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Bacterial meningitis

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Bacterial meningitis

  2. 2. DEFINITIONS:• BACTERIAL MENINGITIS (BM): An acute purulent infection of the cranial and spinal leptomeninges due to bacterial etiology.• ENCEPHALITIS: Inflammation of the brain parenchyma.• MENINGOENCEPHALITIS: Inflammation of the leptomeninges and the brain parenchyma.• ASEPTIC MENINGITIS: Refers to CSF findings consistent with leptomeningeal inflammation but routine bacterial culture are negative. Page 2
  3. 3. INTRODUCTION:• Bacterial meningitis remains a major cause of mortality and neurological sequelae worldwide. In India and other developing countries the mortality rate ranges from 16-32%.• The community incidence of acute BM in India is not known. The exact etiological diagnosis is often not possible. There are limited studies from India regarding the etiology and epidemiological factors associated with BM.• Delay in diagnosis and initiation of antimicrobial therapy can result in poor outcome. Since clinical signs of meningitis cannot always be relied upon, laboratory support is imperative to achieve an early diagnosis.• Due to emergence of antimicrobial resistance recommendations for therapy are changing.• Laboratory surveillance of isolates is crucial to identify for immunization, chart preventive strategies and to help formulate rational empirical treatment for potentially fatal BM. Page 3
  4. 4. ETIOLOGY: The etiology of BM is affected most by the age of the patient.Neonate:Early-onset acquisition S. agalactiae, E.coli, K.pneumoniae, Enterococci, L. monocytogenesNeonate:Late-onset infection S. aureus, Gram-negative enteric bacilli, P. aeruginosaAge: 1–3 months Same as early-onset in neonate + S.pneumoniae, N. meningitidis, and H.influenzae type b.Age: 3 months to 5 years S. pneumoniae, N. meningitidis and H. influenzae type b.Age: >5 years children and adults S. pneumoniae and N. meningitidis. Page 4
  5. 5. RISK FACTORS:A major risk factor for BM is the lack of immunity to specificpathogens associated with young age. PRECIPATING FACTORS ORGANISMS Defects of complement system(C5- Meningococcus C8) and properdin system Splenic dysfunction or asplenia Pneumococcus, H.influenzae type b. T-Lymphocyte defect(aids, cancer, Listeria monocytogenes chemotherapy and congenital) CSF leak and cochlear implants Pneumococcus Lumbosacral dermal sinus and Staph. aureus, Gram negative entric meningomyelocele bacilli e.g: E.coli, Klebsiella etc. CSF shunts Coagulase negative Staphylococci, Staph. aureus. Page 5
  6. 6. PATHOGENISIS AND PATHOPHYSIOLOGY:• Bacteria reach the CNS either by hematogenous spread or by direct extension from a contiguous site.• In neonates, pathogens are acquired from non- sterile maternal genital and intestinal secretions.• Direct inoculation of bacteria into the CNS can result from trauma, skull defects with CSF leaks, congenital dura defects such as a dermal sinuses or meningomyelocele, or extension from a suppurative parameningeal focus. Page 6
  7. 7. Bacteraemia Endothelial damage Bacteria in CSF Pro-inflammatory cytokinesPermeability of Leucocyte attraction and CSF Cerebralblood-brain barrier entrance: meningeal inflammation vasculitis Vasogenic edema Interstitial edema Cytotoxic edema Cerebral blood flow: Ischaemia Intracranial pressure Bloodstream Global perfusion Release of volaemia excitatory amino acidsaminoacids Neuronal injury apoptosis Page 7
  8. 8. CLINICAL FEATURES:• Manifestations of BM depend on the age of the patient and duration of disease.• In general, the younger the patient the more subtle and atypical are the signs and symptoms.• Onset of acute BM has two forms : i. The sudden onset rapidly progressive manifestation of shock, purpura, DIC, reduced level of consciousness leading to death in 24hrs. ii. Common form with- a. Non specific findings- fever(84%), headache(76%),vomiting(70%), anorexia(19%) , poor feeding, symptoms of URTI, myalgia, arthralgia, tachycardia, petechiae, rash etc. b. Alteration in mental status like irritability, lethargy, stupor or coma(5%). Page 8
  9. 9. c. Seizure (20-30%): focal or generalised and as result of cerebritis, infarction or electrolyte disturbance.d. Signs of meningeal irritation(59%)- neck stiffness(65%), kernigs sign(27%) and brudzinski sign(51%).e. Signs of increased ICT include headache, projectile vomiting, reduced (GCS≤8) or fluctuating level of conciousness, abducent nerve palsy, cushing’s reflex, un-equal dilated pupils, papilloedema, decorticate or decerebrate posturing, stupor, coma, signs of herniation.g. Cranial neuropathy- Most common cranial nerves involved include 3rd, 6th, 7th and 8th.h. Focal cerebral signs (20%) - due to cortical necrosis, occlusive vasculitis, cerebritis, abscess. Page 9
  10. 10. NEONATES a) Neonates and infants have nonspecific signs like fever, hypothermia, irritability, lethargy and feeding difficulty. b) Neurologic signs- Excited or depressed and bulging fontanel. Minor convulsions present as blinking eyes, fixed stare, facial twitching and sucking. No clinical feature is diagnostic in isolation, and the most accurate combination of clinical features to rise or lower suspicion of meningitis is still unclear. Pediatrics 2010; 126:952-960. Page 10
  11. 11. MANAGEMENT OF BACTERIAL MENINGITIS: Symptoms and signs of BM YES Check airway, breathing &circulation; gain vascular access YESManage accordingly Signs of shock and raised ICP NO Perform diagnostic tests NO Contraindication to LP Perform LP YES YES <3 months old ? CSF s/o meningitis YES NO Empiric antibiotics for suspected Empiric antibiotic for suspected meningitis: Do not delay antibiotic meningitis : i.v Cefetriaxone. i.v Cefotaxime + iv ampicillin No role of steroids. Add vancomycin, if prolonged Or multiple antibiotic exposure within last 3 months If HSV meningoencephalitis in differential diagnosis give i.v acyclovir Cont’d Page 11
  12. 12. Reduced or fluctuating conscious level or focal neurological signs NO YES Full volume maintenance fluid [Isotonic fluid-DNS or NS]. Perform CT scan Do not restrict fluid unless there is SIADH or raised ICT. Monitor fluid administration, urine output,electrolytes and bloodglucose. Close monitoring for signs of raised ICP ,shock and repeated review. If LP contra-indicated, perform delayed LP when no longer contra- indicated. Specific pathogen identified YES NO Antibiotics for confirmed meningitis. Antibiotics for unconfirmed meningitis. <3 months old? NO YES i.v cefotaxime + ampicillin i.v for ≥14 days Ceftriaxone ≥ 10 days Page 12
  13. 13. Initial management: • Check airway, breathing, circulation, disability (level of consciousness) and environment (presence of rash, temperature control). • Elective intubation and ventilation if necessary. • If signs of shock present manage accordingly with normal saline boluses and vasopressor support. • Seizures managed with anticonvulsants like phenytoin and midazolam. • After the patient has been stabilised further examination and diagnostic tests performed. Page 13
  14. 14. Management of raised ICP.• Early intubation if; GCS <8, Evidence of herniation, Apnea, Inability to maintain airway.• Mild head elevation of 15–30 (Ensure that the child is euvolemic).• Hyperventilation: Target PaCO2: 30–35 mm Hg (suited for acute, sharp increases in ICP or signs of impending herniation).• Mannitol: Initial bolus: 0.25–1 g/kg, then 0.25–0.5 g/kg, q 2–6 h as per requirement, up to 48 hrs.• Hypertonic Saline: Preferable in presence of Hypotension, Hypovolemia, Serum osmolality >320 mOsm/kg, Renal failure, Dose: 0.1–1 ml/kg/hr infusion, Target Na+−145–155 meq/L. Page 14
  15. 15. • Adequate sedation and analgesia.• Prevention and treatment of seizures: use Lorazepam or midazolam followed by phenytoin as initial choice.• Avoid noxious stimuli: use lignocaine prior to ET suctioning [nebulized (4% lidocaine mixed in 0.9% saline) or intravenous (1–2 mg/kg as 1% solution) given 90 sec prior to suctioning].• Control fever: antipyretics, cooling measures.• Maintenance IV Fluids: Only isotonic or hypertonic fluids (Ringer lactate, 0.9% Saline, 5% D in 0.9% NS), No Hypotonic fluids.• Maintain blood sugar: 80–120 mg/dL.• Refractory raised ICP - Barbiturate coma, Hypothermia and Decompressive craniectomy. Page 15
  16. 16. Routine investigations:• Complete blood count: Neutrophilia suggestive of bacterial infection.• Serum glucose: Often low; allows interpretation of CSF glucose.• Electrolytes, urea, and creatinine :To assess for complications and fluid management.• Coagulation studies: To assess for complications.• Blood cultures: Positive in 40–90% depending on the organism.• Inflammatory markers(CRP and procalcitonin): Elevation suggestive of bacterial infection; procalcitonin(≥5ng/mL) of more value; neither can establish nor exclude diagnosis. Page 16
  17. 17. CEREBROSPINAL FLUID EXAMINATION.• CSF analysis and culture remains the definitive method for diagnosis of BM.• Lumbar puncture (LP) should be performed when BM is suspected. In neonates, meningitis accompanies sepsis in 20-25% of cases so procedure to be considered.• If LP is delayed empirical antibiotic should be started within 1hr.• Contraindications to LP: a. Absolute (lumbar puncture is not to be done) i. Signs of raised intracranial pressure (papilloedema, decrebrate posturing) ii. Local skin infection at the LP site. iii. Evidence of obstructive hydrocephalus, cerebral oedema or herniation in CT (or MR) scan of brain Page 17
  18. 18. b. Relative (appropriate therapeutic measures and/or investigations are indicated before lumbar puncture) i. Shock or hypotension ii. Coagulation disorder iii. Presence of focal neurological deficit, especially when posterior fossa lesion is suspected. iv. Glasgow coma score of 8 or less. v. Continuing seizure activity.NORMAL CSF VALUES Neonate ChildTotal WBC (mm3) ≤20 <5DLC-NEUTROPHILS Up to 5% noneProtein (mg/dL) <100 10-40Glucose (mmol/L) ≥2.1 ≥2.5CSF/serum glucose ≥0.6 ≥0.6 Page 18
  19. 19. Typical CSF Parameters in Patients with MeningitisPathogen White blood Percentage Glucose Protein level Positive CSF stain cells per μL of level in mg per dL neutrophilsPyogenic > 500 > 85-90 Low > 100-200 ~70 percentL. monocytogenes > 100 >50 Normal > 50 ~30 percentPartially treated > 100 >80 Normal > 70 ~60 percentpyogenicAseptic, often 10 to 1,000 Early: > 50 Normal Normal or < Not applicableviral Late: < 20 100Tubercular 50 to 500 < 30 Low > 100 RareFungal 50 to 500 < 30 Low Varies High in cryptococcusCSF = cerebrospinal fluid. Page 19
  20. 20. • Early in illness, CSF cell count can be normal despite a positive CSF culture.• Glucose concentration usually is decreased with a CSF to serum glucose ratio of 0.6 or less in neonates and 0.4 or less in children older than 2 months of age.• Gram stain is positive in 80-90% of untreated cases with lower limit of detection of about 105 CFU/mL.• CSF culture not routinely recommended because the yield decreases (80 to <50%) soon after antibiotic therapy (except gram negative Enteric bacilli) and isolates recovered are frequently contaminants. Page 20
  21. 21. • CSF cell count and glucose and protein concentrations generally remain abnormal for several days even after initiating appropriate antibiotic therapy.• Latex agglutination tests and PCR to detect bacterial capsular antigens is useful in some patients with prior antibiotic therapy.• Traumatic LP makes interpretation difficult. Leukocytes and protein are affected; gram stain, culture and glucose are not affected. A more accurate method is to calculate the predicted CSF WBC count by this formula. Peripheral WBC/RBC count× CSF RBC count = CSF WBC count Page 21
  22. 22. Other tests on CSF:• Latex agglutination : Rapid; not 100% specific or diagnostic. Latex agglutination depends on laboratory availability; including N. meningitidis, S. pneumoniae, H. influenzae type b, Escherichia coli and group B streptococci.• PCR: Rapid; good sensitivity, techniques improving. PCR depends on laboratory availability; including N. meningitidis, S. pneumoniae, H. influenzae type b, L. monocytogenes, HSV, CMV, Enterovirus and Mycobacterium tuberculosis.• Lactate : Routine use not currently recommended Page 22
  23. 23. INDICATION FOR REPEAT LP:• Lack of clinical improvement in 48-72 hrs.• Meningitis caused by resistant S. pneumonia strains or by gram negative enteric bacilli.• In neonate with gram negative bacillary meningitis, examination of CSF during treatment after 48-72 hrs of initiation of treatment is necessary to verify that culture are sterile.DO NOT PERFORM REPEAT LP IF: Who are receiving appropriate antibiotics and making good clinical recovery. Before stopping antibiotic therapy if patient is clinically well. Page 23
  24. 24. RADIALOGICAL DIAGNOSIS:• Cranial computed tomography (CT) is of limited use in acute BM. CT in cerebral oedema may show slit-like lateral ventricle and areas of low attenuation.• Diffuse meningial enhancement may be seen.• The main indications for a CT scan in meningitis when it is preferred as a first line investigation prior to LP are: a. Signs of ↑ICT (e.g. papilloedema) b. Suspecting malignancy( focal neurological deficits). c. Deteriorating neurological status. d. Previous neurosurgical procedure or trauma. e. Immunocompromised.• Normal CT scan does not exclude the risk of raised ICT. Page 24
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  26. 26. DIFFERENTIAL DIAGNOSIS OF ACUTE BACTERIAL MENINGITIS:• Other infective meningitis or meningoencephalitis (viral, tuberculous, fungal and parasitic).• Focal infection (Brain abscess, subdural emphysema, cranial and spinal epidural abscess).• Non infective illness ( malignancy, collagen vascular syndrome and exposure to toxins). Page 26
  27. 27. Clinical Decision Rules to Distinguish Bacterial from Aseptic Meningitis in Children with CSF Pleocytosis*Rule Bacterial Meningitis Score MeningitestExclusion criteria 1. Neurosurgical history 1. Neurosurgical history 2. Immunosuppression 2. Immunosuppression 3. CSF red blood cell count ≥ 0.01 × 106 3. CSF red blood cell count ≥ 0.01 × per μL 106 per μL 4. Antibiotic use in the previous 48 4. Antibiotic use in the previous 48 hours hours 5. PurpuraCriteria (further evaluation, 1. Positive CSF Gram stain 1. Positive CSF Gram stainincluding lumbar puncture, is needed 2. Seizure 2. Seizurein patients with one or more 3. Blood neutrophil count ≥ 10,000 per 3. Purpurafindings) μL 4. Toxic appearance (irritability, 4. CSF neutrophil count ≥ 1,000 per μL lethargy, or low capillary refill) 5. CSF protein level ≥ 80 mg per dL 5. CSF protein level ≥ 50 mg per dL 6. Serum procalcitonin level ≥ 0.5 ng per mLSensitivity (95% confidence 99 percent (99 to 100) 100 percent (96 to 100)interval)CSF = cerebrospinal fluid. Curr Opin Neurol. 2009;22(3):292*—White blood cell count ≥ 10 per μL Page 27
  28. 28. Antibiotic management: i. Key is to start promptly. ii. Antibiotic choice is based on -Ability of CSF penetration and its concentration. -Bactericidal property. Page 28
  29. 29. Penetration and estimated bactericidal power of antibiotics used for treatment of bacterial meningitis: Antibiotic CSF penetration Bactericidal power* against β- lactam β- lactam susceptible resistant pathogens pathogensPenicillin/ampicillin 5–15% 1–10 <1Chloramphenicol >20% >10 NACefotaxime/ceftriaxone 5–15% >10 1–10Cefepime/meropenem 5–15% >10 1–10Vancomycin <5% 1–10 1–10Fluoroquinolones >20% >10 >10Rifampicin >20%*concentration in CSF over the minimal bactericidal concentration against the isolated pathogen. Page 29
  30. 30. Recommended initial empiric selection of antibiotics for previously healthy children with suspected bacterial meningitis, by age and epidemiological situationPatients Likely pathogens AntibioticNeonate- S agalactiae, E. coli, Ampicillin+cefotaxime/amikacinEarly-onset acquisition K pneumoniae, enterococci, L monocytogenesNeonate- S aureus, gram-negative Nafcillin (flucloxacillin) orLate-onset infection enteric bacilli, P aeruginosa Vancomycin+ceftazidime ± amikacinAge: 1–3 months Same as early-onset in neonate Ampicillin+cefotaxime or + S pneumoniae, ceftriaxone N meningitidis,and H influenzaAge: 3 months to 5 S pneumoniae, N meningitidis, Cefotaxime or ceftriaxoneyears and H influenzaeAge: >5 years children S pneumoniae and N Cefotaxime or ceftriaxoneand adults meningitidis.In areas with moderate Multi-resistant pneumococci Cefotaxime or ceftriaxoneor greater prevalence + vancomycin(considerof resistant S addition of rifampicin)pneumonia Page 30
  31. 31. Suggested pathogen-specific antimicrobial therapy for childrenwith bacterial meningitis Bacteria Antibiotic of choice Other useful antibioticsN. meningitidis Penicillin G or ampicillin Cefotaxime or ceftriaxoneH. Influenzae type b Cefotaxime or ceftriaxone Ampicillin, chloramphenicolS. pneumoniae:Penicillin-susceptible Penicillin G, ampicillin Cefotaxime or ceftriaxone(MIC<0·1 mcg/mL)Penicillin-intermediate Cefotaxime or ceftriaxone Cefepime or meropenem(MIC=0·1–1·0 mcg/mL) plus vancomycin when MIC >0·5 mcg/mLPenicillin-resistant Cefotaxime or ceftriaxone Cefepime or meropenem(MIC>1·0 mcg/mL) plus vancomycin plus vancomycinCephalosporin-resistant Cefotaxime or ceftriaxone Adding rifampicin(MIC>0·5 mcg/mL) plus vancomycin New fluoroquinolones?L. monocytogenes Ampicillin+gentamicin Trimethoprim-sulfamethoxazoleS. agalactiae Penicillin G+gentamicin Ampicillin+gentamicinEnterococcus species Ampicillin+aminoglycoside Vancomycin+aminoglycosideEnterobacteriaceae Cefotaxime or ceftriaxone Cefepime or meropenemP. aeruginosa Ceftazidime+aminoglycoside Cefepime or meropenemMIC=minimum inhibiting concentration. Page 31
  32. 32. Guidelines for the duration of antibiotic therapy. Pathogen Suggested duration Of therapy(days)H. influenza 5-7N. meningitides 7-10S. pneumonia 10-14L. monocytogenes ≥21Group B streptococci 14-21Gram-negative bacilli (other than 21or 2 wks beyond 1st sterile cultureH. influenzae) (whichever is longer) Page 32
  33. 33. Adjunctive and supportive treatment:1. Fluid management: {NICE clinical guidelines 2012 and Starship children’s health clinical guidelines 2009} i. Resuscitation with normal saline bolus if required. ii. Fluid therapy should focus on avoiding hypovolemia and hypo- osmolality. iii. Fluid type should be 0.9% NaCl with 5% dextrose (10% may require in infants). iv. Give full volume maintenance fluids with appropriate adjustment for ongoing losses unless there is SIADH or raised ICT. v. Hyponatremia at presentation can usually be assumed to be dilutional , on the basis of elevated level of ADH. Increased ADH is due to • Appropriate secretion to compensate for hypovolemia or to maintain cerebral perfusion in the presence of cerebral edema → Full volume maintenance fluid. • Inappropriate secretion due to brain damage and which might contribute to further brain damage → Restriction of fluid may be needed. Page 33
  34. 34. vi. Ongoing management • Frequent clinical review, including a careful assessment of volume status. • Check serum sodium 6-12hrly depending on the initial sodium level, ongoing fluid losses, clinical status and whether there is fluid restriction in place. • In hyponatremia child on fluid restriction, fluid can be increased slowly as condition improves and serum sodium normalises. There is evidence to support not restricting fluid for children in developing countries where death rate are high and disease is often advanced at presentation. {The Cochrane Library 2011, issue 2} Page 34
  35. 35. 2. Role of steroids and glycerol: 1. Corticosteroids significantly reduced hearing loss and neurological sequelae, but did not reduce overall mortality. Data support the use of corticosteroids in patients with bacterial meningitis in high-income countries, but no beneficial effect in low-income countries. {Cochrane database sys rev. 2010 sep;8(9). 2. Adjunctive dexamethasone in the treatment of acute bacterial meningitis does not seem to significantly reduce death or neurological disability. The benefit of adjunctive dexamethasone for all or any subgroup of patients with bacterial meningitis thus remains unproven. {Lancet Neurol. 2010 Mar;9(3)} Page 35
  36. 36. 3. No significant difference was seen in neurological or hearing outcome with use of either glycerol or dexamethasone in children with acute bacterial meningitis. {Indian Pediatr. 2007 Sep;44(9) }4. With bacterial meningitis, the childs presenting status and young age are the most important predictors of hearing impairment. Little relief is obtained from current adjuvant medications like dexamethasone and glycerol. {Pediatrics. 2010 Jan;125(1)} Page 36
  37. 37. COMPLICATIONS:1.Early complications: • Ventriculitis. • Fluid and electrolyte disturbance. • SIADH. • Seizures. • Increased ICP. • Cranial nerve palsies. • Stroke. • Cerebral or cerebellar herniation. • Thrombosis of the dural venous sinuses. • Sub-dural effusion and empyema. • Prolonged fever or secondary fever. Page 37
  38. 38. 2. Late complications: • Hearing loss. • Mental retardation. • Recurrent seizures. • Delaying accusation of language. • Visual impairment. • Behavioural problems. • Hydrocephalous. Page 38
  39. 39. PROGNOSIS: Factors affecting the outcome 1) Age. 2) Etiology. 3) CSF findings at the time of diagnosis- concentration of bacteria or its products, WBC count and glucose concentration (<20mg/dL). 4) Time to sterilization of CSF after start of therapy. 5) Decreased level of consciousness. 6) Seizures occurring during hospitalization. 7) Presence of comorbid conditions Page 39
  40. 40. PREVENTION: 1.VACCINATION- • Immunisation is the most effective means of prevention BM in children. • IAP recommends routine use of Hib vaccine in children with efficacy rate against invasive infection ranges from 70-100%. • IAP recommends pnemococcal and meningococcal vaccination for high risk children as vaccines under special circumstances. • Only meningococcal polysaccharide (MPSV) is avalaible. Minimal age- 2 yrs. Revaccination only once after 3yrs in those at continued high risk. • Minimum age for administration- 6wks for pnemococcal conjugate vaccine(PCV) and 2yrs for polysaccharide vaccine(PPSV). Administer 1 dose of PCV to all children aged 24 through 59mts who are not immunised for age. PPSV revaccination only once after 35yrs only in certain high risk patients. • PCV must be offered to premature and low birth weight infants. • S.agalactiae vaccinaton for pregnant women in future. Page 40
  41. 41. Chemoprophylaxis for Bacterial Meningitis Pathogen Indication Antimicrobial agent Dosage CommentsNeisseria meningitidis Close contact (for more Rifampin Adults: 600 mg every 12 hours Not fully effective and(postexposure than eight hours) with Or for two days rare resistant isolatesprophylaxis) someone with N. Children one month or older: meningitidis infection 10 mg per kg every 12 hours Contact with oral for two days secretions of someone Children younger than one with N. meningitidis month: 5 mg per kg every 12 infection hours for two days Ciprofloxacin (Cipro) Adults: single dose of 500 mg Rare resistant isolates Or Ceftriaxone (Rocephin) Single intramuscular dose of __ 250 mg (125 mg if younger than 15 years)Haemophilus influenzae Living in a household Rifampin 20 mg per kg per day, up to 600 ___(postexposure with one or more mg per day, for four daysprophylaxis) unvaccinated or incompletely vaccinated children younger than 48 monthsStreptococcus agalactiae Previous birth to an infant Penicillin G Initial dose of 5 million units Clindamycin(group B streptococcus; with invasive S. Or intravenously, then 2.5 to 3 susceptibility must bewomen in the intrapartum million units every four hours confirmed byperiod) agalactiae infection during the intrapartum period antimicrobial Colonization at 35 to 37 susceptibility test weeks’ gestation If allergic to penicillin: 2 g followed by 1 g every eight hours Bacteriuria during Cefazolin pregnancy or High risk because of fever, amniotic fluid Clindamycin (Cleocin) 900 mg every eight hours rupture for more than 18 or hours, or delivery before 37 weeks’ gestation Vancomycin 15 to 20 mg per kg every 12 hours Page 41Am Fam Physician. 2010;82(12):1491-1498.
  42. 42. REFERENCES:• Prober CG, Dyner LL. Acute bacterial meningitis. In Kliegman, Stanton, Geme, Schor Behrman. Nelson textbook of pediatrics. 19th edition. Elsevier India Pvt.2012;2087-95.• NICE clinical guideline 102- Bacterial meningitis and meningococcal septicaemia. 2010.• Tacon CL, Flower O. Diagnosis and Management of BacterialMeningitis in the Paediatric Population: A Review. Emerg. Med international.2012• Voss L, Nicholson R. Starship Children’s Health Clinical Guideline. Infectious Diseases.2009• Sankhyan N, Raju KNV, Sharma S, Gulati S. Management of raised intracranial pressure. Indian J Pediatr. 2010;77: 1409-16.• Bamberger DM. Diagnosis, Initial Management, and Prevention of Meningitis. Am Fam Physician.2010;82(12):1491-98.• Sáez-Llorens X, McCracken GH. Bacterial meningitis in children. Lancet.2003; 361: 2139–48. Page 42
  43. 43. • Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the man-agement of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284.• Maconochie IK, Baumer JH. Fluid therapy for acute bacterial meningitis (Review). The Cochrane Library.2011;Issue 2.• Brouwer MC, McIntyre P, de Gans J, Prasad K, de Beek DV. Corticosteroids for acute bacterial meningitis (Review). The Cochrane Library.2010; Issue 9.• Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical Features Suggestive of Meningitis in Children: A Systematic Review of Prospective Data. Pediatrics. 2010;126:952–960.• Chaudhuri A, Martin PM, Kennedyc PGE, Seatond RA, Portegiese P, Bojarf M, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. European Journal of Neurology. 2008;15: 649–59.• Vincent J, Scheld WM. The New Eng J of Med. 1997 ;336 (10): 708-16.• Chavez-Bueno S, McCracken GH. Bacterial Meningitis in Children. Pediatr Clin N Am.2005;52:795– 810. Page 43
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