Meningitis in children

lecture of 75 slide

1. Guideline in the Diagnosis and Management of Acute Bacterial Meningitis DR. Magdy Shafik Senior Pediatric Consultant Diploma, M.S , Ph.D of Pediatrics

2. outlines Definition, Incidence Transmission Types Signs & Symptoms ESCMID guildlines in sign and systoms Investigations ESCMID guildlines in Investigations Prevention Vaccination Treatment guildlines

3. Definition Meningitis is the inflammation of the membranes surrounding the brain & spinal cord, including the dura , arachinoid & pia matter . Encephalitis Meningioencephalitis

4. Incidence Meningitis can occur at all ages but it is commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age. It is more common in males than females

5. Transmission The bacteria are transmitted from person to person through droplets of respiratory or throat secretions . Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils , etc .) The incubation period ranges between 2 -10 days . Average 3-5 day

6. Routes of Infection Nasopharynx Blood stream Direct spread (skull fracture, meningo and encephalocele ) Middle ear infection Infected Ventriculoperitoneal shunts. Congenital defects Sinusitis

7. Types Bacterial Viral (aseptic) Fungal Parasitic Non-infectious

8. Another classification : A) Epidemic meningitis: caused by Neiseria meningitides. وهو الميكروب الوحيد القادر علي إحداث تفشيات وبائية B) Non-epidemic meningitis: E.Coli , L isteria monocytogens H.Influenzae type b, S.Pneumoniae

9. Pyogenic Meningitis ETIOLOGY Meningococcal ’ meningitis- N. meningitidis . ( A , B, C and W135 ) are recognized to cause epidemics. The commonest organisms according to age groups are : E.Coli , Group B streptococci, S.Aureus , Listeria Monotocytogene s 0-2 months H.Influenzae type b, S.Pneumoniae , N.Meningitides . 2 months- 2yrs N.Meningitides (serotypes A,B,C, Y & W135) S.Pneumoniae (serotypes 1,3, 6,7) H.Influenzae 2 yrs – 15+yrs

10. Viral meningitis Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following :  Enterovirus (polio virus, Echovirus , Coxsackievirus )  Herpesvirus (Hsv-1,2, Varicella.Z,EBV )  Paramyxovirus (Mumps, Measles)  Togavirus (Rubella)  Rhabdovirus (Rabies)  Retrovirus (HIV)

11. . Is viral encephalitis contagious ? Brain inflammation itself is not  contagious . But the  viruses  that  cause encephalitis  can be. Of course, getting a  virus  does not mean that someone will develop  encephalitis .

12. Is viral meningitis is contagious? Viral meningitis  is the most common type, but it's not usually life-threatening. The enteroviruses that cause  meningitis  can spread through direct contact with saliva, nasal mucus, or feces. ... But while you may become infected with the  virus , you're unlikely to develop   meningitis  as a complication

13. Fungal Meningitis  It’s rare in healthy people , but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression.  The most common agents are Cryptococcus neoformans , Candida , H capsulatum .

14. Signs & Symptoms The symptoms of meningitis vary and depend on the age of the child and cause of the infection. Common symptoms are :  Flu-like symptoms  fever  lethargy  Altered consciousness  irritability  headache  photophobia  stiff neck  Brudzinski sign  Kernig sign  skin rashes  seizures

15. Other symptoms of meningitis in Neonates/infants can include:  Apnea  jaundice  neck rigidity  Abnormal temperature (hypo/hyperthermia)  poor feeding /weak sucking  a high-pitched cry  bulging fontanelles  Poor reflexes

16. Examination  General physical- Check for Consciousness level according to GCS scoring , jaundice or irritability. . Resuscitation : incase of septic shock, or DIC .. . Vitals : temperature , HR, B.P., R/R .  Signs of Increased ICP- Bulging fontanelle , headache, nausea , vomiting , ocular palsies , altered level of consciousness, and papilledema  Fundus: papilloedema  CN palsies: (esp. occulomotor , facial, and auditory)

17.  Meningismus - check for nuchal rigidity with passive neck flexion (gives 'involuntary resistance).  Brudzinski sign (hip & knee flexion with neck movement)  Kernig sign (extend knee with hip flexed)  Hemiparesis.  Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia ).

18. Meningiococcemic rash

19. European Society for Clinical Microbiology and Infectious Diseases (ESCMID) guildlines 2016

20. Strength of recommendation Recommendation Grade ESCMID strongly suport recommondation for use A ESCMID moderately suport recommendation for use B ESCMID marginally suport recommendation for use C ESCMID suport recommendation against use D

21. TABLE. Quality of evidence Class Conclusions based on: 1 Evidence from at least one properly designed randomized controlled trial . ---------------------------------------------------------------------- 2 Evidence from at least one well- designed clinical trial, without randomization ; from cohort or case–control analytic studies ( preferably from >1 centre ); from multiple time series; or from dramatic results of uncontrolled experiments. ---------------------------------------------------------------------------------- 3 Evidence from opinions of respected authorities , based on clinical experience , descriptive case studies.

22. European Society for Clinical Microbiology and Infectious Diseases ( ESCMID ) guildlines 2016 Quality of evidence Neonates with bacterial meningitis often present with nonspecific symptoms . (Level 2) In children beyond the neonatal age the most common clinical characteristics of bacterial meningitis are fever, headache, neck stiffness and vomiting. There is no clinical sign of bacterial meningitis that is present in all patients . . (Level 2)

23. The sensitivity and negative predictive value of Kernig and Brudzinski sign is low in the diagnosis of meningitis and therefore do not contribute to the diagnosis of bacterial meningitis. (Level 2)

24. Recommendation Bacterial meningitis in children can present solely with nonspecific symptoms . .( Grade A ) Characteristic clinical signs may be absent. In all children with suspected bacterial meningitis ESCMID strongly recommends cerebrospinal fluid examination , unless contraindications for lumbar puncture are present.( Grade A )

25. In adults with bacterial meningitis classic clinical characteristics may be absent and therefore bacterial meningitis should not be ruled out solely on the absence of classic symptoms. .( Grade A )

26. Investigations  CBC  Blood culture  LP- D/r, C/s (color, leukocyte count, differential, glucose , protein )  Electrolytes  PCR  Coagulation profile  liver and kidney function  Chest X-ray  CT/ MRI  Blood gases  EEG ,  ECG

27. Contraindication for LP  .Increase intracranial pressure.  .Unstable patient.  .Skin infection at site of LP.  .Thrombocytopenia.  . Papilloedema .

28. European Society for Clinical Microbiology and Infectious Diseases (ESCMID) guildlines 2016 In neonatal meningitis , CSF leukocyte count, glucose and total protein levels are frequently within normal range or only slightly elevated .(level 2) It has been shown that in both children and adults, classic characteristics (elevated protein levels, lowered glucose levels, CSF pleocytosis ) of bacterial meningitis are present in 90% of patients . A completely normal CSF occurs but is very rare . .(level 2)

29. CSF lactate concentration has a good sensitivity and specificity for differentiating bacterial from aseptic meningitis. The value of CSF lactate is limited i n patients who received antibiotic pretreatment or those with other central nervous system disease in the differential diagnosis . .(level 2) CSF lactate level was significantly high in bacterial than viral meningitis CSF culture is positive in 60–90% of bacterial meningitis patients depending on the definition of bacterial meningitis. Pretreatment with antibiotics decreases the yield of CSF culture by 10–20 %. .(level 2)

30. CSF Gram stain has an excellent specificity and varying sensitivity , depending on the microorganism. The yield decreases slightly if the patient has been treated with antibiotic s before lumbar puncture is performed. .(level 2 ) In patients with a negative CSF culture and CSF Gram stain, PCR has additive value in the identification of the pathogen . .(level 2 )

31. Recommendation It is strongly recommended to perform cranial imaging before lumbar puncture in patients with: Focal neurologic deficits (excluding cranial nerve palsies). New-onset seizures. Severely altered mental status (Glasgow Coma Scale score <10). Severely immunocompromised state. In patients lacking these characteristics , cranial imaging before lumbar puncture is not recommended . (grade A)

32. It is strongly recommended to start antibiotic therapy as soon as possible in acute bacterial meningitis patients. (grade A) The time period until antibiotics are administered should not exceed 1 hour . ( grade A) Whenever lumbar puncture is delayed , e.g. due to cranial CT, empiric treatment must be started immediately on clinical suspicion, even if the diagnosis has not been established (grade A)

33. Case definition : suspected case : fever of 38 or more plus one or more of the following: 1- neck stiffness 2– bulging fontanel in children below 2 years

34. Probable case: suspected case with turbidity of C.S.F which means: cells ↑ 80 / m3 protein ↑100 /dl sugar ↓ 40 / dL plus one or more of the following : 1- Gm staing show : - ve : N. meningiococcal (+ Epedmic ) - H.infulnza b + ve : pneumocci 2- antibodies in C .S .F by( latex antigen detection )

35. Confirmed case : confirmed by lab. : 1- C.S. F culture 2- P.C.R

36. Prevention

37. طرق الحد من انتشار المرض اولا : الوقاية العامة من الالتهاب السحائي ثانيا : اجراءت وقائية خاصة بالاطباء وقائية خاصة باماكن التجمعات مثل المنشات التعليمية : ثالثا

38. اولا : الوقاية العامة من الالتهاب السحائي منع الازدحام في المنشاءات التعليمية التهوية الجيدة داخل المنشاءات التعليمية الالتزام ببرنامج التطعيم دلخل المدارس حيث يتم تطعيم السنة الاولي من المراحل التعليمية ( حضانة- ابتدائي – اعدادي – ثانوي) يبتطعيم الالتهاب السحائي اخذ الجرعات الوقائية من عقار الريفابيسين للمخالطين

39. عند اكتشاف حالة مؤكدة 1- حصر جميع المخالطين المباشرين للحالة ومراقبتهم صحيا لمدة 10 ايام. اعطاء المخالطين ريفامبيسين لمدة يومين للقضاء علي حامل الميكروب . عند اكتشاف حالة داخل تجمع مثل مدرسة - معسكر – حضانة يتم اعطاء جميع المخالطين ريفامبيسين

40. How to give Rifampicin Adult: 600 mg twice daily for 2 days Infant more than 2 months of age : 10 mg/kg twice daily for 2 days neonates less than one month : 5 mg/kg twice daily for 2 days N.B ciprofloxacin and cefotriaxone can be given

41. Vaccinations for Meningitis

42. Types of vaccines Live vaccines Live Attenuated vaccines Killed Inactivated vaccines Toxoids Cellular fraction vaccines Recombinant vaccines Small pox variola vaccine BCG Typhoid oral Plague Oral polio Yellow fever Measles Mumps Rubella Intranasal Influenza Typhus Typhoid Cholera Pertussi s Plague Rabies Salk polio Intra-muscular influenza Japanise encephalitis Diphtheria Tetanus Meningococcal polysaccharide vaccine Pneumococca l polysaccharide vaccine Hepatitis B polypeptide vaccine Hepatitis B vaccine

43. the five most common types (or serogroups ) of meningococcal bacteria found are A, B, C, W and Y . No single vaccine protects against all serogroups ; there are separate vaccines against meningococcal ACWY serogroups and the meniningococcal B serogroup

44. A smaller yet steady rise in the occurrence of meningococcal Y disease has also been seen since 2016. Together , meningococcal W and Y disease cause approximately half of the cases of IMD in Australia. Meningococcal B , which historically caused the majority of meningococcal disease in Australia , continues to cause around half of all reported cases of IMD

45. there are two different types of meningococcal vaccine currently available : purified capsular polysaccharide vaccines protein-polysaccharide conjugate vaccines .

46. Meningococcal vaccines available for use Quadrivalent meningococcal ( MenACWY ) conjugate vaccines against A, C, W and Y serogroups Registered age group Formulation Trade name 9 month- 55 years Quadrivalent diphtheria toxoid conjugate Menactra ® ≥2 months Quadrivalent CRM conjugate Menveo ® ≥6 weeks Quadrivalent tetanus toxoid conjugate Nimenrix ®

47. Recombinant meningococcal B ( MenB ) vaccines against B serogroup in infant> 2 months Meningococcal C ( MenC ) conjugate vaccines against C serogroup Registered for primary immunisation in infants aged 6 weeks-12 months in Austerlia

48. 2 types of meningococcal vaccine in Egypt : 1- A,C V accine : ( polysaccraide ) ويعطي جرعة من اللقاح للفئات العمرية الاتية: السنة الاولي من الحضانة اولي ابتدائي اولي اعدادي اولي ثانوي ينصح بعدم اعطاء التطعيم قبل سنتين

49. 2- Quadirivalent vaccine A,C,W,Y ويعطي للمسافرين والحجاج والمعتمرين

50. Meningococcal ( Menactra ) Polysaccharide Diphtheria Toxoid ( D T )Conjugate Vaccine DOSAGE AND ADMINISTRATION Primary Vaccination •  Children 9 month through 23 months of age: Two doses, three months apart. •  Individuals 2 through 55 years of age: A single dose Booster Vaccination:  A single booster dose may be given to individuals 15 through 55 years of age at continued risk for meningococcal disease, if at least 4 years have elapsed since the prior dose .

51. Nimenrix

52. Nimenrix is   Meningococcal polysaccharide vaccine serogroups A, C, W-135 & Y conjugate vaccine   ( TT )which is used to prevent . meningococcal infections INDICATIONS AND CLINICAL USE: active immunization of individuals from 6 weeks to 55 years of age

53. Treatment of bacterial meningitis

54. Empiric antibiotic in-hospital treatment for community-acquired bacterial meningitis S. pneumoniae susceptible to penicillin Reduced Streptococcus pneumoniae antimicrobial sensitivity to penicillin Patient group Amoxicillin/ampicillin/penicillin plus cefotaxime , or amoxicillin/ampicillin plus an aminoglycoside Neonates <1 month old Cefotaxime or ceftriaxone Cefotaxime or ceftriaxone plus vancomycin or rifampicin Age 1 month to 18 years Cefotaxime or ceftriaxone Cefotaxime or ceftriaxone plus vancomycin or rifampici Age >18 and <50 years Cefotaxime or ceftriaxone plus amoxicillin/ampicillin/ penicillin G Cefotaxime or ceftriaxone plus vancomycin or rifampicin plus amoxicillin/ampicillin/penicillin G Age >50 years, or Age >18 and <50 years plus risk factors for Listeria monocytogenesa

55. Key Question . Does dexamethasone have a beneficial effect on death, functional outcome and hearing loss in adults and children with bacterial meningitis

56. Level 1 1- Corticosteroids significantly reduced hearing loss and neurologic sequelae but did not reduce overall mortality . 2- Data support the use of corticosteroids in patients with bacterial meningitis beyond the neonatal age in countries with a high level of medical care. 3- No beneficial effects of adjunctive --corticosteroids have been identified in studies performed in low-income countries. 4- The use of dexamethasone for neonates is currently not recommended.

57. Does the use of prophylactic treatment of household contacts decrease carriage or secondary cases ? It is strongly recommended to treat household contacts and other close contacts of meningococcal meningitis patients with antibiotic prophylaxis consisting of ceftriaxone, ciprofloxacin or rifampicin (grade A)

58. Prophylactic antibiotic treatment of household contacts of meningococcal meningitis patients prevents secondary cases and eradicates meningococcal carriage (level).

59. In children with bacterial meningitis, testing for hearing loss should be performed during admission ( otoacoustic emission). In the case of hearing loss , patients should be referred to an ear–nose–throat specialist in a medical centre performing cochlear implants ( Garde A) What follow-up o f community-acquired bacterial meningitis patients should be provided (e.g. testing for hearing loss, neuropsychological evaluation)?

60. Routine neuropsychologic examination is not recommended. If cognitive defects occur , neuropsychologic examination should be performed , and referral to a ( neuro )psychologist/rehabilitation physician may be indicated . (Grade B).

61. Take Home Massage 1- Meningitis can occur at all ages but it is commonest in infancy . 95 % of the cases take place between 1 month- 5 years of age . 2 - Epidemic meningitis caused by Neiseria meningitides. 3 - viral meningitis and viral encephalitis is not infectious . 4 - Neonates with bacterial meningitis often present with nonspecific symptoms 5 - It has been shown that in both children and adults, classic characteristics (elevated protein levels, lowered glucose levels, CSF pleocytosis ) of bacterial meningitis are present in 90% of patients. A completely normal CSF occurs but is very rare

62. 6- It is strongly recommended to start antibiotic therapy as soon as possible in acute bacterial . meningitis patients 7- Corticosteroids significantly reduced hearing loss and neurologic sequelae . 8- Prophylactic antibiotic treatment of household contacts of meningococcal meningitis patients prevents secondary cases and eradicates meningococcal carriage

63. THANK YOU