Meningitis in Children

4. Definitions:
 Meningitis is inflammation of the protective
membranes covering the brain and spinal cord,
known collectively as the meninges. The
inflammation may be caused by infection with
viruses, bacteria, or other microorganisms, and
less commonly by certain drugs.
 Meningitis is an inflammation of the meninges
(the covering of the brain and spinal cord).
Meningitis can be caused by infection from
viruses and bacteria (germs). These germs
usually cause everyday illness, such as an ear
infection or pneumonia.

5.  Incidence:
› Incidence is between 3-5 per 100,000
› More than 2,000 deaths annually in the U.S.
› Relative frequency of bacterial species varies with
age.

9. › Neonates (< 1 Month)
 Gm (-) bacilli 50-60%
 Grp B Strep 20-40%
 Haemophilus influenzae type b (Hib)0-3%
 S. pneumo 0-5%

10. › Children (1 month to 15 years)
 Haemophilus influenzae type b (Hib)
40-60%
 Neisseria meningitidis 25-40%
 Streptococcus pneumoniae 10-20%

11. Etiology - in Adults
 S. pneumoniae 30-50%
 N. meningitidis 10-35%
 H. influenzae 1-3%
 G -ve bacilli 1-10%
 Listeria species 5%
 Streptococci 5%
 Staphylococci 5-15%

18. One of the physically
demonstrable symptoms
of meningitis is Kernig's
sign. Severe stiffness of
the hamstrings causes an
inability to straighten the
leg when the hip is flexed
to 90 degrees.

19. Another physically
demonstrable symptoms of
meningitis is Brudzinski's
sign. Severe neck stiffness
causes a patient's hips and
knees to flex when the
neck is flexed.

21.  Most often the WBC count is elevated with a shift toward
immature forms
 Platelets may be reduced if disseminated intravascular
coagulation is present or in the face of meningococcal
bacteremia
 Blood cultures are often positive, and can be very useful in the
event that CSF cannot be obtained before the administration of
antimicrobials.
 At least one-half of patients with bacterial meningitis have
positive blood cultures, with the lowest yield being obtained
with meningococcus

23.  CSF analysis –
 Chemistry and cytologic findings highly suggestive of
bacterial meningitis include a CSF glucose concentration
below 45 mg/dL, a protein concentration above 500
mg/dL, and a white blood cell count above 1000/mm3 .
 X-ray.
 CT scan

25.  Level of consciousness - ideally Glasgow Coma
Scale (GCS) -
 Airway protective reflexes and adequacy of
ventilation, especially if the level of
consciousness is impaired
 Circulatory status, including heart rate, blood
pressure and hydration
 Whether there are clinical signs of coagulopathy

26.  Inadequate airway protection
 Impaired level of consciousness, GCS < 13
 Signs suggestive of severe increase in ICP e.g.
hypertension, bradycardia, papilloedema,pupillary
changes
 Hypoventilation or respiratory failure
 Oxygen saturation < 90% in > 40% oxygen

27.  Uncontrollable or poorly controlled seizures
 Hypotension or tachycardia not responsive to fluid
resuscitation
 Renal failure
 Serum [Na+] <125 mmol/l
 Children with significant purpura or rapidly
progressive petechiae
 Consider if still unstable after 40mls/kg resuscitation
fluid

28.  Quiet environment (if possible)
 Head-up positioning to reduce intracranial
pressure (unless shocked)
 Frequent monitoring of: TPR, BP, Glasgow Coma
Scale
 Measure head circumference daily in children < 2
years old
 Meticulous fluid balance. Monitor urine output in
sick children by nappy weighing, or urethral
catheter.

29.  Weight the child once or twice daily.
 Oxygen is indicated for any patient at risk of hypoxemia
e.g. shock, seizures, decreased level of consciousness,
intercurrent lung disease.
 SaO2 or PaO2 should be measured where supplemental
O2 is being used
 Monitor serum [Na+], looking for evidence of SIADH
(see below)

30.  Suspected bacterial meningitis is a medical emergency
and immediate diagnostic steps must be taken to establish
the specific cause
 Empiric treatment should be begun as soon as the
diagnosis is suspected using bactericidal agent(s) that
achieve significant levels in the CSF

31. USE OF BACTERICIDAL AGENTS
 Bactericidal therapy is generally necessary to cure meningitis
 Bacteriostatic drugs, such as clindamycin and tetracycline,
are inadequate for meningitis
 Chloramphenicol is a bacteriostatic drug for most enteric
Gram negative rods; however, it is usually bactericidal for H.
influenzae, N. meningitidis, and S. pneumoniae and has been
extensively and successfully used to treat meningitis caused
by these organisms

32.  INTIAL EMPRIC THERAPY:
 A third generation cephalasporin such as
Ceftriaxone or Cefotaxime . A combination of
ampicilin 200mg/kg for 10-14 days


33.  Meningococcal or pneumococcal meningitis:
 Pencillin 400-500000 units/kg /day q 4hr.
 Cefotaxime150-200 mg kg/day/q8hr
 Ceftriaxone100-150 mg/kg/day q12hr

34.  H.influenza meningitis:
 Ceftriaxone or Cefotaxime IV is used as a
single dose. The combination of ampicilin
(300-mg/kg/day q6hr)
 Staphylococcal meningitis:
 Vancomycin is the treatment of choice of

35. Anticonvulsant Loading Dose Route
Diazepam 0.25 mg/kg IV
Midazolam 0.5 mg/kg BUCCAL
Phenytoin 20 mg/kg IV
Phenobarbitone 20 mg/kg IV
Diazepam has only a short duration of effect. Ongoing
anticonvulsant therapy should be instituted with Phenytoin.

36.  Many of the viruses and bacteria that can cause meningitis are
common.
 Good personal hygiene is important to prevent any infection.
Washing hands thoroughly and often, especially before eating and
after using the bathroom, is your first line of defense against the
spread of many illnesses.
 Not sharing food drinks, or eating utensils can help stop the
spread of meningitis germs as well. Safe and effective vaccines are
available to protect against bacterial meningitis.

37.  Meningococcal vaccines are active against many strains of
N. meningitis

38.  The addition of anti-inflammatory agents has been attempted
as an adjuvant in the treatment of meningitis
 Early administration of corticosteroids such as
dexamethasone for pediatric meningitis has shown no
survival advantage, but there is a reduction in the incidence
of severe neurologic complications and deafness

39.  A second meta-analysis of trials of meningitis in children
evaluated the findings according to organism
 For H. influenzae type b meningitis, dexamethasone therapy
was associated with a significant reduction in deafness
 For pneumococcal meningitis, dexamethasone was effective
only if given early ; in this setting, there was a significant
reduction in hearing loss
 Two days of therapy was as effective and less toxic than longer
courses of steroid administration

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