ACUTE BAKTERIAL

MENINGITIS IN
INFANT AND CHILDREN

DR. Dr. H. Ruslan Muhyi, Sp. A (K)

SMF/Bagian Ilmu Kesehatan Anak

RSUD Ulin-FK UNLAM
Banjarmasin
 BACTERIAL MENINGITIS
 Is an acute purulent infection in the
subarachnoid space that is associated with
inflammation reaction in the brain and cerebral
blood vessels that cause decreased
conciuosness, seizure, raised intracranial
pressure, and stroke.

 Is inflammation of the meningens caused by a

bacterial pathogen.
 INCIDENCE
 In Asia, there is increasing incidence of H influenzae
type b (Hib). Previously, Salmonella, S pneumoniae
and M tuberculosis.

 In USA, 2.5 to 3.5 cases per 100,000 population.

 H influenzae type b declined 421 cases 1987 to 0.7

per 100,000 in 1997.

 Today the most common bacterial: Streptococcus

pneumoniae, N meningitidis, and H influenzae.
 MENINGITIS
 Classified into two syndromes :

Septic or purulent meningitis is caused by bacterial

or fungal organism.

Aseptic meningitis is caused by viral, neoplastic,

protozoal, spirochetal or other non septic causes.
 Pooled information from 1853 case of meningitis

E. coli 34

Group B strep 30

Listeria spp 6

Other gram negative 8

Other streptococci 4

Staphylococci 4.5

Salmonella spp 1

Pneumococcus 3

Haemophilus 2

Pseudomonas spp 3

Meningococcus 2

Others 3

Fig. Distribution of the most common causes of neonatal maningitis

 TABLE. Estimated age-specifik incidence of
bacterial meningitis (cases per 100,000
population), United States, 1995

Age group Haemophilus Streptococcus Neiseria Group B Listeria

influenzae pneumoniae meningitis Streptococcus

< 1 mo 0 15.7 0 125.0 39.2

1-23 mo 0.7 6.6 4.5 2.8 0

1-29 yr 0.1 0.5 1.1 0.1 0.04

Adapted from Schuchat A, Robinson K, Wenger JD, et al.

Bacterial meningitis in the United States in 1995. N Engl J
Med 1997;337;970
 CLINICAL PRESENTATION
There are two patterns of presentation :

The first is more insidious and develops over one

or several day.

The other is more acute and fulminant. Usually

with severe brain edema and herniation
Signs and Symptoms of Bacterial Meningitis

Fever
Depression of consciousness
Full fontanel
Irritability
Seizures
Headache
Focal neurologic deficits
Petechial skin rash
 Table 3. Clinical signs of neonatal
bacterial meningitis
Symptoms Percentage Signs Percentage

Lethargy 50 Fever or hypothermia 61

Anorexia Respiratory distress 47
Vomiting 49 Irritability 32
Diarrhea Jaundice 28
Convulsions 40 Full/bulging fontanelle 28
Apnea 7 Neck stiffness 15
Altered sleep pattern Hipotonia
High-pitched cry Petechiae
Hypotension, shock
Bradycardia

Source : Frequencies from Klein & Marey (1995)

 Table 1. INCIDENCE AND MORTALITY RATES IN
ACUTE BACTERIAL MENINGITIS

Children
Organism
Incidence (%) Mortality rate (%)
S. pneumoniae 10-20 8
N. meningitidis 25-40 15
H. influenzae 40-60 4
Gram negative bacilli 1-2 NA
S. aureus 1-2 NA
Streptococci 2-4 NA
L. monocytogenes 1-2 8-50
Anaerobes 1-2 NA

NA = not available
 EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL
MENINGITIS

BACTERIAL CELL WALL COMPONENTS

Endotelial Cells CNS-Macrophages Endotoxin Shock

TNF, IL-1, PAF

IL-1
PGE2
Trombosis ↑ CSF pleocytosis

Impaired BBB Infarction Hydrocephalus ↓ Perfusion

Edema

↑ ICP ↑ CBF Microcirculatory Failure

 CSF Examination in Suspected Bacterial
Meningitis

Routin test
Gram’s Stain (60-90%)
Bacterial culture and sensitivities (70-85%)
Cell count and differential
Glucouse
Protein
Bacterial antigen (50-100%)

Special test
Culture for tuberculosis, fungus,virus
Additional bacterial antigen studies
Serology
Cryptococcus antigen
India ink
Coccidioidoruycosis
Polymerase chain reaction
Tabel 3. CEREBROSPINAL FLUID FINDINGS IN
BACTERIAL MENINGITIS

Normal Bacterial meningitis

Opening pressure 50-195 mm CSF >200 mmCSF

(3.8-15 mm Hg)

Cell count <5 cells/mm3 100-10,000 cells/mm3

(15% neutrophils) (86% neutrophils)

Protein 15-50 mg/dL 100 to 500 mg/dL

Glucose 45-80 mg/dL usually <20-40 mg/dL

CSF Glucose Ratio >0.5 <0.4

CSF : Cerebrospinal Fluid

 TREATMENT
Two critical decisions must be consider :

The first concern the choice of antibiotic

therapy.
The second, the benefits versus the risk of
doing a lumbar puncture.
EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS

Mild
-Irritability Lumbar
↑ ICP CT or MRI Scan and Treat
-Lethargy Puncture;
-Headache Start
-Vomiting Antibiotics NL ICP Observe
-Nurchal rigidity And Steroids

Moderate
-Seizures
-Focal deficit Start
-Consciousness Antibiotics ↑ ICP Treat
-Papilledema And Steroids Lumbar
And Do CT or Puncture
Severe MRI Scan NL ICP Observe
-Status epilepticus
-Persistent deficit
-Coma
-Herniation
 DELAYED LP
 Intravenous antibiotics used for 2 to 3 days
prior to lumbar puncture do not alter the CSF
cells count, or protein or glucose
concentrations.

 Substantially decrease the chance of

demonstrating bacteria on Gram stain or
culture.
 TABLE 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN
PATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIA CHOICE OF ANTIBIOTIC

On Gram’s staining

Cocci
Gram-positive Vancomycin plus broad-spectrum cephalosporin
Gram-negative Penicillin G
Bacilli
Gram-positive Ampicillin (or Penicillin G) plus aminoglycoside
Gram-negative Broad-spectrum cephalosporin plus aminoglycoside
 Table 3. RECOMMENDATION FOR ANTIBIOTIC THERAPY IN
PATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIA CHOICE OF ANTIBIOTIC

On culture

S. pneumoniae Vancomycin plus broad-spectrum cephalosporin

H. influenzae Ceftriaxone

N. meningitidis Penicillin G

L. monocytogenes Ampicillin plus gentamicin

S. agalactiae Penicillin G

Enterobactericeae Broad-spectrum cephalosporin plus aminoglycoside

Pseudomonas aeruginosa, Ceftazidime plus aminoglycoside

acinetobacter
 The American Academic of
Pediatrics recommended

 Dexamethasone, 0.6 mg/kg per day in four

divided doses for the first two days of
antibiotic treatment.
 The first dose should be given at the time of,
or shortly before the first dose of antibiotic.
 Empiric therapy for acute bacterial meningitis
in neonatus

0-7 days Ampicillin 150 mg/kg/d divided dose every 8 hours IV plus
cefotaxime 100 mg/kg/d divided dose every 12 hours IV
or
Ceftriaxone 50 mg/kg/d every 24 hours IV
or
Ampicillin 150 mg/kg/d divided dose every 8 hours IV plus
gentamicin 5 mg/kg/d divided dose every 12 hours IV
 Empiric therapy for acute bacterial meningitis
in neonatus

> 7 days Ampicillin 200 mg/kg/d divided dose every 6 hours

IV
AND
Cefotaxime 150 mg/kg/d divided dose every 8 hours
IV
or
Ceftriaxone 75 mg/kg/d every 24 hours IV
Table 2. Empiric therapy for acute bacterial meningitis

1-3 months Ampicillin 200-400 mg/kg/d divided dose every 6

hours IV AND
Cefotaxime 200 mg/kg/d divided dose every 6 hours
IV or
Ceftriaxone 100 mg/kg/d divided dose every 12
hours IV or 80 mg/kg daily IV/IM
Add vancomicyn 60 mg/kg/d IV divided dose every
6 hours IV if penicillin-resistant S pneumococcus
suspected
Table 2. Empiric therapy for acute bacterial meningitis

> 3 months Cefotaxime 200 mg/kg/d divided dose every 6-8

hours IV or
Ceftriaxone 100 mg/kg/d divided dose every 12
hours IV or 80 mg/kg daily IV/IM or
Ampicillin 200 mg/kg/d divided dose every 6 hours
IV PLUS
Chloramphenicol 100 mg/kg/ d divided dose every 6
hours IV;
Add vancomicyn 60 mg/kg/d IV divided dose every
6 hours IV if penicillin-resistant S pneumococcus
suspected
TABLE 4. GUIDELINES FOR THE DURATION
OF ANTIBIOTIC THERAPY

PATHOGEN SUGGESTED DURATION

OF THERAPY (DAYS)
H. influenzae -
N. meningitidis -
S. pneumoniae 10-14
L. monocytogenes 14-21
Group B streptococcus 14-21
Gram negative bacilli (other than 21
H. influenzae)
 Complications during Acute Bacterial Meningitis

Common
Increased intracranial pressure
SIADH
Ventriculomegaly
Seizures
Extra-axial fluid collection
Infarction and necrosis
Cranial nerve involvement (deafness)
Disseminated intravascular coagulation

Uncommon
Subdural empyema
Brain abscess
Cranial nerve deficits other than VIII
 Table. Treatment of the Seriously III Patient with Meningitis

INTRACRANIAL PRESSURE MEASUREMENT

SCAN RESULTS

INCREASED

Normal Hyperventilate to reduce increased cerebral blood volume

Edema Do not hyperventilate; use furosemid or mannitol restrict fluids

Acute ventriculomegaly, Remove CSF by ventricular tap or drain; decrease CSF

hydrocephalus or enlarged production (Diamox or digoxin); increase CSF
subarachnoid spaces reabsorption (steroids)

Subdural effusions Subdural drainage

Infarcts Steroids to reduce peri-infarct edema

 Fundamental principles to the
management of meningitis

 Antibiotic therapy should be prompt and

appropiate
 Cerebral metabolisme should be protected
 Increased intracranial pressure should be
monitor
 Seizure should be prevented or controlled
 Fluid management
 Hyperpyrexia should be controlled
Penetration of antibacterials into CNS

Antibiotics Normal meninges Meningitis

Penicillins

Penicillins G Poor Fair-good

Ampicillin Poor Fair-good
Methicillin Poor -
Nafcillin - Fair

Cephalosporins

Cefazolin Poor Fair-good

Cefotaximes Good Good
Ceftriaxone Good Good
Ceftazidime Good Good

Tetracyclines

Tetracycline - Fair
Oxytetracycline - Fair
Chlortetracycline - Fair
Sources : Infectious Disease in Emergency Medicine. Judith C.
Brillman & Ronald
Penetration of antibacterials into CNS

Antibiotics Normal meninges Meningitis

Aminoglycosides

Gentamycin Poor Fair

Amikasin - Poor
Rifampin Fair Good
Cyproofloxacin Fair Fair

Miscellaneus antibacterials

Chloramphenicol Good Good

Clindamycin Poor Fair
Metronidazole - Good
Trimetrophin Good Good
Vancomycin Poor Good

Sources : Infectious Disease in Emergency Medicine. Judith C.

Brillman & Ronald
 Table. Complications and outcome of patient with acute
bacterial meningitis
Children
(%)

Complications

Acute suizures 31
Cranial nerve palsies 3-5
Deafness 10
Focal neurologic defisits 4-15
Hydrocephalus 2-20
Cerebrovascular involvement 2-12
Cerebral edema 2-8
Cerebral nervous system hemorrhage 2
Herniation 2-6
Mental retardation 4-6
Epilepsy 4-7

Outcome

Good recovery/mild disability 84-88

Severe/moderate disability 8-14
Persistent vegetatif state 1-2
Dead 2-5
 Guidelines for acceptable CSF
values At the end of therapy
1. The percentage of polymorphonuclear
leucocytes (PMNs) in the CSF is more
important than the absolute white blood
cell (WBC) count and is usually 5
percent, but should not exceed 25-30
percent of the total WBC.
2. The CSF glucose concentration should
exceed 20 mg/dl and be more than 20
percent of a concomitantly obtained
serum glucose.
 Table 1. INCIDENCE AND MORTALITY RATES IN
ACUTE BACTERIAL MENINGITIS

Children
Organism
Incidence (%) Mortality rate (%)
S. pneumoniae 10-20 8
N. meningitidis 25-40 15
H. influenzae 40-60 4
Gram negative bacilli 1-2 NA
S. aureus 1-2 NA
Streptococci 2-4 NA
L. monocytogenes 1-2 8-50
Anaerobes 1-2 NA

NA = not available
 Cell damage

Bacteria ↑ Permeability
Peptidoglycan blood-brain
Teichoic acid barier
Endotoxin

Edema
Immune
modulators
↑ Intracranial
Pressure
↓ Glucose

Lactate Blood flow

Hypoxia

Figure 33.1 Pathophysiology of bacterial meningitis

 Lethal to infants
 Meningitis infects the membranes
covering the brain, and it is always
treated as a medical emergency
 National Health and Medical
Research Council (AUS) suggest that
doctors should give the first doses of
antibiotic before a child goes to
hospital
 Important to be a ware of the sign of
meningitis and act quickly
 Acute bacterial meningitis
 A high index of suspicion is required
to diagnose this condition which, if
undetected and untreated, can lead
to significant morbidity or death.
 Table 33.3 Clinical signs of bacterial
meningitis
Symptoms Percentage Signs Percentage

Lethargy 50 Fever or hypothermia 61

Anorexia Respiratory distress 47
Vomiting 49 Irritability 32
Diarrhea Jaundice 28
Convulsions 40 Full/bulging fontanelle 28
Apnea 7 Neck stiffness 15
Altered sleep pattern Hipotonia
High-pitched cry Petechiae
Hypotension, shock
Bradycardia

Source : Frequencies from Klein & Marey (1995)

 Table 1. Complications and Outcome In Acute Bacterial Meningitis

Children
(%)

Complications

Acute suizures 31
Cranial nerve palsies 3-5
Deafness 10
Focal neurologic defisits 4-15
Hydrocephalus 2-20
Cerebrovascular involvement 2-12
Cerebral edema 2-8
Cerebral nervous system hemorrhage 2
Herniation 2-6
Mental retardation 4-6
Epilepsy 4-7

Outcome

Good recovery/mild disability 84-88

Severe/moderate disability 8-14
Persistent vegetatif state 1-2
Dead 2-5
 TABLE 1. Chronic complications of
bacterial meningitis

Hearing loss
Behavior disorders
Mental retardation
Neuropsychiatric dysfunction
Seizures
Auditory disfunction
Spasticity, paresis
Diabetes insipidus
Hydrocephalus
Transverse myelitis
Blindness
Polyarteritis
 Table 2. Antibiotics Recommended for Empirical Therapy in
Patients With Suspected Bacterial Meningitis Who Have A
Nondiagnostic Gram’s Stain of Cerebrospinal Fluid

Group of Patients Likely Pathogen Choice of Antibiotic

Immunocomperent
Age, < 3 mo S. agalactiae, E. coli or Ampicillin plus broad-
L. monocytogenes spectrum cephalosporin
Age, 3 mo to <18 yr N. meningitidis, S. pneumoniae, Broad-spectrum cephalosporin
H. influenzae

With impired cellular L. monocytogenes or gram- Ampicillin plus ceftazidine

negative bacilli

With head trauma, Staphylococci, gram-negative Vancomycin and ceftazidine

neurosurgery, or bacilli, or S. pneumoniae
cerebrospinal fluid
shunt
The American Academy of Pediatrics
(AAP) recommended in 1997 :

Vancomycin plus Cefotaxim or

Ceftriaxone should be administered
initially to all children older than 1
month with definite or probable
bacterial meningitis.