Meningitis pediatric

1. Group members
1. Nitsukal Gulilat
2. Miheret Biratu
3. Mesfin Abreham
4. Rediet Assefa
5. Misgana Tonja
6. Mebrat G/yesus
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2. • Comma secondary to complicated pyogenic meningitis; ?clinical
malaria; moderately acute malnutrition
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3. Presentation Outline
• Case identification
• Case Summary/HPI/
• Subjective findings
• Objective findings
• Assessment
• Current Medication
• Drug therapy problem
• Pharmaceutical Care
• Follow up and Monitoring evaluation
• Patient education
• References
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4. 1. Case Identification
• Card no:14537/15
• Name..... B.B
• Sex: ............M
• Age:........... 10
• Weight: ......27
• Admission date:28/06/2015
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2. Chief Compliance(C/C):
• Failure to communicate of 4 hours duration.

5. 3. HPI(History of Present illness):
• This is a ten years old male child who relatively health three days back at
which time he developed non barking, non whooping cough of four days
duration and abnormal body movement characterized by flexion and extension
of extremities, up rolling of eye, drawing of saliva of one day duration each
lasting 3-5 minutes.
• He also have global type headache and high grade persistent fever of two days
duration for this compliant he was taken to local health center where he was
given unspecified PO and IV medication but he hasn’t shown improvement
and referred to our hospital for better evaluation and management with
diagnosis of coma 2º to complicated pyogenic meningitis.
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6. 3. HPI(History of Present illness): {cont’d}
• Then on the next day of admission the child developed abnormal body
movement characterized by flexion and extension of extremities and up rolling
of eyes two episodes per day each lasting more than three minutes.
other wise he has no history of :- cough or contact with chronic cough
N TB diagnosed person.
- yellow discoloration of eyes
- herbal medicine intake
He is the second child of the family with total family size of 5 living in two
room with separate kitchen and one door one window. He is now on family
diet. He is grade three student with good grade.
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7. 4. Subjective Information
• FHx: -
• SHx: -
• Immunization: He is vaccinated according to EPI
• Drug allergy: -
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8. 5. Objective Information
• PMHx:
• PMnHx:
• P/E(Pertinent Only)
 GA: comatose
HEENT: pink conjunctivas
CVS: S1 and S2 well heard no murmur no gallop
Chest: clear chest with good air entry
Abdomen: full abdomen moves with respiration
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9. IGS: no rush, no pallor
MSS: no edema , no gravis, deformity
CNS: lethargic
• GCS : E 2, V 2, M 3 = 7/15
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5. Objective Information(cont’d)

10. Investigations( Imaging and Laboratory results)
• CBC N
• WBC 10.89 H 3.6-10.2
• RBC 3.84- L 4.06-5.63
• HGB 12.3 L 12.5-16.3
• HCT 34.7 L 36.7-47.1
• NEU 79.3 H 43.5-73.5
• MONO 9.0 L 15.2-43.3
• EOS 0.1 L 0.8-8.1
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 Anthropometry
Wight 27 kg
Height 143 cm
BMI/age 13 kg/m2 (14.2 – 19.4 kg/m2)
Ht/age b/n 0 & 1

11. Vital sign(V/S):
Date
(in E.C)
PR
(beats/mi
n)
RR
(breath/mi
n)
Temp.
(ºC)
BP
(mmHG)
Oxygen saturation
On O2 Off O2
28/06/15 128 26 39.4 109/73 87%
29/06/15 99 21 38.1 107/64 99%
30/06/15 109 22 37.1 110/65 96%
01/06/15 106 24 36.9 110/70 _
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12. 6. Assessment/Diagnosis:
• Coma secondary to complicated pyogenic meningitis + ?clinical malaria +
Moderate acute malnutrition.
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13. 7. Current Medications:
S.N indications Current medication Start date Stop date
1. Pyogenic meningitis Ceftriaxon 100 mg/kg/day IV BID 28/06/15
2. for MRSA converge Vancomicin 60 mg/kg/day IV TID 28/06/15
3. Clinical malaria Artsunate 2.4 mg/kg/day IV QD 28/06/15 02/07/15
4 Seizure 2º to p. meningitis Phenobarbital 20 mg/kg LD then
MD 5 mg/kg/day PO BID
- -
5. increasd ICP Manitol 500 mg/kg IV LD then
MD 250 mg/kg IV TID MD
28/06/15
6. Suspected brain absesse Mertrindazol 30 mg/kg/day IV TID 30/06/15
7. Suspected HSV encephalitis Acyclovir 80 mg/kg/day IV QID 29/06/15
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14. 8. Pharmaceutical care
• Goal of therapy:
 Control seizure and stabilize our patient
 Eradicate infections
 Decrease singe and symptoms
 Prevention of neurologic sequelae, such as seizures, deafness, coma,
and death
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15. • Pharmaceutical assessment/DTP:
S.N Drug relate needs Drug therapeutic problems Recommendations given
_ _ _
_ _ _
_ _ _
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8. Pharmaceutical care(cont’d)

16. • Pharmaceutical intervention
• Proceed with current management
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8. Pharmaceutical care(cont’d)

17. 9. Monitoring and follow-up Evaluations
(Effectiveness and Safety)
• Vital signs
• Clinical sign and symptoms
• Neuro sign chart
• GCS
• CSF Analysis
• Brain CT scan
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18. 10. Patient Education Points:
• Adhere to the treatment.
• Take more care until the boy is seizure free.
• Give balanced, fortified foods And additional meal in order to
correct MAM.
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19. Pyogenic meningitis
• is an inflammation of the membranes of the brain or spinal cord, i.e. of the dura
matter or the pia-arachnoid matter in response to bacterial infection
• Characterized by an intense headache, fever, intolerance to light and sound and
rigidity of muscles (neck)
• Causes(Ethiology): common
• Streptococcus pneumoniae: Causes Pneumococcal Meningitis (~50%)
• N. meningitidis: Causes Meningococcal Meningitis (~25%)
• Group B streptococci (~15%)
• Listeria monocytogenes (~10%)
• H. influenzae (<10% )
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20. 20

21. Pathogenesis
Source of Infection
• Contiguous spread: URTI(Sinusitis, OM), birth defect
• Hematogenous: bacteremia seeding meninges
• Direct inoculation: Trauma, neurosurgical complications
• Reactivation of latent Diseases: TB, S.Pneumoniae infection
CNS Response to Infection
• Contact with bacterial cell wall components triggers cytokine releases (TNF, PAF, IL-1)
• Platelet activating factor (PAF) triggers clotting cascade, forming microthrombi
• Cytokine cascade stimulates vasodilation and vascular permeability
• Compromised BBB allows entry of neutrophils and other blood components
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22. Pathogenesis (Cont’d)
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Increased ICP
Decreased Cerebral Blood Flow
Signs/Sx of Meningitis
•Headache
•Fever
•Neck stiffness
•Altered mental status
•Seizures
•Abnormal CSF findings
Ischemia and Direct Tissue
Damage

23. Risk factors
• Head trauma
• Age
• Weakened immune system
• Upper respiratory tract infection
• Unvaccinated child
• Live in Overcrowded place
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24. Clinical presentation
• Clinical presentation varies with age and atypical and the less pronounced in
younger patient
Classic signs and symptoms include
- fever, chills, vomiting - severe headache.
- Irritability - Lethargy
- Bulging fontanelle – fluid build up in skull cavity
- Apneas (temporary absence of breathing)
- Purpuric rash – bleeding into the skin and mucosa from small vessels
- Convulsions(more common in children)
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25. Clinical presentation(cont’d)
• Signs and Symptoms in children
• fever, neck stiffness, altered mental status or headache.
• Chills, vomiting, photophobia, coma, and severe headache
• Kernig's and Brudzinski's signs may also be present but are poorly
sensitive and frequently are absent in children
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26. Differential Signs And Symptoms
• Purpuric rush(tiny red skin), joint pain during illness typically indicate
meningococcal involvement, or H. influenzae meningitis.
• A history of head trauma with or without skull fracture or presence of a
chronically draining ear is associated with pneumococcal involvement.
• Rashes rarely occur with pneumococcal meningitis
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27. 27

28. 28

29. Diagnosis
• CSF are collected by lumbar puncture
• CSF Analysis for Glucose, WBC & total protein conc.
• CSF protein > 100 mg/dl and
• CSF glucose <50% of the simultaneously obtained peripheral value suggest
bacterial meningitis
• CSF WBC >100/mm2
• Magnetic resonance imaging (MRI) or cranial computed tomography (CT)
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30. Other Diagnostic Tests
• Blood and other specimens should be cultured according to clinical judgment
because meningitis frequently can arise via hematogenous dissemination or
can be associated with infections at other sites
• A minimum of 20mL of blood in each of two to three separate cultures per
each 24- hour period is necessary for the detection of most bacteremias
• Gram stain and culture of the CSF are the most important laboratory tests
performed for bacterial meningitis.
• When performed before antibiotic therapy is initiated
• Gram stain is both rapid and sensitive and can confirm the diagnosis of
bacterial meningitis in 75% to 90% of cases
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31. • PCR techniques can be used to diagnose meningitis caused by N. meningitidis,
S. pneumoniae, and H. influenzae type b (Hib)
• PCR is considered to be highly sensitive and specific.
• The GCS score interpretation:-13-15points: Favorable prognosis for
recovering
- 9-12 points: Doubtful prognosis
- less 8 points: Unfavorable prognosis
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Other Diagnostic Tests(cont’d)

32. Treatment
The goals of treatment include:
• Eradication of infection with amelioration of signs and symptoms
• Prevention of neurologic sequelae, such as seizures, deafness, coma, and death
General approaches for treatment
• The administration of fluids, electrolytes, antipyretics, analgesia, and other supportive
measures are particularly important for patients presenting with bacterial meningitis
• Appropriate antibiotic therapy empirical or definitive should be started as
soon as possible.
• Antibiotic dosages for treatment of CNS infections must be
• Maximized to optimize penetration to the site of infection
• Use of bactericidal drugs effective for the infecting organism
• Use of drugs that enter the CSF
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33. General Approaches for Treatment(cont’d)
• Empiric antimicrobial therapy should be instituted as soon as possible to eradicate
the causative organism
• Antimicrobial therapy should last at least 48 to 72 hours or until the diagnosis of
bacterial meningitis can be ruled out
• Continued therapy should be based on the assessment of clinical improvement,
cultures, and susceptibility testing results.
• Once a pathogen is identified, antibiotic therapy should be tailored to the specific
pathogen.
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34. Dexamethasone as an Adjuvant Treatment
• In addition to antibiotics, dexamethasone is a commonly used therapy for the treatment of
pediatric meningitis
• Several studies have shown that dexamethasone causes a significant improvement in CSF
concentrations of:
• Proinflammatory cytokines
• Glucose
• Protein
• As well as a significantly lower incidence of neurologic sequelae commonly associated
with bacterial meningitis
• Prevent complications(deafness)
• However, there are conflicting results
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35. Dexamethasone as an Adjuvant Treatment(cont’d)
• The American Academy of Pediatrics suggests that the use of dexamethasone be
considered For infants and children aged 2 months or older with:
• Pneumococcal meningitis
• H. influenzae meningitis.
• Dexamethasone given 0.15 mg/kg every 6 hours for 2 days or 0.4 mg/kg every 12 hours
for 2 - 4 days
• Dexamethasone should be administered prior to the first antibiotic dose, due to
• Decrease penetration of Ampicillin, vancomycin, Aminoglycosides ,Rifampin which
is Depend on inflammation of meninges for penetration
• They also may be effective if given concurrently with or soon after the first dose of
antibiotics.
• Use of dexamethasone is contraindicated in neonates or any infant younger than 6
weeks(2 month) due to adverse neurodevelopmental outcomes(cerebral palsy) 35

36. Empirical Therapy of Bacterial Meningitis
• 1.Preterm infants to infants <1 month: -Ampicillin + cefotaxime/aminoglycoside
• 2.Infants 1 - 3 month: -Ampicillin + cefotaxime or ceftriaxone
• 3.Immunocompetent children >3 month & adults: -Cefotaxime or ceftriaxone +
vancomycin
• 4.Adults >55 and adults of any age with alcoholism or other debilitating illnesses:
-Ampicillin + cefotaxime or ceftriaxone + vancomycin
• 5.Hospital-acquired meningitis, post-traumatic or post-neurosurgery meningitis,
neutropenic patients, or patients with impaired cell-mediated immunity.
-Ampicillin + ceftazidime + vancomycin
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37. 37
S.N Name of the antibiotics Their Meningeal doses
1. Penicillin G 250,000 to 300,000 U/kg per day IV in 4 or 6 divided doses
2. Ampicillin 300 mg/kg/day IV BID or QID
3. Gentamycin 7.5 mg/kg/day IV QD or TID
4. Cefotaxime 225 - 300 mg/kg/day IV TID or QID
5. Ceftriaxone 100 mg/kg/day IV QD or BID
6. Ceftazidime 150 mg/kg/day IV TID
7. Vancomycin 60 mg/kg/day IV TID
8. Cefepime 150 mg/kg/day IV TID
9. Meropenem 120 mg/kg/day IV TID
10. Metronidazole
30 mg/kg/day IV TID (when brain abscess & Ventriculitis is suspected.)
Adjuvant therapy(steroid)
11. Dexamethasone 0.15 mg/kg/dose IV QID for 2 – 4 days, in the treatment of H. influenzae
type b meningitis in children older than 6 wk of age.

38. Treatment duration
• Meningitis caused by S. pneumoniae is successfully treated with 10 to 14 days of
antibiotic therapy.
• Meningitis caused by N. meningitidis usually can be treated with a 7-day course
• A longer course, ≥21 days, is recommended for patients infected with L.
monocytogenes
• Therapy should be individualized, and some patients may require longer courses
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39. Prognosis
• Appropriate antibiotic therapy and supportive care have reduced the mortality rate of
bacterial meningitis beyond the neonatal period to < 10%.
• The highest mortality rates are observed with pneumococcal meningitis.
• Severe neurodevelopmental sequelae may occur in 10–20% of patients recovering
from bacterial meningitis, and as many as 50% have some neurologic sequelae.
• The prognosis is worse among infants younger than 6 mo and in those with a high
bacterial burden in their CSF.
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40. Prognosis(cont’d)
• Those with seizures occurring more than 4 days into therapy or with coma or focal
neurologic signs on presentation also have an increased risk of long-term sequelae.
• Sensorineural hearing loss is the most common sequela of bacterial meningitis and,
usually, is already present at the time of initial presentation.
• All patients with bacterial meningitis should undergo careful audiologic assessment
before or soon after discharge from the hospital. Frequent reassessment on an
outpatient basis is indicated for patients who develop a hearing deficit.
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41. Complications
• complications can include
- seizures - increased ICP,
- stroke - hearing/vision loss (partial/total)
- bulging fontanel, - cerebral or cerebellar herniation,
- problem with memory and concentration
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42. Chemoprophylaxis
• For N. meningitidis: indicated in close contacts of patients with meningococcal
meningitis.
Rifampicin: 5 mg/kg/dose PO Bid for 2 days(Children aged <1 month)
Rifampicin: 10 mg/kg/dose PO Bid for 2 days(Children aged ≥1 month)
Ceftriaxone 125 mg IM stat dose for Children age <15 year.
Ceftriaxone 250 mg IM stat dose for Children >15 age.
Ciprofloxacillin 20 mg/kg PO (Max 500 mg) stat
• For Haemophilus Influenzae– may be indicated for certain close contacts of a child with
Hib meningitis, depending upon individual circumstances.
Rifampicin: 10 mg/kg/day PO QD for 4 days(Children aged <1 month)
Rifampicin: 20 mg/kg/day PO QD for 4 days(Children aged ≥1month)
• For S. pneumoniae – Although it does not have a role in preventing the spread of
pneumococcal meningitis, chemoprophylaxis is an important aspect of prevention of
invasive pneumococcal infections in children with functional or anatomic asplenia.
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43. Vaccines
Vaccines directed against each of the major pathogens causing
bacterial meningitis in children are:
S. pneumoniae
N. meningitidis
H. Influenzae
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44. Reference
• Pharmacotherapy IV lecture note
• Nelson textbook of pediatrics
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