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

8. 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 drinkingutensils, etc.)
The incubation period ranges between 2 -10
days. Average 3-5 day

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

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

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

12. 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 Monotocytogenes
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

14. 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)

15. 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.

16. 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

17. 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.

18. 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

19. 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

20. 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)

21. 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).

24. Meningiococcemic rash
•

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

26. Strength of recommendation
RecommendationGrade
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 useD

27. 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.

28. 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)

29. • 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)

30. 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)

31. • 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)

32. 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

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

34. 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)

35. • CSF lactate concentration has a good sensitivity
and specificity for differentiating bacterial from
aseptic meningitis.
• The value of CSF lactate is limited in 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)

36. • 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 antibiotics 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)

37. 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)

38. • 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)

39. • 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

40. • 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 )

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

42. Prevention

43. ‫المرض‬ ‫انتشار‬ ‫من‬ ‫الحد‬ ‫طرق‬
‫اوال‬:‫السحائي‬ ‫االلتهاب‬ ‫من‬ ‫العامة‬ ‫الوقاية‬
‫ثانيا‬:‫باالطباء‬ ‫خاصة‬ ‫وقائية‬ ‫اجراءت‬
‫التعليمية‬ ‫المنشات‬ ‫مثل‬ ‫التجمعات‬ ‫باماكن‬ ‫خاصة‬ ‫وقائية‬ : ‫ثالثا‬

44. ‫اوال‬:‫السحائي‬ ‫االلتهاب‬ ‫من‬ ‫العامة‬ ‫الوقاية‬
•‫التعليمية‬ ‫المنشاءات‬ ‫في‬ ‫االزدحام‬ ‫منع‬
•‫التعليمية‬ ‫المنشاءات‬ ‫داخل‬ ‫الجيدة‬ ‫التهوية‬
•‫تط‬ ‫يتم‬ ‫حيث‬ ‫المدارس‬ ‫دلخل‬ ‫التطعيم‬ ‫ببرنامج‬ ‫االلتزام‬‫عيم‬
‫التعليمية‬ ‫المراحل‬ ‫من‬ ‫االولي‬ ‫السنة‬(‫حضانة‬-‫ابتدائي‬–
‫اعدادي‬–‫ثانوي‬)‫السحائي‬ ‫االلتهاب‬ ‫يبتطعيم‬
•‫من‬ ‫الوقائية‬ ‫الجرعات‬ ‫اخذ‬‫للمخال‬ ‫الريفابيسين‬ ‫عقار‬‫طين‬

46. ‫مؤكدة‬ ‫حالة‬ ‫اكتشاف‬ ‫عند‬
•1-‫لمدة‬ ‫صحيا‬ ‫ومراقبتهم‬ ‫للحالة‬ ‫المباشرين‬ ‫المخالطين‬ ‫جميع‬ ‫حصر‬10
‫ايام‬.
•‫الميكرو‬ ‫حامل‬ ‫علي‬ ‫للقضاء‬ ‫يومين‬ ‫لمدة‬ ‫ريفامبيسين‬ ‫المخالطين‬ ‫اعطاء‬‫ب‬.
•‫مدرسة‬ ‫مثل‬ ‫تجمع‬ ‫داخل‬ ‫حالة‬ ‫اكتشاف‬ ‫عند‬-‫معسكر‬–‫حضانة‬‫اعطاء‬ ‫يتم‬
‫المخالطين‬ ‫جميع‬‫ريفامبيسين‬

47. 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

49. Vaccinations for
Meningitis

50. 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
•Pertussis
•Plague
•Rabies
•Salk polio
•Intra-
muscular
influenza
•Japanise
encephalitis
•Diphtheria
•Tetanus
•Meningococcal
polysaccharide
vaccine
•Pneumococcal
polysaccharide
vaccine
•Hepatitis B
polypeptide
vaccine
•Hepatitis B
vaccine

51. •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

52. 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

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

57. Meningococcal vaccines available for use
Quadrivalent meningococcal (MenACWY) conjugate vaccines
against A, C, W and Y serogroups
Registered age groupFormulationTrade name
9 month- 55
years
Quadrivalent diphtheria
toxoid conjugate
Menactra®
≥2 monthsQuadrivalent CRM
conjugate
Menveo®
≥6 weeksQuadrivalent tetanus
toxoid conjugate
Nimenrix®

58. 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

59. 2 types of meningococcal vaccine in Egypt:
1- A,C V accine : (polysaccraide)
‫االتية‬ ‫العمرية‬ ‫للفئات‬ ‫اللقاح‬ ‫من‬ ‫جرعة‬ ‫ويعطي‬:
‫الحضانة‬ ‫من‬ ‫االولي‬ ‫السنة‬
‫ابتدائي‬ ‫اولي‬
‫اعدادي‬ ‫اولي‬
‫ثانوي‬ ‫اولي‬
‫ينصح‬‫اعطاء‬ ‫بعدم‬‫سنتين‬ ‫قبل‬ ‫التطعيم‬

60. 2- Quadirivalent vaccine A,C,W,Y
‫والمعتمرين‬ ‫والحجاج‬ ‫للمسافرين‬ ‫ويعطي‬

61. 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.

63. Nimenrix

64. 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

65. Treatment of bacterial
meningitis

66. 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/penicilli
n 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/penicilli
n G
Age >50 years, or
Age >18 and <50 years
plus risk factors for
Listeria monocytogenesa

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

68. 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.

69. • 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)

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

71. 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 of community-acquired
bacterial meningitis patients should be provided
(e.g. testing for hearing loss, neuropsychological
evaluation)?

72. 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).

73. 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

74. 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

75. THANK YOU