Treatment: General Principle• Avoidance of delay• Emperical antibiotic
• Drug entry into CSF —Most drugs reach peak  concentrations in the CSF that are only 10 to  20 percent of peak concentrat...
Immediate management•   Assurance of adequate ventilation and cardiac perfusion.•   Initiation of hemodynamic monitoring• ...
Supportive care• Fluid and electrolyte management —   – Isotonic fluid to maintain blood pressure and cerebral     perfusi...
• In US (nelson)  – 25-50% S.pneumoniae resistant to penicillin  – 25 % S Pneumoniae resistant to cefotax or    ceftraixon...
JIPMER StudyOrganisms were isolated from thecerebrospinal fluid (CSF) in 35% ofcases. Among infants and children, thetwo m...
Emperic Therapy• empiric regimen should include  coverage for Hib, penicillin resistant  S. pneumoniae and N. meningitidis...
Antibiotic Therapy• Certainly Bacterium  – Once the pathogen has been identified and the    antibiotic sensitivities deter...
Dexamethasone• Animal studies:hearing loss is associated with the  severe inflammatory changes• RCT and meta-analyses indi...
Duration of treament•   S. pneumoniae: 10-14 days•   N. meningitidis: 5-7 days•   Hib: 7-10 days•   Gram –ve: 3 weeks•   C...
Bacterial Meningitis -           Treatment       Neonatal (<3 mo)• Ampicillin (covers Listeria)  +• Cefotaxime  – High CSF...
Pneumococcal meningitis
Antibiotic susceptibility• Susceptible• Non-susceptible• Resistant
Pneumococcal resistance• Strep pneumococcus - most common  cause of invasive bacterial infections in  children >2 months o...
Mechanism of resistance• PCN-binding proteins synthesize  peptidoglycan for new cell wall  formation• PCN, cephalosporins,...
Pneumococcal meningitis –           Mgmt• Vancomycin + cefotaxime or  ceftriaxone, if > 1 month old• If hypersensitive (al...
• PCN-susceptible organism:  – PenG 250,000 - 400,000 U/kg/day ÷    Q4-6h  – Ceftriaxone 100 mg/kg/day ÷ Q 12 -    24 h  –...
ROLE OF VANCOMYCIN• Combination therapy since late  90’s• At initiation-  – Baseline urinalysis  – BUN and creatinine• Ent...
Vancomycin use in   pneumococcal meningitis• Vancomycin 60 mg/kg/day ÷ Q 6 h• Trough levels immediately before 3rd  dose• ...
RESISTANT CASES• Meropenem            • Rifampin – Carbapenem            – 20 mg/kg/day ÷ Q – 120 mg/kg/day ÷ Q      12   ...
Dexamethasone Role• Consider if H flu & S pneumo  meningitis & > 6 wks old       0.6  mg/kg/day ÷ Q 6h x 2d∀ ↓ local synth...
Pneumococcal meningitis -          Treatment• LP after 24-48 hours to evaluate  therapy if:  – Received dexamethasone  – P...
Infection control precautions• CDC recommends Standard  Precautions• Airborne, Droplet, Contact are NOT  recommended• Naso...
Meningococcemia - Isolation• Capable of transmitting organism up  to 24 hours after initiation of  appropriate therapy• Dr...
Meningococcemia - Treatment• Antibitotic resistance rare• Antibitotics:  – PCN  – Cefotaxime or Ceftriaxone• Patient shoul...
Meningococci – Care Takers• Day care where child attends >25 h/  wk, kids are >2 years old, & 2 cases  have occurred• Day ...
Meningococcemia - Prophylaxis• No randomized controlled trials of  effectiveness• Treat within 24 hours of exposure• Vacci...
• Rifampin  – Urine, tears, soft contact lenses orange;    OCP’s ineffective  – <1 mo 5 mg/kg PO Q 12 x 2 days  – >1 mo 10...
Meningococcal meningitis -           Outcomes• Substantial morbidity: 11% - 9% of  survivors have sequelae  – Neurologic d...
Summary• Antibiotics ASAP, even if LP not yet done• Vanco + cephalosporin until some  identification known  – CSF, Latex, ...
Meningitis - Treatment duration•   Neonates: 14 – 21 days•   Gram negative meningitis: 21 days•   Pneumococcal, H flu: 10 ...
Out patient therapy• Completion of at least 6 days of inpatient  therapy• Afebrile for at least 24 to 48 hours before  ini...
Response to therapy• duration of fever is typically four to six  days after the initiation of adequate  therapy• Persisten...
Repeat CSF• Poor clinical response after 24-36 hours of  antibiotics• Persistence or recurrence of fever• Gram –ve meningi...
Neuroimaging• Focal neurologic signs, increasing head  circumference, or prolonged obtundation,  irritability, or seizures...
Prognosis• Mortality:meta-analysis: 4520 children  4.8 %in developed countries and 8.1 % in  developing countries• Hib:3.8...
Poor prognostic factors•   Etiology: more with pneumocaccal•   Seizure after 72 hours•   CSF sugar < 20 mg per dl at admis...
Meningitis - Acute complications                • Hydrocephalus                • Subdural effusion                  or emp...
Complications of meningitis in infants andchildren.- Hearing loss is the most encountered sequelae; it occurs        * in ...
• Thrombocytosis, eosinophilia, and anemia may  develop during therapy for meningitis. Anemia  may be due to hemolysis or ...
Bacterial meningitis - Outcomes• Neonates: ~20% mortality• Older infants and children:  – <10% mortality  – 33% neurologic...
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  • Spinal fluid levels in normal infants are approximately 10-20% of the serum concentrations and may reach 50% when the meninges are inflamed. Amikin has been demonstrated to cross the placental barrier and yield significant concentrations in amniotic fluid It penetrates into the cerebrospinal fluid in the presence of inflamed meninges. Because piperacillin sodium is excreted by the biliary route as well as by the renal route, it can be used safely in appropriate dosage
  • Resistant organisms do NOT cause more sggressive disease
  • Add Vancomycin for neonate, if CSF suspicious of pneumococcus
  • Conflicting results of small studies May decrease fever, giving false impression of improvement
  • No randomized controlled trials of the effects of prophylaxis among contacts Abx eradicate throat carriage No evidence that doing this reduces the risk of meningococcal disease
  • Recurrent fever may be associated with subdural effusion, abscess, drug fever. May warrant repeat LP. Effusions may or may not need intervention – depends on if it is increasing or causing neurologic sxs.
  • Neurologic abnormalities include: cranial nerve dysfunction paresis hyper/hypotonia ataxia seizure disorder blindness language delay mental retardation behavioral problems
  • Presentation2

    1. 1. Treatment: General Principle• Avoidance of delay• Emperical antibiotic
    2. 2. • Drug entry into CSF —Most drugs reach peak concentrations in the CSF that are only 10 to 20 percent of peak concentrations in the serum. This is because the blood-brain barrier blocks macromolecule entry into the CSF, with small, lipophilic molecules penetrating most easily.• The peak concentration of drugs in CSF increases with inflammation of the blood-brain barrier. The mean CSF/serum ratio two hours after administration of the same intravenous dose of penicillin was 42 percent on the first day of therapy but fell to less than 10 percent on the tenth day, when the inflammatory changes had subsided
    3. 3. Immediate management• Assurance of adequate ventilation and cardiac perfusion.• Initiation of hemodynamic monitoring• Establishment of venous access.• Administration of fluids as necessary to treat septic shock, if present.• Administration of dexamethasone if warranted. before or immediately after the first dose of antimicrobial therapy.• Administration of the first dose of empiric antibiotics• Administration of glucose (0.25 g/kg) for documented hypoglycemia (serum glucose concentration less than 40 mg/dL• Treatment of acidosis and coagulopathy
    4. 4. Supportive care• Fluid and electrolyte management — – Isotonic fluid to maintain blood pressure and cerebral perfusion. – Children who are hypovolemic, but not in shock, should be rehydrated with careful and frequent attention to fluid status. – For children who are neither in shock nor hypovolemic, moderate fluid restriction (1200 mL/m2 per day) initially, especially if the serum sodium is less than 130 meq/L. Fluid administration can be liberalized gradually as the serum sodium reaches 135 meq/L. Most children can receive maintenance fluid intake within 24 hours of hospitalization.• Monitoring — – increased intracranial pressure, seizure activity, development of infected subdural effusions, particularly during the first two to three days of treatment, – Heart rate, blood pressure, and respiratory rate should be monitored regularly with a frequency appropriate to the care setting. – A complete neurologic examination should be performed daily; rapid assessment of neurologic function should be performed several times per day for the first several days of treatment. – Head circumference should be measured daily in children younger than 18 months
    5. 5. • In US (nelson) – 25-50% S.pneumoniae resistant to penicillin – 25 % S Pneumoniae resistant to cefotax or ceftraixone – 30-40 % Hib resistant to ampicillin• In INDIA ?
    6. 6. JIPMER StudyOrganisms were isolated from thecerebrospinal fluid (CSF) in 35% ofcases. Among infants and children, thetwo major pathogens were H. influenzae(17%) and S. pneumoniae (12%).RESULTS: The illness at presentationwas mild in 13% and severe in 36% ofcases. The
    7. 7. Emperic Therapy• empiric regimen should include coverage for Hib, penicillin resistant S. pneumoniae and N. meningitidis. E.coli in young infants• High dose of 3rd generation cephalosporin + Vancomycin
    8. 8. Antibiotic Therapy• Certainly Bacterium – Once the pathogen has been identified and the antibiotic sensitivities determined, the most appropriate drugs should selected. • N meningitidis : penicillin, tert- cephalosporin • S pneumoniae: penicillin, tert- cephalosporin, vancomycin • H influenzae: ampicillin, tert- cephalosporin • S aureus: penicillin, nefcillin, vancomycin • E coli: ampicillin, chloramphenicol, tert- cephalosporin
    9. 9. Dexamethasone• Animal studies:hearing loss is associated with the severe inflammatory changes• RCT and meta-analyses indicate that dexamethasone therapy provides no survival advantage in children, but reduces the incidence of deafness and severe neurologic complications in selected children, predominantly those with meningitis caused by Hib. The data are insufficient to demonstrate a clear benefit in children with pneumococcal meningitis• before or within one hour of the first dose of antibiotic therapy• concern that the CSF concentration of vancomycin may be diminished when administered with dexamethasone• > 6 weeks of age• 0.15 mg/kg per dose) every 6 hours for 2 to 4 days
    10. 10. Duration of treament• S. pneumoniae: 10-14 days• N. meningitidis: 5-7 days• Hib: 7-10 days• Gram –ve: 3 weeks• CSF analysis near the end of therapy, particularly in young infants, needs longer therapy if – Percentage of neutrophils >30 percent, – or CSF glucose concentration <20 mg/dL
    11. 11. Bacterial Meningitis - Treatment Neonatal (<3 mo)• Ampicillin (covers Listeria) +• Cefotaxime – High CSF levels – Less toxicity than aminoglycosides – No drug levels to follow – Not excreted in bile ∴ not inhibit bowel flora
    12. 12. Pneumococcal meningitis
    13. 13. Antibiotic susceptibility• Susceptible• Non-susceptible• Resistant
    14. 14. Pneumococcal resistance• Strep pneumococcus - most common cause of invasive bacterial infections in children >2 months old• Incidence of PCN-, cefotaxime- & ceftriaxone-nonsusceptible isolates has ↑’d to ~40%• Strains resistant to PCN, cephalosporins, and other β-lactam antibiotics often resistant to trimethoprim-sulfamethoxazole (Bactrim™, Septra™), erythromycin, chloramphenicol, tetracycline
    15. 15. Mechanism of resistance• PCN-binding proteins synthesize peptidoglycan for new cell wall formation• PCN, cephalosporins, and other β- lactam antibiotics kill S pneumoniae by binding irreversibly to PCN-binding proteins located in the bacterial cell wall• Chromosomal changes can cause the binding affinity for the β-lactam
    16. 16. Pneumococcal meningitis – Mgmt• Vancomycin + cefotaxime or ceftriaxone, if > 1 month old• If hypersensitive (allergic) to β-lactam antibiotics, use vancomycin + rifampin• D/C vancomycin once testing shows PCN-susceptibility• Consider adding rifampin if susceptible & condition not improving, or cefotaxime or ceftriaxone MIC high• Not vancomycin alone
    17. 17. • PCN-susceptible organism: – PenG 250,000 - 400,000 U/kg/day ÷ Q4-6h – Ceftriaxone 100 mg/kg/day ÷ Q 12 - 24 h – Cefotaxime 225 - 300 mg/kg/day ÷ Q 8 h – Chloramphenicol 50 - 100 mg/kg/day ÷Q6h• Adequate cephalosporin levels in CSF ~2.8 hours after dose administration
    18. 18. ROLE OF VANCOMYCIN• Combination therapy since late 90’s• At initiation- – Baseline urinalysis – BUN and creatinine• Enters the CSF in the presence of inflamed meninges within 3 hours• Should not be used as solo agent, but with cephalosporin for synergy
    19. 19. Vancomycin use in pneumococcal meningitis• Vancomycin 60 mg/kg/day ÷ Q 6 h• Trough levels immediately before 3rd dose• (10-15 mcg/mL or less)• Peak serum level 30-60 minutes after completion of a 30-minute infusion (35-40 mcg/mL)
    20. 20. RESISTANT CASES• Meropenem • Rifampin – Carbapenem – 20 mg/kg/day ÷ Q – 120 mg/kg/day ÷ Q 12 8h – Not a solo agent ↑ seizure – Slowly incidence, ∴ not bactericidal generally used in meningitis – Resistance reported
    21. 21. Dexamethasone Role• Consider if H flu & S pneumo meningitis & > 6 wks old 0.6 mg/kg/day ÷ Q 6h x 2d∀ ↓ local synthesis of TNF-α, IL-1, PAF & prostaglandins resulting in ↓ BBB permeability, ↓ meningeal irritation• Debate if it ↓ incidence of hearing loss• If used, needs to be given shortly before or at the time of antibiotic administration• May adversely affect the penetration of antibiotics into CSF
    22. 22. Pneumococcal meningitis - Treatment• LP after 24-48 hours to evaluate therapy if: – Received dexamethasone – PCN-non-susceptible – MIC’s not available – Child’s condition not improving
    23. 23. Infection control precautions• CDC recommends Standard Precautions• Airborne, Droplet, Contact are NOT recommended• Nasopharyngeal cultures of family members and contacts is NOT recommended• No isolation of contacts• No chemoprophylaxis for contacts
    24. 24. Meningococcemia - Isolation• Capable of transmitting organism up to 24 hours after initiation of appropriate therapy• Droplet precautions x 24 hours, then no isolation• Incubation period 1 - 10 days, usually <4 days
    25. 25. Meningococcemia - Treatment• Antibitotic resistance rare• Antibitotics: – PCN – Cefotaxime or Ceftriaxone• Patient should get rifampin prior to discharge
    26. 26. Meningococci – Care Takers• Day care where child attends >25 h/ wk, kids are >2 years old, & 2 cases have occurred• Day care where kids not all vaccinated• Persons who have had “intimate contact” w/ oral secretions prior & during 1st 24 h of antibiotics• “Intimate contact” – 300-800x risk (kissing, eating/ drinking utensils, mouth-to- mouth, suctioning, intubating)
    27. 27. Meningococcemia - Prophylaxis• No randomized controlled trials of effectiveness• Treat within 24 hours of exposure• Vaccinate affected population, if outbreak
    28. 28. • Rifampin – Urine, tears, soft contact lenses orange; OCP’s ineffective – <1 mo 5 mg/kg PO Q 12 x 2 days – >1 mo 10 mg/kg (max 600 mg) PO Q 12 x 2 days• Ceftriaxone ≤12 y 125 mg IM x 1 dose – >12 y 250 mg IM x 1 dose• Ciprofloxacin ≥18 y 500 mg PO x 1 dose
    29. 29. Meningococcal meningitis - Outcomes• Substantial morbidity: 11% - 9% of survivors have sequelae – Neurologic disability – Limb loss – Hearing loss• 10% case-fatality ratio for meningococcal sepsis• 1% mortality if meningitis alone
    30. 30. Summary• Antibiotics ASAP, even if LP not yet done• Vanco + cephalosporin until some identification known – CSF, Latex, exam• Isolate if bacterial x 24 hours, Universal Precautions• Monitor for status changes – Pupils, LOC, HR, BP, resp – Seizures – Hemodynamics – DIC, coagulopathy – Fluid, electrolyte issues
    31. 31. Meningitis - Treatment duration• Neonates: 14 – 21 days• Gram negative meningitis: 21 days• Pneumococcal, H flu: 10 days• Meningococcal: 7 days
    32. 32. Out patient therapy• Completion of at least 6 days of inpatient therapy• Afebrile for at least 24 to 48 hours before initiation of outpatient therapy.• No significant neurologic dysfunction or focal findings.• No seizure activity.• Clinical stability.
    33. 33. Response to therapy• duration of fever is typically four to six days after the initiation of adequate therapy• Persistence of fever beyond 8 days and secondary fever have a number of causes, including: – Inadequate treatment – Development of nosocomial infection – Discontinuation of dexamethasone – Development of a suppurative complication (pericarditis, pneumonia, arthritis, subdural empyema) – Drug fever (a diagnosis of exclusion)
    34. 34. Repeat CSF• Poor clinical response after 24-36 hours of antibiotics• Persistence or recurrence of fever• Gram –ve meningitis
    35. 35. Neuroimaging• Focal neurologic signs, increasing head circumference, or prolonged obtundation, irritability, or seizures (>72 hours after the start of treatment);• Persistently positive CSF cultures despite appropriate antibiotic therapy• Persistent elevation of CSF neutrophils at the completion of standard duration of therapy (more than 30 to 40 percent)• Recurrent meningitis
    36. 36. Prognosis• Mortality:meta-analysis: 4520 children 4.8 %in developed countries and 8.1 % in developing countries• Hib:3.8 %, N. meningitidis: 7.5 %, S. pneumoniae: 15.3 %• Neurological sequele:16% in developed and 26 % in developing countries – Deafness — 11 percent, including bilateral severe or profound deafness in 5 percent – Mental retardation — 4 percent – Spasticity and/or paresis — 4 percent – Seizures — 4 percent
    37. 37. Poor prognostic factors• Etiology: more with pneumocaccal• Seizure after 72 hours• CSF sugar < 20 mg per dl at admission• Delayed sterlization of CSF : > 24 hours
    38. 38. Meningitis - Acute complications • Hydrocephalus • Subdural effusion or empyema ~30% • Stroke • Abscess • Dural sinus thrombophlebitis
    39. 39. Complications of meningitis in infants andchildren.- Hearing loss is the most encountered sequelae; it occurs * in 30% cases of S. pneumoniae meningitis, * in 20% of H. influenzae meningitis, * in 10% of N. meningitidis meningitis.– Mental retardation, seizures, delay in language acquisition,visual impairment, behavioural problems and hydrocephalus.
    40. 40. • Thrombocytosis, eosinophilia, and anemia may develop during therapy for meningitis. Anemia may be due to hemolysis or bone marrow suppression.• DIC is most often associated with the rapidly progressive pattern of presentation and is noted most commonly in patients with shock and purpura.• The combination of endotoxemia and severe hypotension initiates the coagulation cascade; the coexistence of ongoing thrombosis may produce symmetric peripheral gangrene.
    41. 41. Bacterial meningitis - Outcomes• Neonates: ~20% mortality• Older infants and children: – <10% mortality – 33% neurologic abnormalities at discharge – 11% abnormalities 5 years later• Sensorineural hearing loss 2 - 29%
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