Acute bacterial (Pyogenic) meningitis - Dr. S. Srinivasan, Professor of Pediatrics

Acute bacterial (Pyogenic)meningitis - Dr. S. Srinivasan, Professor of Pediatrics

1. Acute Bacterial ( Pyogenic ) Meningitis S.Srinivasan Professor of Paediatrics MGMCRI, Pillayarkuppam Puducherry S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February 2016

2. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children

3. Definition Etiology Predisposing Factors Pathogenesis Symptoms & Signs Acute Bacterial ( Pyogenic ) Meningitis in Children S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Diagnosis Differential Diagnosis Complications Prognosis Treatment Follow Up

4. Definition Acute Inflammation of the meninges ( the protective membranes covering the brain and spinal cord ) caused by Bacterial ( pyogenic ) organisms S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children

5. Neonatal Meningitis: Causative Bacteria Age Most Common Bacteria <1 month Escherichia coli Group B streptococci Enterobacteria Listeria monocytogenes Haemophilus influenzae Coagulase negative staphylococci (in hospital) Streptococcus pneumoniae Acute Bacterial ( Pyogenic ) Meningitis in Children

6. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 AGE Bacteria causing Ac.Bact.Meningitis Neonates & Infants < 2 mths Escherichia coli, Staph.aureus , Gram Negative bacteria (hospital flora); Listeria monocytogenes , Gp.B Strep., 2 mths – 3 to 5 years H. influenzae , Strep. pneumoniae , N eisseria memingitides Beyond 5 yrs S trep. pneumoniae ( 1,3,6,7), N eisseria meningitides (A,B,C), H. influenzae Acute Bacterial Meningitis

7. Post-Neonatal Childhood Bacterial Meningitis 1 to 23 months Strep. pneumoniae Neisseria meningitides Group B streptococci Haemophilus influenzae 2 to 18 years Neisseria meningitides Streptococcus pneumoniae Haemophilus influenzae Causative Bacteria Acute Bacterial ( Pyogenic ) Meningitis in Children S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

8. Bacterial Culture positivity rate in Post Neonatal Childhood Bacterial Meningitis Hemophilus influenzae 40 - 70% Streptococcus pneumoniae 30 - 40% Neisseria meningitides 10 -20 % Streptococcus pyogenes <10 % Culture Negativity <20% < Varies with age of the child > S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

9. Predisposing Risk Factors Sinusitis, Mastoiditis , Otitis . Spleen : Asplenia , Functional / Anatomical Trauma, or Removal : Pneumococcal Bacterial Meningitis. Compromised Immune System: HIV    S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Others Neurosurgery Head Trauma, Parameningeal Infection, Anatomical Def. of cranium , Spinal cord & Meninges

10. Risk Factors in Neonatal Meningitis Maternal infections during delivery PROM Prolonged, diffcult delivery with frequent PV Exams Preterm babies Neural tube Defects – Spina Bifida Occulta , Pilonidal Sinus S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

11. Pathogenesis Inflammation of Spinal Nerves & Roots Signs of Meningeal irritation Adhesive thickening of Arachnoid in basal cisterns Hydrocephalus Fibrosis & Obstn of Aqueduct of Sylvius &/or Foramina of Luschka &/or Magendie Endarterial & small cortical venous Thromboembolic episodes Cerebral infarctions and atrophy Neuronal membrane depolarization Seizures Transcellular Electrolyte imbalance

12. Pathogenesis of Ac.Bacterial Meningitis Haematogenous ( mostly ); Spread from local site infections Entry of bacteria through BBBarrier Ac.Bacterial Meningitis Cellular reaction with outpouring of Polymorphs & fibrin Release of Cytokines , Chemokines & Inflammatory Mediators Release of cell wall & membrane debris on cell death Meningeal Exudative Inflammation Vascular Compromise Inflammatory Cerebral Oedema Increased Intracranial tension and pressure ( coning ) effects S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

13. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Symptoms & Signs Acute Bacterial Meningitis

14. Altered sensorium Bulging fontanelle Headache Convulsions Nuchal rigidity Opisthotonus Hypothermia Coma Symptoms in infants and children Fever Irritability Excessive fussiness Altered Behaviour Refusal of feeds Lethargy Anorexia Nausea Vomiting Photophobia S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

15. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

16. General Physical Examination S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Breathing, Airway &Circulation : Adequate/Compromised Altered Sensorium and Severity , Coma Scale Vital Parameters: Temperature,Pulse,BP , Respn : Rate,Type , Regularity, CFT, Hydration Status Skin : Mottling, Color change,of vascular compromise Purpura , Infections, Dermal sinus, & other stigma of Spina Bifida Occulta ,

17. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

18. Skin in Acute Bacterial Meningitis Complications S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

19. Examination for signs of Meningeal Irritation Meningismus Nuchal stiffness / rigidity Kernig’s Sign Brudzinski’s neck – leg sign Brudzinski’s crossed leg sign Higher Functions Cranial Nerves Motor-coordination Neurological Signs S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

20. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Elicitation of Meningeal Signs Brudzinski’s contralateral reflex sign The childt’s hip and knee are passively flexed on one side Contralateral leg bends in reflex response

21. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

22. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

23. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Investigations in Acute Bacterial Meningitis Complete Blood Count LP: CSF Examination Microscopy- Colour , Cells, opening Pressure Biochemistry: Glucose, Proteins Gram staining Blood & CSF Culture Electrolytes; ABG in severe cases Chest x-ray CT/MRI Scans EEG PCR Others

24. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 CONTRAINDICATIONS FOR PERFORMING LUMBAR PUNCTURE IN CHILDREN Increased ICP Papilloedema Unstable Child – Shock, Resp.depression , low GCS Infection in the local site Severe Thrombocytopenia / DIC

25. CSF Findings in CNS Infections infection Pressure WBC /µL Glucose Protein Ac Bacterial meningitis 200-300 100-5000; > 50%PMN < 40mg/dl > 100 mg/dl TBM 100 - 300 100 – 500 Lymphocytes Low; <40 mg/dl Elevated; >100mg/dl Viral meningitis 90-200 10-300; Lymphocytes Normal or Less in Mumps /LCM Normal or slight rise Aseptic Meningitis 50 - 200 10 – 300 Lymphocytes Normal Normal or slight rise Cryptococcal 100-300 <500; Lymphocytes Low 50-200 NORMAL 80-200 <5 Lympho-cytes 50-75mg/dl 15-40mg/dl S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

26. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

27. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

28. Non-motile Gram-negative, coccobacillary , facultatively anaerobic bacterium, and it’s Oxidase and Catalase postive S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

29. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

30. Other Investigations S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Detects Latex Particle Agglutination Of C.S.F Specific Bacterial Antigen H.influenzae , S.pneumoniae , N.memingitidis , E.coli , etc Countercurrent ImmunoElectrophoresis Smears from purpuric spots –Grams staining S.pneumoniae,N.memingitidis , DNA Sequencing Advanced centers Bacterial identification S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

31. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial Meningitis - DIFFERENTIAL DIAGNOSIS Partially treated Meningitis Viral Encephalitis Cerebral Malaria Tuberculous Meningitis Enteric Encephalopathy Leptospirosis Metabolic/ Toxic Encephalopathies Dengue Haemorrhagic Fever

32. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Complications Increased Intracranial tension & coning pressure effects Subdural Effusion Septicaemia & Septic Shock Seizures SIADH Acute Hydrocephalus Cranial Nerve paralysis DIC Purpura Fulminans and Gangrene

33. ? Complication S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

34. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

35. Complications Commoner after bacterial meningitis than after viral meningitis Sensorineural hearing loss: partial or total Seizure and Epileptic State Cognitive problems: Memory and concentration; Learning difficulties and behavioural problems Motor Problems involving co-ordination and balance  Speech problems Visual disturbances Cerebral Palsy S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

36. Greatest risk for hearing loss 1 Males 2 Nuchal Rigidity 3 Increased ICP 4 Low CSF glucose levels 5 S Pneumoniae  Infection 6 Abnormal CT Scan Findings S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

37. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 S pneumoniae  : 26.3-30% Hib : 7.7-10.3%;   N meningitidis  : 5-10.3%. Overall mortality for bacterial meningitis 5-10% Neonates: 15-20% Older children: 3-10%. Neurologic Sequelae : 30%

38. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Age: Neonates, Preterms Organisms: Pneumococci > H.imfluenzae > Meningococci Gm – ve Organisms, Salmonellae and Enterobacteriaceae DIC Endotoxic shock Neural tube Anomalies Immunosuppresse individuals. Poor Prognostic Factors

39. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Poor Prognosis for Bilateral Sensoryneural Hearing Loss Males Increased Nuchal Rigidity Prolonged Sezures Low Coma Score Low CSF glucose levels S pneumoniae  infection  Abnormal CT findings

40. 4% -6% of all bacterial meningitis cases 1 in 4 survivors had : Serious and disabling sequelae Functionally important behavior disorder or neuropsychiatric problem Auditory dysfunction that impaired their performance in school Prognosis

41. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

42. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

43. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

44. Empiric Antibiotic Treatment in childhood Acute Bacterial Meningitis S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

45. Organism Age Group Antibiotic Unknown Infants less than 1 month Ampicillin Cefotaxime Gentamicin Children over 1 month of age and Adults Ampicillin Cefotaxime Vancomycin S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Unidentified Gram-negative bacilli Children and Adults Cefazidime Gentamicin -Unidentified Gram positive organisms Children and Adults Ceftriaxone Vancomycin Ampicillin

46. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Haemophilus influenzatype b Ceftriaxone Meningococci Penicillin G plus ceftriaxone

47. STREPTOCOCCI Vancomcin Nafcillin (with or without rifampin ) LISTERIA SP Ampicillin Gentamicin Trimethoprim-sulfamethoxaxzole ENTERIC GRAM-NEGATIVE BACTERIA(ESCHERICHIA COLI, PROTEUS SP, KLEBSIELLA SP) Ceftriaxone Gentamicin PSEUDOMONAS Ceftazidime Cefepime *These may be used with the addition of aminoglycoside STAPHYOCOCCI Vancomycin Nafcillin *May be prescribed with or without rifampin S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016

48. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children Treatment of Complications 1) Convulsions: I.V.Diazepam 2) Cerebral Oedema : Mannitol ; i.v.dexamethasone 3) Drainage of Subdural Empyema 4) Surgical management of Hydrocephalus

49. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children Supportive Treatment 1) Correction of Fluid and Electrolyte Disturbances 2) Control & Maintenance of normal body temperature 3) Control of Convulsions ( Anticonvulsant drugs) 4) Control of increased intracranial pressure and cerebral odema 5) Care of comatose /unconscious child ( Skin, Eyes, Bladder , Bowel, Lungs )

50. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children Supportive Treatment 6) Protocol based Management of Septic Shock with Fluids, Electrolyte & Inotropes 7) Management of Disseminated Intravascular Coagulation 8) Nutritional Support 9) Monitoring of head circumference, vital parameters, Intracranial tension, response to drugs

51. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Acute Bacterial ( Pyogenic ) Meningitis in Children Supportive Treatment 10) Treatment of Complications like hydrocephalus, subdural empyema , etc.,

52. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Immunization Routine Immunization with available vaccines against Haemophilus , Pneumococcus Meningococcus ( Routine or in, High Risk Children) Vaccination before travelling to endemic areas

53. S.Srinivasan , Professor of Paediatrics , MGMCRI, Pillayarkuppam , Puducherry 8 th &9 th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19 TH February2016 Prevention of Acute Bacterial Meningitis Antibiotic Chemoprophylaxis with Antibiotics given to close contacts H.influenzae type B Rifampicin 20mg/kg/day for 4 days N. Meningitidis Rifampicin 20mg/kg/day or 600mg oral for 2 days in older children Ceftriaxone single dose Ciprofloxacin single dose