This document provides an overview of bacterial meningitis, including protective factors, routes of infection, presentation based on age, general management and treatment, complications, and prevention. Key points include: the blood-brain barrier protects the CNS from infection; common causative organisms and routes of entry vary by age; symptoms in young children are often nonspecific; general management focuses on supportive care, antibiotics, and treating increased ICP; complications can include subdural effusions, hydrocephalus, and seizures; and prevention involves vaccination and chemoprophylaxis.

1. Dr.G.Rajkumar
Professor of Paediatrics

2. Outline
• Protective factors
• Route of infection
• Etiopathogenesis
• Spotlight on presentation based on age & type
• General management and treatment
DR GRK DSMCH 2

3. PROTECTIVE FACTORS
• The central nervous system (CNS) is extremely
resistant to infection by bacterial pathogens due
to a combination of protective effects of
• Its bony structures (skull and vertebral
column),
• Meninges, and
• Blood-brain barrier
DR GRK DSMCH 3

4. Blood-Brain Barrier
DR GRK DSMCH 4

5. • Blood Brain Barrier 3D.mp4
DR GRK DSMCH 5

6. • The blood–brain barrier (BBB) is a separation
of circulating blood from the brain extracellular
fluid (BECF) in the central nervous
system (CNS).
• It occurs along all capillaries and consists
of tight junctions around the capillaries that do
not exist in normal circulation.
DR GRK DSMCH 6

7. • Endothelial cells restrict the diffusion of microscopic
objects (e.g., bacteria) and large
or hydrophilic molecules into the cerebrospinal
fluid (CSF), while allowing the diffusion of
small hydrophobic molecules (O2, CO2, hormones).
• Cells of the barrier actively
transport metabolic products such as glucose across
the barrier with specific proteins.
• This barrier also includes a thick basement
membrane and astrocytic endfeet.
DR GRK DSMCH 7

8. Risk factors
• Age < 5 years
• Male child
• Over crowding
• Poverty
• Anatomical defects of skull or spine
• Immunodeficiency

9. Causative organisms
• Bacterial
• Viral
• Protozoal
• Fungal

10. Route of entry
• Haematogenous spread
• Direct implantation traumatic, iatrogenic,
congenital malformations NTD
• Local extension-mastoid, sinus, CSOM, tooth
• PNS to CNS-Rabies, Herpes Zoster
• Hematogenous spread is the most
common route, and the upper respiratory
tract is the most common source of entry
of microorganisms.

11. • ......DownloadsBacterial Meningitis
fulminant video Animation by Cal Shipley,
M D[via torchbrowser.com].mp4

12. Age Specific organisms

14. Acute encephalitis syndrome (AES)
• It is characterized as
 Acute -onset of fever and
 A change in mental status (mental confusion,
disorientation, delirium, or coma)
 And/or new-onset of seizures in a person of any
age at any time of the year.
• Commonly affects children and young adults
and can lead to considerable morbidity and
mortality.

15. CAUSES OF ENCEPHALITIS
• Japanese encephalitis virus (JEV) (5%-35%).
• Herpes simplex virus,
• Influenza A virus,
• West Nile virus,
• Chandipura virus,
• Mumps , measles,
• Dengue ,
• Parvovirus B4,
• Enteroviruses ,
• Epstein-Barr virus and
• Scrub typhus,
• S.pneumoniae

18. Symptoms of neonatal bacterial meningitis-nonspecific
• Poor feeding
• Lethargy
• Irritability
• Apnea
• Listlessness
• Apathy
• Fever
• Hypothermia
• Seizures
• Jaundice
• Bulging fontanelle
• Pallor
• Shock
• Hypotonia
• Shrill cry
• Hypoglycemia
• Intractable metabolic
acidosis

19. Meningitis in infants and children
• Nuchal rigidity
• Opisthotonos
• Bulging fontanelle
• Convulsions/Coma
• Photophobia
• Headache
• Alterations of the
sensorium
• Irritability/Lethargy
• Nausea
• Poor feeding
• Vomiting
• Fever/ Hypothermia
• Rash
• Shock
• Hypotonia
• Hypoglycemia
• Jaundice

20. • The younger the child, the less likely he or she is to
exhibit the classic symptoms of fever, headache,
and meningeal signs.
• A child younger than 3 months may have very
nonspecific symptoms, including hyperthermia or
hypothermia, change in sleeping or eating habits,
irritability or lethargy, vomiting, high-pitched cry, or
seizures.
• A child who is quiet at rest but who cries when
moved or comforted may have meningeal irritation
(paradoxical irritability).

21. • After the age of 3 months, the child may
display symptoms more often associated with
bacterial meningitis, with fever, vomiting,
irritability, lethargy, or any change in behavior.
• After the age of 2-3 years, children may
complain of headache, stiff neck, and
photophobia.

22. Children older than 1 year of age
 Nausea and vomiting
 Headache/Photophobia
 Fever
 Altered mental status (seems confused or odd)
 Lethargy/Coma
 Seizure activity
 Neck stiffness or neck Pain
 Knees automatically brought up toward the body when
the neck is bent forward or pain in the legs when bent
(called Brudzinski sign)
 Inability to straighten the lower legs after the hips have
already been flexed 90 degrees (called Kernig sign)
 Rash

23. Clinical signs of meningeal irritation
DR GRK DSMCH 23

24. • ......DownloadsBrudzinski's Sign[via
torchbrowser.com].mp4
• ......DownloadsKernig’s Sign - Meningeal
stretch test[via torchbrowser.com].mp4

25. WHEN TO SUSPECT TBM?
 TBM is a Subacute illness presenting in 3
stages.
The first stage -nonspecific - difficult to
suspect and diagnose -low-grade fever,
headache, irritability, drowsiness, malaise,
vomiting, photophobia, listlessness, and poor
weight gain/weight loss.
In infants, loss of developmental milestones,
bulging AF, fever, cough, altered consciousness,
and seizures may be present.

26. WHEN TO SUSPECT TBM?
Neck stiffness is characteristically absent.
This lasts for approximately 1–2 weeks.
A history of contact with an active patient of
TB in children (~50% cases) can also be
elicited.

27. WHEN TO SUSPECT TBM?
The second stage is usually abrupt in onset.
It is characterized by
Lethargy ,
Neck rigidity,
Positive meningeal signs,
Hypertonia,
Seizures ,
Vomiting , and
Focal neurological deficit(s).

28. WHEN TO SUSPECT TBM?
Development of hydrocephalus,
raised intracranial pressure,
encephalitis with disorientation/movement
disorders/speech impairment,
cranial nerve involvement (sixth nerve) and
vision loss
Most patients are clinically diagnosed in this
stage.

29. WHEN TO SUSPECT TBM?
This is followed by the third stage, which might
be associated with
Decerebrat e/decorticate posturing,
Hemiplegia ,
Coma , and
Eventually death.

31. Encephalitis presentation
• The classic presentation is diffuse or FND with
• Behavioral and personality changes, with
decreased level of consciousness
• Neck pain, stiffness
• Photophobia, Lethargy
• Generalized or focal seizures (60% of children with CE)
• Acute confusion or amnestic states
• Flaccid paralysis (10% of patients with WNE)
• Severe headache is not always found. Less
commonly paraspinal backache.

32. Complication of meningitis
• Subdural effusion
– occur in about 10%-30% of children
– Subdural effusions appear to be more frequent in
the children under the age of 1 year and in
haemophilus influenzae and pneumococal
infection.
– Clinical manifestations are enlargement in head
circumference, bulging fontanel, cranial sutures
diastasis and abnormal transillumination of the skull.
– Subdural effusions may be diagnosed by the
examination of CT or MRI and subdural pricking.
DR GRK DSMCH 32

33. • Ependymitis
– Neonate or infant with meningitis
– Gram-negative bacterial infection
– Clinical manifestation
• Persistent hyperpyrexia,
• Frequent convulsion
• Acute respiratory failure
• Bulging fontanel
• Ventriculomegaly (CT)
• Cerebrospinal fluid by ventricular puncture
–WBC>50×109/L
–Glucose<1.6mmol/L
–Protein>o.4g/L
DR GRK DSMCH 33

34. • Cerebullar hyponatremia
– Syndrome of inappropriate secretion of
antidiuretic hormone (SIADH)
• Hyponatremia
• Degrade of blood osmotic pressure
• Aggravated cerebral edema
• Frequent convulsion
• Aggravated conscious disturbance
DR GRK DSMCH 34

35. • Hydrocephalus
– Increased intracranial pressure
– Bulging fontanel
– Augmentation of head circumference
– Brain function disorder
• Other complication
– Deafness or blindness
– Epilepsy
– Paralysis
– Mental retardation
– Behavior disorder
DR GRK DSMCH 35

36. TREATMENT
GENERAL AND SUPPORTIVE MEASURES
• Monitor of vital sign
• Correcting metabolic imbalances
– Supplying sufficient heat quantity
– Correcting hypoglycemia
– Correcting metabolic acidemia
– Correcting fluids and electrolytes disorder
• Application of cortical hormone
– Lessening inflammatory reaction
– Lessening toxic symptom
– Lessening cerebral edema
DR GRK DSMCH 36

37. • Treatment of hyperpyrexia and seizures
– Physiotherapy and/or drug
– Convulsive management
• Diazepam
• Phenobarbital
– Sub hibernation therapy
• Treatment of increased intracranial pressure
– Dehydration therapy
• 20%Mannitol 5ml/kg vi q6h
• Lasix 1-2mg/kg vi
DR GRK DSMCH 37

38. – Treatment of septic shock and DIC
• Volume expansion
• Dopamine
• Corticosteroids
• Heparin
• Fresh frozen plasma
• Platelet transfusions
DR GRK DSMCH 38

39. Treatment of Complication
• Subdural effusions
– Subduaral pricking
• Draw-off effusions on one side is 20-30ml/time.
• Once daily or every other day is requested.
• Time cell of pricking may be prolonged after 2
weeks.
• Ependymitis
– Ventricular puncture — drainage
• Pressure in ventricle be depressed.
• Ventricular puncture may give ventricle an injection
of antibiotic.
DR GRK DSMCH 39

40. • Hydrocephalus
– Operative treatment
• Adhesiolysis
• By-pass operation of cerebrospinal fluid
• Dilatation of aqueduct
• SIADH (Cerebral hyponatremia)
– Restriction of fluid
– supplement of serum sodium
– diuretic
DR GRK DSMCH 40

41. 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
DR GRK DSMCH 41

42. Pneumococcal meningitis – Mgmt
• Vancomycin + cefotaxime or ceftriaxone, if > 1
month old
• If hypersensitive (allergic) to -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
DR GRK DSMCH 42

43. Meningococcemia - Prophylaxis
• 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
DR GRK DSMCH 43

44. Meningococcal Vaccination
Currently licensed vaccine is composed of
elements of polysaccharide coat of the
bacteria
Serogroups A, C, W-135, and Y
Recommended for control of serogroup C
meningococcal disease outbreaks although its
not guaranteed to control them
Recommended for use among certain high
risk-groups
DR GRK DSMCH 44

45. PROGNOSIS
• Appropriate antibiotic therapy reduces the mortality
rate for bacterial meningitis in children, but mortality
remain high.
• Overall mortality in the developed countries ranges
between 5% and 30%.
• 50 percent of the survivors have some sequelae of the
disease.
DR GRK DSMCH 45

46. • Prognosis depends upon many factors:
– Age
– Causative organism
– Number of organisms and bacterial virulence
– Duration of illness prior to effective antibiotic
therapy
– Presence of disorders that may compromise host
response to infection
DR GRK DSMCH 46

47. Poor prognostic factors
• Etiology: more with pneumocaccal
• Seizure after 72 hours
• CSF sugar < 20 mg per dl at admission
• Delayed sterilization of CSF : > 24 hours
DR GRK DSMCH 47

52. Prevention
• Vaccination
• Chemoprophylaxis

53. TAKE HOME/HOSTEL
• Hematogenous spread is most common
meningitis-N.meningitis,H.influenza,S.pneumo
most common
• Younger children have subtle presentation
• Sub acute onset with 3 stages in TBM
• Behavioural changes in encephalitis
• Prevention by vaccination &chemoprophylaxis
• Treatment and complications
DR GRK DSMCH 53