This document discusses pediatric bacterial meningitis in the Philippines. It notes that bacterial meningitis is a leading cause of mortality in children ages 0-4 in the Philippines. Treatment recommendations must be tailored to the pathogens and susceptibility patterns identified in the Philippine setting. Signs and symptoms of meningitis vary by age, and lumbar puncture is essential for diagnosis. Empiric antibiotic therapy should cover the most likely causative organisms based on local data. Routine use of dexamethasone as an adjuvant therapy is not recommended in the Philippine setting. Ongoing surveillance of antimicrobial resistance is needed to guide treatment.

1. Pediatric Bacterial Meningitis
in the Philippines
Cecilia C. Maramba-Untalan, MD

2. Bacterial Meningitis in the Philippines
One of the top leading causes of mortality in
children 0-4 yrs old
Pathogens and susceptibility patterns are
different from those identified in other
countries
Management recommendations must be
appropriate for the Philippine setting
Task Force on Meningitis convened in order
to address this problem

3. Signs and Symptoms of Meningitis
are variable and depend on the age of the
patient, and the duration of illness before
treatment
neonates and young infants may have
minimal signs and symptoms
signs of symptoms of neonatal sepsis are
indistinguishable from neonatal meningitis
all neonates being evaluated for sepsis
should be evaluated for meningitis

4. Signs and Symptoms of Bacterial Meningitis
Signs and
symptoms
Neonates Older infants and children
Nonspecific Fever or hypothermia,
abnormally sleepy or lethargic,
disinterest in feeding, poor
feeding, cyanosis, grunting,
apneic episodes, vomiting
Fever, anorexia, confusion,
irritability, photophobia,
nausea, vomiting, headache,
seizure
Meningeal
inflammation
Neck rigidity, Neck rigidity, Kernig and
Brudzinski sign
Increased
intracranial
pressure
Bulging fontanel, diastasis of
sutures, convulsions,
opisthotonus
Headache, bulging fontanel,
diastasis of sutures in infants,
papilledema, mental
confusion, altered state of
consciousness
Focal
neurologic
signs
Hemiparesis, ptosis, facial
nerve palsy
Hemi paresis, ptosis,
deafness, facial nerve palsy,
optic neuritis

5. Lumbar puncture is essential
Cornerstone in the diagnosis
should be performed in all cases whenever the
diagnosis of meningitis is known or suspected on the
basis of clinical signs
Contraindications to doing a lumbar tap
1. presence of significant cardio-pulmonary compromise and shock
2. signs of increased ICP
3. suspected case of space occupying lesion
4. infection in the area that the spinal needle will traverse to obtain
CSF
5. hematologic problems
Laboratory Diagnosis of Bacterial Meningitis

6. CSF Findings in Bacterial Meningitis
a. CSF pressure - usually elevated
b. CSF cells count and chemistry
leukocytosis- >1000/cu mm
% PMN - 90%
Glucose- <40 mg/dl
CSF blood to glucose ratio <0.40
Protein 50-500 mg/dl
c. stained smears of CSF
gram stain - (+) for bacteria
AFB smear - (-)
India ink - (-)
d. CSF culture
*a negative culture does rule out meningitis

7. Other CSF Tests Useful in Diagnosis
Bacterial Meningitis
Antigen detection tests - Coagglutination -
- Latex agglutination
- antigens of H. influenzae B, S.
pneumoniae, Group B. streptococcus, E. coli
and Neisseria meningitidis
Antigen detection tests should never be
substituted for culture and gram stain
if only a small amount of CSF is obtained, do
gram stain and culture

8. Other Useful Laboratory Tests
Culture of other normally sterile fluids aside from
CSF
Blood culture- should be obtained in every patient
suspected of having bacterial meningitis
Middle ear fluid- in patients with otitis media
• do not do cultures from throat, nasopharynx
and urine

9. Neuroimaging and Bacterial Meningitis
Cranial Ultrasound
- when lumbar puncture is contraindicated and when
the anterior fontanel is open
- most useful in diagnosing complications of meningitis
- normal ultrasound does not rule out the presence of
meningitis
Study by Lee, et al*
224 cases of bacterial meningitis
202 had abnormal cranial ultrasound findings
highly echogenic sulci- 75%
thick, highly echogenic convexity leptomeninges - 47%
hydrocephalus - 44%
effusion or empyema - 33%
malacic changes - 9%

10. Neuroimaging and Bacterial Meningitis
Computed tomography and Magnetic resonance
Imaging
- in early stages of meningitis may be normal or
nonspecific
Study by Cabral, et al* - out of 41 children with
bacterial meningitis, only 14 had abnormal CT scan
For MRI
-meningeal enhancement demonstrated is nonspecific
and is also seen in tumors, intracranial hemorrhage,
trauma and after radiation therapy
indicated only for cases of suspected intracranial
complications of bacterial meningitis and are not
routinely required

11. Empiric Therapy for Bacterial
Meningitis
Bacterial meningitis is a medical emergency,
delay in treatment may lead to increased
sequelae or death
Drug of choice must be bactericidal for pathogen
involved
Must achieve adequate levels in the CSF
Initial regimen should cover most likely
pathogens for specific age groups, and reach
bactericidal levels in the CSF
Knowledge of local susceptibility patterns is
essential

12. Philippine Data
Meningitis is the 8th leading cause of death in 0-4
yrs old
(Arciaga)
most common cause is H. influenzae and S.
pneumoniae
<1 yr old - Gram negative bacilli
Group B streptococcus is an infrequent cause of
meningitis and Listeria monocytogenes has not
been isolated in CSF cultures
For a developing country with limited resources, the
most cost-effective drug must be used.

13. Carlos C, et al. (Philippine) Antimicrobial Resistance Surveillance Program,
January-December, 2000
3
4
11
0
2
4
6
8
10
12
%resistance
AMP CHL SXT
Percent resistance of
Hemophilus influenzae, 2000
No significant resistance of H. influenzae to
cotrimoxazole, ampicillin and chloramphenicol
The three drugs are still recommended for use for
H. influenzae

14. Higher resistance to penicillin than 1999
Only 13(18%) of 72 resistance isolates were sent for
confirmation of which only 4(6%) were truly penicillin
resistant by MIC
True extent of penicillin resistant S. pneumoniae still
unknown
7
18.4
11.8
0
2
4
6
8
10
12
14
16
18
20
%
resistance
CHL PEN SXT
Percent resistance of Streptococcus
pneumoniae 2000

15. 3.7
76.3
33.6
5.8
19.1
56.2
1.9
0
10
20
30
40
50
60
70
80
%
resistance
AMIK AMP AMS CRO GEN SXT FEP
Percent resistance of
Escherichia coli , 2000
8.9
40
13.6
23.9
0.7
2.6
0
5
10
15
20
25
30
35
40
%
resistance
AMK AMS CRO GEN IMP FEP
Percent resistance of
Klebsiella spp, 2000
13.9
33.9
17.6
32.5
14.0
7.4
0
5
10
15
20
25
30
35
%
resistance
AMK CIP CAZ GEN IMP FEP
Percent resistance of
Pseudomonas aeruginosa , 2000
Pseudomonas aeruginosa- resistance was
generally higher than 1999.
Many Enterobacteriacae show high
resistance rates.
Aminoglycosides have high resistance
rates.
Physicians should base their treatment
recommendations for gram negative
bacilli on their region’s prevailing
resistance patterns.

16. Empiric Therapy for Bacterial Meningitis
Patient
group
Likely etiology Antimicrobial choice
Primary Alternative
0-2 mos E. coli
Gram (-) bacilli
S. pneumoniae
Ampicillin or
Penicillin +
Aminoglycoside
Ampicillin +
Cefotaxime or
Ceftriaxone
2mos – 5 yrs H. influenzae
S. pneumoniae
N. meningitidis
Ampicillin or
Chloramphenicol
Cefotaxime or
Ceftriaxone
>5 yrs S. pneumoniae
N. meningitidis
Penicillin G Chloramphenicol

17. Empiric Therapy for Bacterial Meningitis
Patient group Likely etiology Antimicrobial choice
Primary Alternative
Immunodeficient G(-) organisms
S. aureus
S. pneumoniae
Ampicillin +
Ceftazidime +
Aminoglycoside
TMP/SMX +
Ceftazidime +
Aminoglycoside
Neurosurgical
problems &
open head
trauma
S. pneumoniae
S. aureus
Coliforms
P. aeruginosa
Oxacillin +
Ceftazidime or
TMP/SMX
Ceftazidime +
Vancomycin
Closed head
trauma
S. pneumoniae Penicillin G Chloramphenicol
or Ceftriaxone or
Cefotaxime
Shunt meningitis
and
meningocoeles
S. epidermidis
S. aureus
Coliforms
Oxacillin +
Cefotaxime or
Ceftriaxone
Vancomycin +
Ceftriaxone or
Cefotaxime

18. Bacteria Standard therapy Alternative therapies
H. Influenzae
ß lactamase negative
ß lactamase positive
Ampicillin
Chloramphenicol
Chloramphenicol, 3rd gen Ceph1
Neissersia meningitidis
Penicillin MIC <0.1 µg/ml
Penicillin MIC >0.1 µg/ml
Penicillin
Chloramphenicol
Ampicillin
3rd gen Ceph
Streptococcus pneumoniae
Penicillin MIC <0.1 µg/ml
Penicillin MIC 0.1- 1.0 µg/ml
Penicillin MIC >2.0 µg/ml
Penicillin
3rd gen ceph
Vancomycin + 3rd gen ceph
Ampicillin, Chloramphenicol
Meropenem, Vancomycin
Meropenem
Enterobacteriaceae 3rd gen ceph Cefepime, Meropenem,
Cotrimoxazole
Pseudomonas aeruginosa Ceftazidime +
aminoglycoside
Cefepime, Meropenem +
aminoglycoside
Staphylococcus aureus
Methicillin sensitive
Methicillin resistant
Oxacillin or nafcillin
Vancomycin
Vancomycin
Specific Antimicrobial Therapy for Bacterial Meningitis*
Tunkel AR, Scheld WM, Amer Family Physician 1997, 56(5):1355-62

19. Duration of Therapy of
Bacterial Meningitis*
Pathogen Suggested duration
of therapy (days)
H. influenzae 7-10
S. pneumoniae 10-14
N. meningitidis 7
Grp. B. streptococci 14-21
G(-) bacilli 21
*Quagliarello, et al, NEJM 1997, 336(10):708-716

20. •
Rational for Use of Dexamethasone
The bacteria that have invaded the CSF
proliferate, undergo degradation, and release
toxins and techoic acids. The inflammatory
response is activated and principal mediators are
IL-1ß, TNF, PAF, PMN’s and macrophages.
promote leukocyte-cerebral capillary endothelial
cell interaction, platelet-mediated thrombosis,
and cytotoxic, interstitial and vasogenic edema
dexamethasone inhibits the synthesis of
interleukin 1 and TNF

21. Meta-analysis* of 11 trials
(mostly in developed countries)
dexamethasone given prior to antibiotics
reduces the incidence of hearing loss for
Hib meningitis, but did not decrease
mortality
*McIntyre et al. JAMA. 1997; 278:925-931

22. Dexamethasone studies from developing
countries
Islamabad (placebo controlled double-blind, 2mos-12 yrs on
Ampicillin and Chloramphenicol)- dexamethasone group had
increased risk of sequelae and worsened mortality
Pakistan*- (double-blind placebo controlled trial in 89
children)
Dexamethasone Placebo
Mortality 25% 12%
Neurologic sequelae 26.5% 24%
Hearing impairment 24% 30%
may be due to late presentation of patients; use of antibiotics prior to
hospital presentation; CSF results wherein no bacteria was isolated
1997 WHO Workshop on the Treatment of Bacterial Meningitis in
Developing Countries: Dexamethasone as routine adjuvant therapy
was NOT recommended

23. THE ROUTINE USE OF
DEXAMETHASONE IN
CHILDREN WITH BACTERIAL
MENINGITIS IN THE
PHILIPPINE SETTING IS NOT
RECOMMENDED*
*Task force Meningitis, PSMID

24. Use of Dexamethasone may be used:
a. in cases where the causative organism can
be reliably diagnosed, particularly those with
H. influenzae meningitis
b. in patients with markedly increased
intracranial pressure
- dose of 0.15 mg/kg/dose IV q 6 hrs for 2 days
- 1st dose of dexamethasone should be given
prior to or with the 1st dose of antibiotics
- give with an H2 antagonist

25. Supportive management
IV Fluids and hydration
maintain normal blood pressure, watch out
for SIADH
Control of increased intracranial pressure
Nutritional support
Prevention- chemoprophylaxis,
immunizations, infection control

26. Conclusions
Must come up with own guidelines
because conditions in other countries
are different and specific
recommendations may be inappropriate
for other settings
Local data is essential to provide a
rational approach to the management of
bacterial meningitis in children

27. TASK FORCE ON MENINGITIS*
SUBGROUP ON DIAGNOSIS
Lulu C. Bravo, MD
Aida Salonga, MD
Rose Capeding, MD
Ma. Liza Gonzales, MD
Rosalinda Soriano, MD
Enrique Carandang, MD
Michelle Medalla, MD
Mabel San Juan
SUBGROUP ON THERAPY
Salvacion R. Gatchalian, MD
(Chairman of Task Force)
Malen Ortiz, MD
Rosemarie Arciaga, MD
Estrella Paje-Villar, MD
Celia Carlos, MD
Elaine Galicia, MD
Cecilia Maramba-Untalan, MD
Grace Martinez, MD
Ms. Jenny Panisales
•SUBGROUP ON PREVENTION
Josefina Carlos, MD
Prof. Grace Agustin
Prof. Victoria Vidal
Cleotilde How, MD
Mary Anne Banez, MD
Ms. Racquel Ardiente
Lorna Abad, MD
*convened by Philippine Society of
Microbiology and Infectious Diseases