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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016

2. S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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,
Neisseria memingitides
Beyond
5 yrs
Strep. pneumoniae( 1,3,6,7),
Neisseria 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH 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

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
8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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