ACUTE BAKTERIAL

ACUTE BAKTERIAL
MENINGITIS IN
MENINGITIS IN
INFANT AND CHILDREN
INFANT AND CHILDREN
DR.
DR.
Dr. H. Ruslan Muhyi, Sp. A (K
Dr. H. Ruslan Muhyi, Sp. A (K
SMF!Ba"ian Il#u K$s$ha%an Ana&
SMF!Ba"ian Il#u K$s$ha%an Ana&
RSUD Ulin'FK UNLAM
RSUD Ulin'FK UNLAM
Ban(ar#asin
Ban(ar#asin
BACTERIAL MENINGITIS
BACTERIAL MENINGITIS

Is an acute purulent infection in the

Is an acute purulent infection in the
subarachnoid space that is associated with
subarachnoid space that is associated with
inflammation reaction in the brain and cerebral
inflammation reaction in the brain and cerebral
blood vessels that cause decreased
blood vessels that cause decreased
conciuosness, seizure, raised intracranial
conciuosness, seizure, raised intracranial
pressure, and stroke.
pressure, and stroke.

Is inflammation of the meningens caused by a

Is inflammation of the meningens caused by a
bacterial pathogen.
bacterial pathogen.
INCIDENCE
INCIDENCE

In Asia, there is increasing incidence of

In Asia, there is increasing incidence of
H influenzae
H influenzae
type b (Hib)
type b (Hib)
. Previously,
. Previously,
Salmonella
Salmonella
,
,
S pneumoniae
S pneumoniae

and
and
M tuberculosis
M tuberculosis
.
.

In USA, .! to ".! cases per #$$,$$$ population.

In USA, .! to ".! cases per #$$,$$$ population.

H influenzae type b
H influenzae type b
declined %# cases #&'( to $.(
declined %# cases #&'( to $.(
per #$$,$$$ in #&&(.
per #$$,$$$ in #&&(.

)oday the most common bacterial*

)oday the most common bacterial*
Streptococcus
Streptococcus
pneumoniae
pneumoniae
,
,
N meningitidis
N meningitidis
, and
, and
H influenzae
H influenzae
.
.
MENINGITIS
MENINGITIS

+lassified into two syndromes *

+lassified into two syndromes *
Septic or purulent meningitis is caused by bacterial
Septic or purulent meningitis is caused by bacterial
or fungal organism.
or fungal organism.
Aseptic meningitis is caused by viral, neoplastic,
Aseptic meningitis is caused by viral, neoplastic,
protozoal, spirochetal or other non septic causes.
protozoal, spirochetal or other non septic causes.
)**l$+ in,*r#a%i*n ,r*# -./0 1as$ *, #$nin"i%is )**l$+ in,*r#a%i*n ,r*# -./0 1as$ *, #$nin"i%is
Fi". Dis%ri2u%i*n *, %h$ #*s% 1*##*n 1aus$s *, n$*na%al #anin"i%is Fi". Dis%ri2u%i*n *, %h$ #*s% 1*##*n 1aus$s *, n$*na%al #anin"i%is
3
2
3
2
3
1
4.5
4
8
6
30
34
Others
Meningococcus
Pseudomonas spp
Haemophilus
Pneumococcus
Salmonella spp
Staphlococci
Other streptococci
Other gram negati!e
"isteria spp
#roup $ strep
%. coli
TABLE. Es%i#a%$+ a"$'sp$1i,i& in1i+$n1$ *,
TABLE. Es%i#a%$+ a"$'sp$1i,i& in1i+$n1$ *,
2a1%$rial #$nin"i%is (1as$s p$r -33,333
2a1%$rial #$nin"i%is (1as$s p$r -33,333
p*pula%i*n, Uni%$+ S%a%$s, -44/
p*pula%i*n, Uni%$+ S%a%$s, -44/
Adapted from Schuchat A, Robinson K, Wenger JD, et al. Adapted from Schuchat A, Robinson K, Wenger JD, et al.
Bacterial meningitis in the United States in 1!. " #ngl J Bacterial meningitis in the United States in 1!. " #ngl J
$ed 1%&''%&%( $ed 1%&''%&%(
Age group Age group Haemophilus Haemophilus
influenzae influenzae
Streptococcus Streptococcus
pneumoniae pneumoniae
Neiseria Neiseria
meningitis meningitis
Group B Group B
Streptococcus Streptococcus
Listeria Listeria
, # mo , # mo $ $ #!.( #!.( $ $ #!.$ #!.$ "&. "&.
#-" mo #-" mo $.( $.( ... ... %.! %.! .' .' $ $
#-& yr #-& yr $.# $.# $.! $.! #.# #.# $.# $.# $.$% $.$%
CLINICAL )RESENTATI5N
CLINICAL )RESENTATI5N
)here are two patterns of presentation *
)here are two patterns of presentation *
)he first is more insidious and develops over one
)he first is more insidious and develops over one
or several day.
or several day.
)he other is more acute and fulminant. Usually
)he other is more acute and fulminant. Usually
with severe brain edema and herniation
with severe brain edema and herniation
Signs and Symptoms of Bacterial Meningitis
Signs and Symptoms of Bacterial Meningitis
Fever Fever
Depression of consciousness Depression of consciousness
/ull fontanel /ull fontanel
Irritability Irritability
Seizures Seizures
0eadache 0eadache
/ocal neurologic deficits /ocal neurologic deficits
Petechial skin rash Petechial skin rash
Ta2l$ 0. Clini1al si"ns *, n$*na%al
Ta2l$ 0. Clini1al si"ns *, n$*na%al
2a1%$rial #$nin"i%is
2a1%$rial #$nin"i%is
Source : Source : Frequencies from Klein & Marey (1995) Frequencies from Klein & Marey (1995)
Symptoms Symptoms Percentage Percentage Signs Signs Percentage Percentage
Lethargy Lethargy !$ !$ Fever or hypothermia Fever or hypothermia .# .#
Anore1ia Anore1ia Respiratory distress Respiratory distress %( %(
Vomiting Vomiting %& %& Irritability Irritability " "
2iarrhea 2iarrhea 3aundice 3aundice ' '
Convulsions Convulsions %$ %$ /ull4bulging fontanelle /ull4bulging fontanelle ' '
Apnea Apnea ( ( 5eck stiffness 5eck stiffness #! #!
Altered sleep pattern Altered sleep pattern 0ipotonia 0ipotonia
0igh-pitched cry 0igh-pitched cry Petechiae Petechiae
0ypotension, shock 0ypotension, shock
6radycardia 6radycardia
Ta2l$ -. INCIDENCE AND M5RTALIT6 RATES IN
Ta2l$ -. INCIDENCE AND M5RTALIT6 RATES IN
ACUTE BACTERIAL MENINGITIS
ACUTE BACTERIAL MENINGITIS
5A 7 not available 5A 7 not available
Organism Organism
Children Children
Incidence !" Incidence !" #ortality rate !" #ortality rate !"
S pneumoniae S pneumoniae #$-$ #$-$ ' '
N meningitidis N meningitidis !-%$ !-%$ #! #!
H influenzae H influenzae %$-.$ %$-.$ % %
Gram negati!e bacilli Gram negati!e bacilli #- #- 5A 5A
S aureus S aureus #- #- 5A 5A
Streptococci Streptococci -% -% 5A 5A
L monocytogenes L monocytogenes #- #- '-!$ '-!$
Anaerobes Anaerobes #- #- 5A 5A
E7ALUATI5N 5F THE )ATIENT 8ITH ACUTE BACTERIAL E7ALUATI5N 5F THE )ATIENT 8ITH ACUTE BACTERIAL
MENINGITIS MENINGITIS
$%C&'RI%L C'LL (%LL CO#PO)')&S $%C&'RI%L C'LL (%LL CO#PO)')&S
8ndotelial +ells 8ndotelial +ells +5S-9acrophages +5S-9acrophages 8ndoto1in Shock 8ndoto1in Shock
)5/, I:-#, PA/ )5/, I:-#, PA/
I:-# I:-#
P;8 P;8

)rombosis )rombosis < < +S/ pleocytosis +S/ pleocytosis
Impaired 666 Impaired 666 Infarction Infarction 0ydrocephalus 0ydrocephalus = = Perfusion Perfusion
8dema 8dema
< < I+P I+P < < +6/ +6/ 9icrocirculatory /ailure 9icrocirculatory /ailure
CSF E9a#ina%i*n in Susp$1%$+ Ba1%$rial
CSF E9a#ina%i*n in Susp$1%$+ Ba1%$rial
M$nin"i%is
M$nin"i%is
Routin test Routin test
Gram Gram s Stain (60-90%) s Stain (60-90%)
acterial culture an! sensiti"ities (#0-$5%) acterial culture an! sensiti"ities (#0-$5%)
%ell count an! !ifferential %ell count an! !ifferential
Glucouse Glucouse
&rotein &rotein
acterial anti'en (50-100%) acterial anti'en (50-100%)
Special test Special test
%ulture for tu(erculosis) fun'us)"irus %ulture for tu(erculosis) fun'us)"irus
*!!itional (acterial anti'en stu!ies *!!itional (acterial anti'en stu!ies
Serolo'y Serolo'y
%ry+tococcus anti'en %ry+tococcus anti'en
,n!ia in- ,n!ia in-
%occi!ioi!oruycosis %occi!ioi!oruycosis
&olymerase c.ain reaction &olymerase c.ain reaction
Ta2$l 0. CEREBR5S)INAL FLUID FINDINGS IN
Ta2$l 0. CEREBR5S)INAL FLUID FINDINGS IN
BACTERIAL
BACTERIAL
MENINGITIS
MENINGITIS
+S/ * +erebrospinal /luid +S/ * +erebrospinal /luid
)ormal )ormal $acterial meningitis $acterial meningitis
>pening pressure >pening pressure !$-#&! mm +S/ !$-#&! mm +S/
?".'-#! mm 0g@ ?".'-#! mm 0g@
A$$ mm+S/ A$$ mm+S/
+ell count +ell count ,! cells4mm ,! cells4mm
" "
?#!B neutrophils@ ?#!B neutrophils@
#$$-#$,$$$ cells4mm #$$-#$,$$$ cells4mm
" "
?'.B neutrophils@ ?'.B neutrophils@
Protein Protein #!-!$ mg4d: #!-!$ mg4d: #$$ to !$$ mg4d: #$$ to !$$ mg4d:
;lucose ;lucose %!-'$ mg4d: %!-'$ mg4d: usually ,$-%$ mg4d: usually ,$-%$ mg4d:
+S/ ;lucose Catio +S/ ;lucose Catio A$.! A$.! ,$.% ,$.%
TREATMENT
TREATMENT
)wo critical decisions must be consider *
)wo critical decisions must be consider *
)he first concern the choice of antibiotic
)he first concern the choice of antibiotic
therapy.
therapy.
)he second, the benefits versus the risk of
)he second, the benefits versus the risk of
doing a lumbar puncture.
doing a lumbar puncture.
E7ALUATI5N 5F THE )ATIENT 8ITH ACUTE BACTERIAL MENINGITIS E7ALUATI5N 5F THE )ATIENT 8ITH ACUTE BACTERIAL MENINGITIS
Mil+ Mil+
-Irritability -Irritability
-:ethargy -:ethargy
-0eadache -0eadache
-Domiting -Domiting
-5urchal rigidity -5urchal rigidity
M*+$ra%$ M*+$ra%$
-Seizures -Seizures
-/ocal deficit -/ocal deficit
-+onsciousness -+onsciousness
-Papilledema -Papilledema
S$:$r$ S$:$r$
-Status epilepticus -Status epilepticus
-Persistent deficit -Persistent deficit
-+oma -+oma
-0erniation -0erniation
Lu#2ar Lu#2ar
)un1%ur$; )un1%ur$;
S%ar% S%ar%
An%i2i*%i1s An%i2i*%i1s
An+ S%$r*i+s An+ S%$r*i+s
S%ar% S%ar%
An%i2i*%i1s An%i2i*%i1s
An+ S%$r*i+s An+ S%$r*i+s
An+ D* CT *r An+ D* CT *r
MRI S1an MRI S1an
< < IC) IC)
NL IC) NL IC)
Lu#2ar Lu#2ar
)un1%ur$ )un1%ur$
CT *r MRI S1an an+ Tr$a%
52s$r:$
IC)
NL IC)
Tr$a%
52s$r:$
DELA6ED L)
DELA6ED L)

Intravenous antibiotics used for to " days

Intravenous antibiotics used for to " days
prior to lumbar puncture do not alter the +S/
prior to lumbar puncture do not alter the +S/
cells count, or protein or glucose
cells count, or protein or glucose
concentrations.
concentrations.

Substantially decrease the chance of

Substantially decrease the chance of
demonstrating bacteria on ;ram stain or
demonstrating bacteria on ;ram stain or
culture.
culture.
TABLE 0. REC5MMENDATI5N F5R ANTIBI5TIC THERA)6 IN TABLE 0. REC5MMENDATI5N F5R ANTIBI5TIC THERA)6 IN
)ATIENTS 8ITH BACTERIAL MENINGITIS )ATIENTS 8ITH BACTERIAL MENINGITIS
&*P' $%C&'RI% &*P' $%C&'RI% C+OIC' OF %)&I$IO&IC C+OIC' OF %)&I$IO&IC
On ,ram-s staining On ,ram-s staining
Cocci Cocci
;ram-positive ;ram-positive
;ram-negative ;ram-negative
Dancomycin plus broad-spectrum cephalosporin Dancomycin plus broad-spectrum cephalosporin
Penicillin ; Penicillin ;
$acilli $acilli
;ram-positive ;ram-positive
;ram-negative ;ram-negative
Ampicillin ?or Penicillin ;@ plus aminoglycoside Ampicillin ?or Penicillin ;@ plus aminoglycoside
6road-spectrum cephalosporin plus aminoglycoside 6road-spectrum cephalosporin plus aminoglycoside
Ta2l$ 0. REC5MMENDATI5N F5R ANTIBI5TIC THERA)6 IN Ta2l$ 0. REC5MMENDATI5N F5R ANTIBI5TIC THERA)6 IN
)ATIENTS 8ITH BACTERIAL MENINGITIS )ATIENTS 8ITH BACTERIAL MENINGITIS
&*P' $%C&'RI% &*P' $%C&'RI% C+OIC' OF %)&I$IO&IC C+OIC' OF %)&I$IO&IC
On culture On culture
S pneumoniae S pneumoniae Dancomycin plus broad-spectrum cephalosporin Dancomycin plus broad-spectrum cephalosporin
H influenzae H influenzae +eftria1one +eftria1one
N meningitidis N meningitidis Penicillin ; Penicillin ;
L monocytogenes L monocytogenes Ampicillin plus gentamicin Ampicillin plus gentamicin
S agalactiae S agalactiae Penicillin ; Penicillin ;
8nterobactericeae 8nterobactericeae 6road-spectrum cephalosporin plus aminoglycoside 6road-spectrum cephalosporin plus aminoglycoside
"seudomonas aeruginosa "seudomonas aeruginosa, ,
acinetobacter acinetobacter
+eftazidime plus aminoglycoside +eftazidime plus aminoglycoside
Th$ A#$ri1an A1a+$#i1 *,
Th$ A#$ri1an A1a+$#i1 *,
)$+ia%ri1s r$1*##$n+$+
)$+ia%ri1s r$1*##$n+$+

2e1amethasone, $.. mg4kg per day in four

2e1amethasone, $.. mg4kg per day in four
divided doses for the first two days of
divided doses for the first two days of
antibiotic treatment.
antibiotic treatment.

)he first dose should be given at the time of,

)he first dose should be given at the time of,
or shortly before the first dose of antibiotic.
or shortly before the first dose of antibiotic.
E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
in n$*na%us
in n$*na%us
./0 days ./0 days Ampicillin #!$ mg4kg4d divided dose every ' hours ID plus Ampicillin #!$ mg4kg4d divided dose every ' hours ID plus
cefota1ime #$$ mg4kg4d divided dose every # hours ID cefota1ime #$$ mg4kg4d divided dose every # hours ID
or or
+eftria1one !$ mg4kg4d every % hours ID +eftria1one !$ mg4kg4d every % hours ID
or or
Ampicillin #!$ mg4kg4d divided dose every ' hours ID plus Ampicillin #!$ mg4kg4d divided dose every ' hours ID plus
gentamicin ! mg4kg4d divided dose every # hours ID gentamicin ! mg4kg4d divided dose every # hours ID
E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
in n$*na%us
in n$*na%us
1 0 days 1 0 days Ampicillin $$ mg4kg4d divided dose every . hours Ampicillin $$ mg4kg4d divided dose every . hours
ID ID
%)D %)D
+efota1ime #!$ mg4kg4d divided dose every ' hours +efota1ime #!$ mg4kg4d divided dose every ' hours
ID ID
or or
+eftria1one (! mg4kg4d every % hours ID +eftria1one (! mg4kg4d every % hours ID
Ta2l$ <. E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
Ta2l$ <. E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
2/3 months 2/3 months Ampicillin $$-%$$ mg4kg4d divided dose every . Ampicillin $$-%$$ mg4kg4d divided dose every .
hours ID hours ID %)D %)D
+efota1ime $$ mg4kg4d divided dose every . hours +efota1ime $$ mg4kg4d divided dose every . hours
ID ID or or
+eftria1one #$$ mg4kg4d divided dose every # +eftria1one #$$ mg4kg4d divided dose every #
hours ID or '$ mg4kg daily ID4I9 hours ID or '$ mg4kg daily ID4I9
Add vancomicyn .$ mg4kg4d ID divided dose every Add vancomicyn .$ mg4kg4d ID divided dose every
. hours ID if penicillin-resistant . hours ID if penicillin-resistant S pneumococcus S pneumococcus
suspected suspected
Ta2l$ <. E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
Ta2l$ <. E#piri1 %h$rapy ,*r a1u%$ 2a1%$rial #$nin"i%is
1 3 months 1 3 months +efota1ime $$ mg4kg4d divided dose every .-' +efota1ime $$ mg4kg4d divided dose every .-'
hours ID hours ID or or
+eftria1one #$$ mg4kg4d divided dose every # +eftria1one #$$ mg4kg4d divided dose every #
hours ID or '$ mg4kg daily ID4I9 hours ID or '$ mg4kg daily ID4I9 or or
Ampicillin $$ mg4kg4d divided dose every . hours Ampicillin $$ mg4kg4d divided dose every . hours
ID ID PL4S PL4S
+hloramphenicol #$$ mg4kg4 d divided dose every . +hloramphenicol #$$ mg4kg4 d divided dose every .
hours IDE hours IDE
Add vancomicyn .$ mg4kg4d ID divided dose every Add vancomicyn .$ mg4kg4d ID divided dose every
. hours ID if penicillin-resistant . hours ID if penicillin-resistant S pneumococcus S pneumococcus
suspected suspected
TABLE =. GUIDELINES F5R THE DURATI5N
TABLE =. GUIDELINES F5R THE DURATI5N
5F ANTIBI5TIC THERA)6
5F ANTIBI5TIC THERA)6
P%&+O,') P%&+O,') S4,,'S&'D D4R%&IO) S4,,'S&'D D4R%&IO)
OF &+'R%P* D%*S" OF &+'R%P* D%*S"
H influenzae H influenzae - -
N meningitidis N meningitidis - -
S pneumoniae S pneumoniae #$-#% #$-#%
L monocytogenes L monocytogenes #%-# #%-#
;roup 6 streptococcus ;roup 6 streptococcus #%-# #%-#
;ram negative bacilli ?other than ;ram negative bacilli ?other than
H influenzae H influenzae@ @
# #
Complications during Acute Bacterial Meningitis
Complications during Acute Bacterial Meningitis
Common Common
Increased intracranial pressure Increased intracranial pressure
SIA20 SIA20
Dentriculomegaly Dentriculomegaly
Seizures Seizures
81tra-a1ial fluid collection 81tra-a1ial fluid collection
Infarction and necrosis Infarction and necrosis
+ranial nerve involvement ?deafness@ +ranial nerve involvement ?deafness@
2isseminated intravascular coagulation 2isseminated intravascular coagulation
4ncommon 4ncommon
Subdural empyema Subdural empyema
6rain abscess 6rain abscess
+ranial nerve deficits other than DIII +ranial nerve deficits other than DIII
Ta2l$. Tr$a%#$n% *, %h$ S$ri*usly III )a%i$n% >i%h M$nin"i%is Ta2l$. Tr$a%#$n% *, %h$ S$ri*usly III )a%i$n% >i%h M$nin"i%is
SC%) R'S4L&S SC%) R'S4L&S
I)&R%CR%)I%L PR'SS4R' #'%S4R'#')& I)&R%CR%)I%L PR'SS4R' #'%S4R'#')&
I)CR'%S'D I)CR'%S'D
5ormal 5ormal 0yperventilate to reduce increased cerebral blood volume 0yperventilate to reduce increased cerebral blood volume
8dema 8dema 2o not hyperventilateE use furosemid or mannitol restrict fluids 2o not hyperventilateE use furosemid or mannitol restrict fluids
Acute ventriculomegaly, Acute ventriculomegaly,
hydrocephalus or enlarged hydrocephalus or enlarged
subarachnoid spaces subarachnoid spaces
Cemove +S/ by ventricular tap or drainE decrease +S/ Cemove +S/ by ventricular tap or drainE decrease +S/
production ?2iamo1 or digo1in@E increase +S/ production ?2iamo1 or digo1in@E increase +S/
reabsorption ?steroids@ reabsorption ?steroids@
Subdural effusions Subdural effusions Subdural drainage Subdural drainage
Infarcts Infarcts Steroids to reduce peri-infarct edema Steroids to reduce peri-infarct edema
Fun+a#$n%al prin1ipl$s %* %h$
Fun+a#$n%al prin1ipl$s %* %h$
#ana"$#$n% *, #$nin"i%is
#ana"$#$n% *, #$nin"i%is

Antibiotic therapy should be prompt and

Antibiotic therapy should be prompt and
appropiate
appropiate

+erebral metabolisme should be protected

+erebral metabolisme should be protected

Increased intracranial pressure should be

Increased intracranial pressure should be
monitor
monitor

Seizure should be prevented or controlled

Seizure should be prevented or controlled

/luid management
/luid management

0yperpyre1ia should be controlled

0yperpyre1ia should be controlled
)$n$%ra%i*n *, an%i2a1%$rials in%* CNS
)$n$%ra%i*n *, an%i2a1%$rials in%* CNS
Sources / ,nfectious 0isease in 1mer'ency Me!icine2 3u!it. %2 Sources / ,nfectious 0isease in 1mer'ency Me!icine2 3u!it. %2
rillman & 4onal! rillman & 4onal!
%nti5iotics %nti5iotics )ormal meninges )ormal meninges #eningitis #eningitis
Penicillins Penicillins
Penicillins ; Penicillins ; Poor Poor /air-good /air-good
Ampicillin Ampicillin Poor Poor /air-good /air-good
9ethicillin 9ethicillin Poor Poor - -
5afcillin 5afcillin - - /air /air
Cephalosporins Cephalosporins
+efazolin +efazolin Poor Poor /air-good /air-good
+efota1imes +efota1imes ;ood ;ood ;ood ;ood
+eftria1one +eftria1one ;ood ;ood ;ood ;ood
+eftazidime +eftazidime ;ood ;ood ;ood ;ood
&etracyclines &etracyclines
)etracycline )etracycline - - /air /air
>1ytetracycline >1ytetracycline - - /air /air
+hlortetracycline +hlortetracycline - - /air /air
)$n$%ra%i*n *, an%i2a1%$rials in%* CNS
)$n$%ra%i*n *, an%i2a1%$rials in%* CNS
Sources / ,nfectious 0isease in 1mer'ency Me!icine2 3u!it. %2 Sources / ,nfectious 0isease in 1mer'ency Me!icine2 3u!it. %2
rillman & 4onal! rillman & 4onal!
%nti5iotics %nti5iotics )ormal meninges )ormal meninges #eningitis #eningitis
%minoglycosides %minoglycosides
;entamycin ;entamycin Poor Poor /air /air
Amikasin Amikasin - - Poor Poor
Cifampin Cifampin
Fair Fair ;ood ;ood
%y+rooflo5acin %y+rooflo5acin Fair Fair /air /air
#iscellaneus anti5acterials #iscellaneus anti5acterials
+hloramphenicol +hloramphenicol ;ood ;ood ;ood ;ood
+lindamycin +lindamycin Poor Poor /air /air
9etronidazole 9etronidazole - - ;ood ;ood
)rimetrophin )rimetrophin ;ood ;ood ;ood ;ood
Dancomycin Dancomycin Poor Poor
Goo! Goo!
Ta2l$. C*#pli1a%i*ns an+ *u%1*#$ *, pa%i$n% >i%h a1u%$
Ta2l$. C*#pli1a%i*ns an+ *u%1*#$ *, pa%i$n% >i%h a1u%$
2a1%$rial #$nin"i%is
2a1%$rial #$nin"i%is
+hildren +hildren
?B@ ?B@
Complications Complications
Acute suizures Acute suizures "# "#
+ranial nerve palsies +ranial nerve palsies "-! "-!
2eafness 2eafness #$ #$
/ocal neurologic defisits /ocal neurologic defisits %-#! %-#!
0ydrocephalus 0ydrocephalus -$ -$
+erebrovascular involvement +erebrovascular involvement -# -#
+erebral edema +erebral edema -' -'
+erebral nervous system hemorrhage +erebral nervous system hemorrhage
0erniation 0erniation -. -.
9ental retardation 9ental retardation %-. %-.
8pilepsy 8pilepsy %-( %-(
Outcome Outcome
;ood recovery4mild disability ;ood recovery4mild disability '%-'' '%-''
Severe4moderate disability Severe4moderate disability '-#% '-#%
Persistent vegetatif state Persistent vegetatif state #- #-
2ead 2ead -! -!
Guidelines for acceptable CSF
Guidelines for acceptable CSF
values At the end of therapy
values At the end of therapy
12 12
6.e +ercenta'e of +olymor+.onuclear
6.e +ercenta'e of +olymor+.onuclear
leucocytes (&M7s) in t.e %SF is more
leucocytes (&M7s) in t.e %SF is more
im+ortant t.an t.e a(solute 8.ite (loo!
im+ortant t.an t.e a(solute 8.ite (loo!
cell (9%) count an! is usually 5
cell (9%) count an! is usually 5
+ercent) (ut s.oul! not e5cee! :5-;0
+ercent) (ut s.oul! not e5cee! :5-;0
+ercent of t.e total 9%2
+ercent of t.e total 9%2
:2 :2
6.e %SF 'lucose concentration s.oul!
6.e %SF 'lucose concentration s.oul!
e5cee! :0 m'<!l an! (e more t.an :0
e5cee! :0 m'<!l an! (e more t.an :0
+ercent of a concomitantly o(taine!
+ercent of a concomitantly o(taine!
serum 'lucose2
serum 'lucose2
Ta2l$ -. INCIDENCE AND M5RTALIT6 RATES IN
Ta2l$ -. INCIDENCE AND M5RTALIT6 RATES IN
ACUTE BACTERIAL MENINGITIS
ACUTE BACTERIAL MENINGITIS
5A 7 not available 5A 7 not available
Organism Organism
Children Children
Incidence !" Incidence !" #ortality rate !" #ortality rate !"
S pneumoniae S pneumoniae #$-$ #$-$ ' '
N meningitidis N meningitidis !-%$ !-%$ #! #!
H influenzae H influenzae %$-.$ %$-.$ % %
Gram negati!e bacilli Gram negati!e bacilli #- #- 5A 5A
S aureus S aureus #- #- 5A 5A
Streptococci Streptococci -% -% 5A 5A
L monocytogenes L monocytogenes #- #- '-!$ '-!$
Anaerobes Anaerobes #- #- 5A 5A
Fi"ur$ 00.- )a%h*physi*l*"y *, 2a1%$rial #$nin"i%is Fi"ur$ 00.- )a%h*physi*l*"y *, 2a1%$rial #$nin"i%is
Hyp*9ia
La1%a%$ Bl**+ ,l*>
= Glu1*s$
< In%ra1ranial
)r$ssur$
I##un$
#*+ula%*rs
E+$#a
Ba1%$ria
)$p%i+*"ly1an
T$i1h*i1 a1i+
En+*%*9in
< )$r#$a2ili%y
2l**+'2rain
2ari$r
C$ll +a#a"$
Lethal to infants
Lethal to infants

Menin'itis infects t.e mem(ranes

Menin'itis infects t.e mem(ranes
co"erin' t.e (rain) an! it is al8ays
co"erin' t.e (rain) an! it is al8ays
treate! as a me!ical emer'ency
treate! as a me!ical emer'ency

7ational =ealt. an! Me!ical

7ational =ealt. an! Me!ical
4esearc. %ouncil (*>S) su''est t.at
4esearc. %ouncil (*>S) su''est t.at
!octors s.oul! 'i"e t.e first !oses of
!octors s.oul! 'i"e t.e first !oses of
anti(iotic (efore a c.il! 'oes to
anti(iotic (efore a c.il! 'oes to
.os+ital
.os+ital

,m+ortant to (e a 8are of t.e si'n of

,m+ortant to (e a 8are of t.e si'n of
menin'itis an! act quic-ly
menin'itis an! act quic-ly
Acute bacterial meningitis
Acute bacterial meningitis

* .i'. in!e5 of sus+icion is require!

* .i'. in!e5 of sus+icion is require!
to !ia'nose t.is con!ition 8.ic.) if
to !ia'nose t.is con!ition 8.ic.) if
un!etecte! an! untreate!) can lea!
un!etecte! an! untreate!) can lea!
to si'nificant mor(i!ity or !eat.2
to si'nificant mor(i!ity or !eat.2
Ta2l$ 00.0 Clini1al si"ns *, 2a1%$rial
Ta2l$ 00.0 Clini1al si"ns *, 2a1%$rial
#$nin"i%is
#$nin"i%is
Source : Source : Frequencies from Klein & Marey (1995) Frequencies from Klein & Marey (1995)
Symptoms Symptoms Percentage Percentage Signs Signs Percentage Percentage
Lethargy Lethargy !$ !$ Fever or hypothermia Fever or hypothermia .# .#
Anore1ia Anore1ia Respiratory distress Respiratory distress %( %(
Vomiting Vomiting %& %& Irritability Irritability " "
2iarrhea 2iarrhea 3aundice 3aundice ' '
Convulsions Convulsions %$ %$ /ull4bulging fontanelle /ull4bulging fontanelle ' '
Apnea Apnea ( ( 5eck stiffness 5eck stiffness #! #!
Altered sleep pattern Altered sleep pattern 0ipotonia 0ipotonia
0igh-pitched cry 0igh-pitched cry Petechiae Petechiae
0ypotension, shock 0ypotension, shock
6radycardia 6radycardia
Ta2l$ -. C*#pli1a%i*ns an+ 5u%1*#$ In A1u%$ Ba1%$rial M$nin"i%is Ta2l$ -. C*#pli1a%i*ns an+ 5u%1*#$ In A1u%$ Ba1%$rial M$nin"i%is
+hildren +hildren
?B@ ?B@
Complications Complications
Acute suizures Acute suizures "# "#
+ranial nerve palsies +ranial nerve palsies "-! "-!
2eafness 2eafness #$ #$
/ocal neurologic defisits /ocal neurologic defisits %-#! %-#!
0ydrocephalus 0ydrocephalus -$ -$
+erebrovascular involvement +erebrovascular involvement -# -#
+erebral edema +erebral edema -' -'
+erebral nervous system hemorrhage +erebral nervous system hemorrhage
0erniation 0erniation -. -.
9ental retardation 9ental retardation %-. %-.
8pilepsy 8pilepsy %-( %-(
Outcome Outcome
;ood recovery4mild disability ;ood recovery4mild disability '%-'' '%-''
Severe4moderate disability Severe4moderate disability '-#% '-#%
Persistent vegetatif state Persistent vegetatif state #- #-
2ead 2ead -! -!
&%$L' 26 Chronic complications of
&%$L' 26 Chronic complications of
5acterial meningitis
5acterial meningitis
0earing loss 0earing loss
6ehavior disorders 6ehavior disorders
9ental retardation 9ental retardation
5europsychiatric dysfunction 5europsychiatric dysfunction
Seizures Seizures
Auditory disfunction Auditory disfunction
Spasticity, paresis Spasticity, paresis
2iabetes insipidus 2iabetes insipidus
0ydrocephalus 0ydrocephalus
)ransverse myelitis )ransverse myelitis
6lindness 6lindness
Polyarteritis Polyarteritis
Ta2l$ <. An%i2i*%i1s R$1*##$n+$+ ,*r E#piri1al Th$rapy in Ta2l$ <. An%i2i*%i1s R$1*##$n+$+ ,*r E#piri1al Th$rapy in
)a%i$n%s 8i%h Susp$1%$+ Ba1%$rial M$nin"i%is 8h* Ha:$ A )a%i$n%s 8i%h Susp$1%$+ Ba1%$rial M$nin"i%is 8h* Ha:$ A
N*n+ia"n*s%i1 Gra#?s S%ain *, C$r$2r*spinal Flui+ N*n+ia"n*s%i1 Gra#?s S%ain *, C$r$2r*spinal Flui+
,roup of Patients ,roup of Patients Li7ely Pathogen Li7ely Pathogen Choice of %nti5iotic Choice of %nti5iotic
Immunocomperent Immunocomperent
Age, , " mo Age, , " mo

Age, " mo to ,#' yr Age, " mo to ,#' yr
S agalactiae# $ coli S agalactiae# $ coli or or L L
monocytogenes monocytogenes
N meningitidis# S pneumoniae# N meningitidis# S pneumoniae#
H influenzae H influenzae
Ampicillin plus broad- Ampicillin plus broad-
spectrum cephalosporin spectrum cephalosporin
6road-spectrum cephalosporin 6road-spectrum cephalosporin
Fith impired cellular Fith impired cellular L monocytogenes L monocytogenes or gram- or gram-
negative bacilli negative bacilli
Ampicillin plus ceftazidine Ampicillin plus ceftazidine
Fith head trauma, Fith head trauma,
neurosurgery, or neurosurgery, or
cerebrospinal fluid cerebrospinal fluid
shunt shunt
Staphylococci, gram-negative Staphylococci, gram-negative
bacilli, or bacilli, or S pneumoniae S pneumoniae
Dancomycin and ceftazidine Dancomycin and ceftazidine
6.e *merican *ca!emy of &e!iatrics
6.e *merican *ca!emy of &e!iatrics
(**&) recommen!e! in 199# /
(**&) recommen!e! in 199# /
?ancomycin +lus %efota5im or
?ancomycin +lus %efota5im or
%eftria5one s.oul! (e a!ministere!
%eftria5one s.oul! (e a!ministere!
initially to all c.il!ren ol!er t.an 1
initially to all c.il!ren ol!er t.an 1
mont. 8it. !efinite or +ro(a(le
mont. 8it. !efinite or +ro(a(le
(acterial menin'itis2
(acterial menin'itis2