1. Neonatal Meningitis
Management: up to date
By
Senior Pediatric and neonatology Consultant
Egyptian Followship Trainer
Diploma, M.S ,Ph.D of Pediatrics
2. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
3. • 1-Neonatal meningitis is a devastating
condition.
• 2-Prognosis has not improved in decades,
despite the advent of improved
antimicrobial therapy and heightened index
of suspicion among clinicians caring for
affected infants.
4. • 3-Meningitis is a life-threatening disease,
affecting 0.1–0.4 neonates per 1,000 live
births, with a higher incidence in preterm
and chronically hospitalized infant.
• 4-Approximately 10% of affected infants
die, and 20–50% of survivors develop
seizures, cognitive deficiencies, motor
abnormalities, and hearing and visual
impairments
5. • 5-Clinicians frequently use the presence of
positive blood cultures to determine whether
neonates should undergo lumbar puncture.
• 6-Abnormal cerebrospinal fluid (CSF)
parameters are often used to predict neonatal
meningitis and determine length and type of
antibiotic therapy in neonates with a positive
blood culture and negative CSF culture.
6. • 7-Neonatal meningitis frequently occurs in
the absence of bacteremia and in the
presence of normal CSF parameters.
• 8-No single CSF value can reliably exclude
the presence of meningitis in neonates.
• 9-The CSF culture is critical to establishing
the diagnosis of neonatal meningitis.
7. • 10-The 3 major pathogens in developed
countries are: Group B streptococcus, gram
negative rods and Lysteria monocytogenes.
• 11-Signs and symptoms of NM may be
subtle, unspecific, vague, atypical or absent.
• 12-In order to exclude NM, all infants with
proven or suspected sepsis should undergo
lumbar puncture.
8. • 13-Positive culture of cerebrospinal fluid
may be the only way to diagnose NM and to
identify the pathogen, as CSF parameters
may be normal at early stages and NM may
occur frequently (up to 30% of cases) in the
absence of bacteraemia
9. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
10. Clinical features
• The signs of meningitis in very young
infants may be very difficult to detect.
• Characteristic features found in older
patients, such as neck stiffness, do not occur
• General signs of illness, including apnoeic
attacks, vomiting and lethargy are common
and significant
11. • Some features will indicate that there is an
illness affecting the brain.
• Thus convulsions, which may result from an
illness of the brain, such as meningitis, or a
metabolic disturbance, such as
hypoglycaemia or hypocalcaemia, are an
indication for lumbar puncture.
• Diarrhea
12. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
13. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
15. Culture of cerebrospinal fluid (CSF) is the
traditional gold standard for diagnosis of
bacterial meningitis.
However, deciding when to perform LP to
obtain and analyze CSF is challenging.
Factors complicating this decision include the
non-specific signs and symptoms of meningitis
in the infant, cardiorespiratory instability that
may preclude positioning of an infant for LP,
and considerable practice variation
16. Meningitis is estimated to occur in
approximately 1–2% of suspected cases of
sepsis within the first 72 h of life, or early-
onset sepsis, though the risk is limited almost
entirely to symptomatic infants
17. • The American Academy of Pediatrics policy
statement on suspected or proven early-onset
bacterial sepsis supports performing LP as
part of the sepsis evaluation of the neonate
with symptoms concerning for early-onset
sepsis, but recommends a more limited
evaluation in the asymptomatic neonate with
sepsis risk factors .
• In contrast to early-onset sepsis, evaluations
for late-onset sepsis (after the first 72 h of life)
are almost always performed in response to
concerning signs and symptoms.
18. • Several studies have noted
discordance between blood culture
and CSF culture results, with
negative blood cultures in up to a
third of infants with bacterial
meningitis.
19. • Interpretation of CSF results is frequently
problematic. If LP is delayed, and infants
are exposed to empiric broad-spectrum
antibiotics, clinical yield of bacterial culture
of CSF can be compromised .
• In these situations, clinicians rely on
interpretation of CSF parameters, such as
cell count, glucose, and protein levels to
presumptively diagnose meningitis.
20. • Many other factors influence interpretation
of these values in neonates, including
gestational age, postnatal age, and trauma
sustained during LP causing contamination
of CSF with blood
21. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
23. • Although use of cytokines as biomarkers of
meningitis has not achieved sufficient
accuracy to be employed in clinical practice,
these data complement a wealth of omics
data from humans and model organisms
with bacterial meningitis that now exist.
24. • Efforts to integrate these data sets and
assemble pathway maps of genes, proteins,
and metabolites altered in the setting of
bacterial meningitis will be of great benefit
to advance the field.
25. Outline
• 1-Golden Rule in Neonatal Meningitis
• 2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
27. • Decisions on the choice of a specific
antimicrobial agent are based on knowledge
of its activity against the causative pathogen
and relative penetration into cerebrospinal
fluid (CSF) in the presence of meningeal
inflammation.
28. • guidelines for treatment of meningitis
• When bacterial meningitis is suspected as
part of EOS, ampicillin with either an
aminoglycoside or cefotaxime is commonly
recommended as initial empirical therapy to
cover GBS, E. coli, Listeria monocytogenes,
and Klebsiella species .
• For neonates with late-onset meningitis, a
regimen containing an antistaphylococcal
antibiotic, such as nafcillin or vancomycin,
plus cefotaxime or ceftazidime with or
without an aminoglycoside is recommended
29. • The duration of antimicrobial therapy
• GBS meningitis is usually treated for 14 to
21 days, assuming prompt eradication of
bacteria from the CSF.
• For uncomplicated neonatal meningitis
caused by Gram-negative bacteria, a
minimum of 21 days is recommended
30. • Failure to achieve CSF sterilization or
persistence of symptoms should prompt the
clinicians to look for possible complications
such as brain abscess, ventriculitis, or
subdural empyema.
• Infants with intracranial abscesses should
be treated with a combination of surgical
aspiration or drainage of the abscess plus
antimicrobial therapy for 4–6 weeks
31. • Early neuroimaging by ultrasonography,
MRI, or CT is indicated to assess the need
for surgical intervention. Imaging should be
repeated even after the antibiotic therapy
has been completed.
• In neonates, cefotaxime is often preferred
over ceftriaxone (particularly for those who
have hyperbilirubinemia)
32. • Repeat lumbar puncture to document CSF
sterilization and improvement of CSF
parameters is not indicated routinely.
However, it should be done in all patients
who have not responded clinically after 48
hours of appropriate antimicrobial
therapy.
33. • Neonates with meningitis due to Gram-
negative bacilli should undergo repeated
lumbar punctures to document CSF
sterilization, because the duration of
antimicrobial therapy is determined.
34. Outline
1-Golden Rule in Neonatal Meningitis
2- Clinical Feature
• 3-Diagostic Challenge
4-Omics to Extend Knowledge of Bacterial
Meningitis
5-Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
6-Prevention
36. • Prevention of neonatal meningitis
• is primarily intrapartum (during
labor) antibiotic prophylaxis for pregnant
mothers to decrease chance of early-onset
meningitis by GBS.
• For late-onset meningitis, prevention is
passed onto the caretakers to stop the
spread of infectious microorganisms.
37. • A-Proper hygiene habits are first and
foremost.
• B-stopping improper antibioticuse; such as
over-prescriptions,
• C-use of broad spectrum antibiotics.
• D-extended dosing times.
• E-possible prevention may be vaccination of
mothers against GBS and E. coli, however, this
is still under development.
42. • من لمدة مناعة يعطي التطعيم
3
-
5
سنوات
Safe for pregnant women التطعيم
Chemoprophylaxis for pregnant women :
Ceftriaxone 250 mg im once
