelae.
30% with pneumococcal meningitis and 10%meningococ ,5-20% H.influ.
seizures ,learning disability ,blindness ,paresis , ataxia , hydrocephallus ,mental retardation

33. Poor prognosis Young age .(< 6mo)
long duration of illness before antibiotic therapy.
late –onset seizure (>4days).
shock ,coma, focal neurologic sign
low or absent CSF WBC in the presence of visible bacteria on gram stain of CSF .
immuno compromised status.

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