This document provides an overview of meningitis in pediatrics. It discusses the demography and epidemiology, with the highest incidence being in neonates infected during birth. The most common causes vary by age. Clinical features include fever, irritability, and headache. Diagnosis involves lumbar puncture to examine CSF. Bacterial causes include pneumococcus, meningococcus, and H. influenzae. Treatment involves high dose IV antibiotics for 7-14 days. Complications can include seizures, cerebral edema, and death if not treated promptly. Prevention involves vaccination and antibiotic prophylaxis for contacts of cases.

1. MENINGITIS IN PEDIATRICS
Asmamaw A

2. outlines
 Introduction
 Demography and epidemology
 Predisposing factors
 Etiology and Epidemology
 Causes of meninigitis
 Bacterial meningitis
 Methods of transmission
 DX
 S&S
 Treatment

3. DEMOGRAPHY AND EPIDEMIOLOGY
 The highest incidence is among neonates, who
are usually infected by bacteria found in the birth
canal at the time of parturition.
◦ Group B streptococci (Streptococcus agalactiae)
account for the majority of cases; other causes include
Listeria monocytogenes, E.coli, other Gram-negative
bacilli, and enterococci.
 From age 1 to 23 months, the most common
organisms are Streptococcus pneumoniae and
Neisseria meningitidis

4. Predisposing factors
 Mucosal invasion of the nasopharynx
 Direct extension of bacteria across a skull
fracture in the area of the cribriform plate
 Systemic bacteremia as with endocarditis or a
urinary tract infection or pneumonia
 Asplenia, corticosteroid excess, and HIV
infection

5. Etiology and epidemiology of meningitis
con.
 Lack of immunity ( IgM or igG anti capsular antibody ) to
specific pathogens with young age.
 recent colonization with pathogenic bacteria .
 Close contact with invasive disease ( respiratory tract
secration)
 Crowding , poverty , black race , male .
 Defect in complement (C5- C8 ) associated with
recurrent meningococcal infection .

6. Etiology of meningitis con…
 Ventricular peritoneal shunts
 CSF leake due fracture,paranasal sinus
pneumococcal
 Head trauma
 Neurosurgical procedures
 Splenic dysfunction
 Immuno suppress patients with t- cell defect(
AIDS,malignancy)

7. Meningitis
o The brain and spinal cord are covered by
connective tissue layers collectively called the
meninges which form the blood-brain
barrier(BBB).
1-the pia mater (closest to the CNS)
2-the arachnoid mater
3-the dura mater (farthest from the CNS).
The meninges contain cerebrospinal fluid (CSF).
Meningitis is an inflammation of the meninges, which,
if severe, may become encephalitis, an
inflammation of the brain.

9. Central Nervous System Infections
 Meningitis is the most common causes of
fever associated with signs and symptoms
of CNS disease in children.
 Specific microbes depend on :
age, immune status, epidemiology of the
pathogen.

10. Causes of Meningitis
-Bacterial Infections
-Viral Infections
-Fungal Infections
(Cryptococcus neoformans
Coccidiodes immitus)
-Inflammatory diseases
(SLE)
Cancer
-Trauma to head or spine.

11. Viral cause of meninigitis
 Non polio enterovirus
 Mumps virus
 Measles virus
 Influenza virus
 Herpes simplex virus

12. Bacterial meningitis…..
Etiological Agents:
 Pneumococcal, Streptococcus
pneumoniae (38%)
 Meningococcal, Neisseria meningitidis
(14%)
 Haemophilus influenzae (4%)
 Staphylococcal, Staphylococcus aureus
(5%)
 Tuberculous, Mycobacterium

13. Meningococcal Meninigitis
Etiological Agent: Neisseria meningitidis
Clinical Features: sudden onset. Sudden high
fever,seisures,poor feeding,headache,nausea
and vomiting
Reservoir: Humans only. 5-15% healthy
carriers
Mode of transmission: direct contact with
patients oral or nasal secretions. Saliva.
Incubation period: 1-10 days. Usually 2-4 days
Infectious period: as long as meningococci are
present in oral secretions or until 24 hrs of
effective antibiotic therapy

14. Cause of Bacterial Meningitis with
age group
• Birth - 4 wks: GBS, E.coli
 4 - 12 wks: GBS, E.coli,
Pneumococcus
Salmonella, Listeria, H. Influenza
 3 mths - 3 yrs: Pneumococcus,
Meningococcus
H. Influenza
 3 yrs+ adult: Pneumococcus,
Meningococcus

15. Mode of transmission
 Respiratory secretion/ droplet
 Person to person contact(kissing
,saliva,contaminated food,mucus)

16. Bacterial Meningitis -
Pathogenesis
 Infection of upper respiratory tract
 Invasion of blood stream
(bacteraemia)
inflammation of meninges

17. Investigation
 LP
 Blood culture
 Latex particle agglutination
 Countercurrent immunoelectrophoresis

18.  DIAGNOSIS
1) Lumbar puncture
 Between L3 & L4 or L4 & L5
 Confirms DX of meningitis
 CSF
 Pressure …..usually elevated to 100-300 mmH2O ( Nl
=50-80 mmH2O )
 Gross appearance……turbid (WBC >200-400 /mm3)
 WBC count (Nl =less than 5 , lymphocyte > 75% or
monocytes )
 Usually elevated to >1000/mm3 (100 – 10,000/mm3 or
more )
 Neutrophil predominance ( 75- 95% )
 In 20 % of cases WBC < 250/mm3
 Absent pleocytosis …….sever overwhelming sepsis
with meningitis
 Pleocytosis with lymphocyte predominance…….during
early stages
 Elevated protein …usually 100-500 mg/dl (Nl = 20 - 45
mg/dl )
 Reduced glucose….usually <40 mg/dl (or <50% of serum
glucose ) ( Nl =>50mg/dl or 75 %of serum glucose )
 Gram stain : positive in 70-90 % of cases
 Culture

19.  Contraindications for LP
- Increased ICP
- Sever cardiopulmonary compromise
- Infection of the skin overlying the site of the LP
- Thrombocytopenia( < 20,000/mm3 ) : Relative c/I
 Traumatic LP
- Affects CSF, WBC & protein concentration
- Does not affect G/S , culture & Glucose level
- Repeat LP after sometime
2) Latex particle agglutination
- Highly sensitive but less specific
3) Blood culture : Positive in 80 -90 % of cases
4) Countercurrent immuno electrophoresis (CIE)
-Rapid & very specific

20. Typical Cerebrospinal Fluid Findings in
Patients with Bacterial Meningitis
Cerebrospinal Fluid Parameter Typical Finding
Opening pressure 200-500 mm H2O
White blood cell count 1000-5000/mm3
Percentage of neutrophils ≥80%
Protein 100-500 mg/dL
Glucose ≤40 mg/dL
CSF-to-serum glucose ratio ≤0.4
Gram stain Positive in 60%-90%
Culture Positive in 70%-85%
Polymerase chain reaction Promising*

21. CSF
 Collect 1 ml of csf in each of 3 vials
Tube 1 culture and gram stain
Tube 2 glucose,protein
Tube 3 cell count and differential

22. Meningitis: Clinical features
Newborn & Infants: non-specific
 Fever
 Irritability
 Lethargy
 Poor feeding
 High pitched cry, bulging AF
 Convulsions,

23. Kernig’s sign

24. Brudzinski’s sign

25. Meningitis: older children

26.  TREATMENT
A) Antibiotics
◦ Always use high dose ,parenteral (IV)
antibiotics.
◦ Initial (empirical )choice of therapy
 Vancomycin 60 mg/kg/24 hr, given every 6
hr
OR
 Ceftriaxone 100 mg /Kg /24 hr once per
day or
50 mg/Kg /dose every 12 hrs for 7 – 10
days
OR

27.  Patient allergic to b-lactam antibiotics
-CAF 100 mg /Kg /24hr given every 6 hr
OR
- Patient can be desensitized to the
antibiotic
◦ If patient is immuno compromised
-Ceftazidime and aminoglycoside need to be
included because of risk of gram –ve bacterial
meningitis e.g. P.aeruginosa ,E .coli

28. Duration of antibiotic therapy
a) Generally total of 10 days
b) Specific ( based on etiologic agent ) in
uncomplicated cases
 N .meningitidis…….5 -7 days
 H .influenzae type b……….7 10 days
 S .Pneumoniae………..10-14 days
 CSF culture –ve………7- 10 days
 Gram –ve bacilli……03 weeks or 2 weeks after
CSF sterilization
( usually after 2 – 10 days of treatment )
 Neonates ……..03 weeks
** N.B. In complicated cases of meningitis ,give
antibiotics for 10-14 days

29. Prophylaxis
 Rifampicin:
Children 5mg/kg bid x 2/7
Adults: 600 mg bid x 2/7
Pregnant contact:
Cefuroxime IM x 1 dose

30. Corticosteroids
 Rapid killing of bacteria releases toxic cell
products.
 This precipitates cytokine mediated infl.
response- edema & neutrophilic response.
This will lead to additional neurologic injury
with worsening of CNS Sx:
- Dexamethasone- 0.15mg/kg/dose q6hr-
2days (benefit max if given 1-2 hr before
antibiotics)
-.

31. Supportive care
 NPO
 IV fluid: 800-1000ml/m2/24hr(1/2-2/3rd
of maintenance)- shock treated
aggressively.
 Septic shock- dopamine
 Signs of ↑ ICP
-ET intubation& hyperventiln
(PCO2~25mmHg)
- IV lasix (1mg/kg), mannitol (0.5-1g/kg)
 Seizures- first Rx-diazepam iv,or
lorazepam

32. cont’d
- do serum glucose, calcium, & sodium
levels
- After initial Rx, phenytoin (loading dose
of 15-20mg/kg, maintenance 5mg/kg/d)
 Neurologic ass’t: esp.1st 72 hrs
-PR, BP, RR, Level of consciousness,
pupils, motor, Cranial nerves, Sz,
Head circumference, Urine output.
- Lab.- Sp. Gravity of urine

33. Meningitis - Complications
 Septic shock - DIC
 Cerebral oedema
 Seizures,
 kidney failure
 Arteritis/venous thrombosis
 Subdural effusions
 Hydrocephalus . Abscess . Brain
damage
 Deafness

34. Prevention
 -Vaccination & antibiotic prophylaxis
- N.meningitidis- rifampin
10mg/kg/dose q12 hr for 2 days –for
all close contacts of patients with
meningococcal meningitis.
- HIB- rifampin 20mg/kg/day,once, 4
days for all household contacts
 Washing Hands frequently
 Not share eating utensil,plates

35.  THANK YOU