acubacterialmeningitis18feb-160314072922-converted.pptx

acubacterialmeningitis18feb-160314072922-converted.pptx
Acute Bacterial (Pyogenic) Meningitis S.Srinivasan Professor of Paediatrics MGMCRI, Pillayarkuppam Puducherry S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016
Acute Bacterial (Pyogenic) Meningitis in Children S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016
• Definition • Etiology • Predisposing Factors • Pathogenesis • Symptoms & Signs Acute Bacterial (Pyogenic) Meningitis in Children  Diagnosis  Differential Diagnosis  Complications  Prognosis  Treatment  Follow Up S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016
Definition Acute Inflammation of the meninges ( the protective membranes covering the brain and spinal cord ) caused by Bacterial ( pyogenic ) organisms Acute Bacterial (Pyogenic) Meningitis in Children S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February 2016
Neonatal Meningitis: Causative Bacteria Age Most Common Bacteria <1 month • Escherichia coli • Group B streptococci • Enterobacteria • Listeria monocytogenes •Haemophilus influenzae •Coagulase negative staphylococci (in hospital) •Streptococcus pneumoniae Acute Bacterial (Pyogenic) Meningitis in Children
AGE Bacteria causing Ac.Bact.Meningitis Neonates & Infants < 2 mths Escherichia coli, Staph.aureus, Gram Negative bacteria (hospital flora); Listeria monocytogenes, Gp.B Strep., 2 mths – 3 to 5 years Strep. pneumoniae, Neisseria meningitides, H.influenzae Beyond 5 yrs Strep. pneumoniae( 1,3,6,7), Neisseria meningitides (A,B,C), H.influenzae S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Acute Bacterial Meningitis
Post-Neonatal Childhood Bacterial Meningitis 1 to 23 months •Strep. pneumoniae •Neisseria meningitides •Group B streptococci •Haemophilus influenzae 2 to 18 years •Neisseria meningitides •Streptococcus pneumoniae •Haemophilus influenzae Causative Bacteria Acute Bacterial (Pyogenic) Meningitis in Children S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Bacterial Culture positivity rate in Post Neonatal Childhood Bacterial Meningitis Hemophilus influenzae 40 - 70% Streptococcu s pneumoniae 30 - 40% Neisseria meningitides 10 -20 % Streptococcus pyogenes <10 % Culture Negativity <20% < Varies with age of the child > S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Predisposing Risk Factors Sinusitis, Mastoiditis, Otitis. Spleen : Asplenia, Functional / Anatomical Trauma, or Removal : Pneumococcal Bacterial Meningitis. Compromised Immune System: HIV Others S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Neurosurgery Head Trauma, Parameningeal Infection, Anatomical Def. of cranium , Spinal cord & Meninges
Risk Factors in Neonatal Meningitis • Maternal infections during delivery • PROM • Prolonged, diffcult delivery with frequent PV Exams • Preterm babies • Neural tube Defects –Spina Bifida Occulta, Pilonidal Sinus S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Pathogenesis Signs of Meningeal irritation Hydrocephalus Cerebral infarctions and atrophy Seizures Inflammation of Spinal Nerves & Roots Adhesive thickening of Arachnoid in basal cisterns Fibrosis & Obstn of Aqueduct of Sylvius &/or Foramina of Luschka &/or Magendie Endarterial & small cortical venous Thromboembolic episodes Neuronal membrane depolarization
Pathogenesis of Ac.Bacterial Meningitis  Haematogenous ( mostly ); Spread from local site infections Entry of bacteria through BBBarrier Ac.Bacterial Meningitis  Cellular reaction with outpouring of Polymorphs & fibrin Release of Cytokines , Chemokines & Inflammatory Mediators Release of cell wall & membrane debris on cell death  Meningeal Exudative Inflammation Vascular Compromise Inflammatory Cerebral Oedema  Increased Intracranial tension and pressure ( coning ) effects S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Symptoms & Signs Acute Bacterial Meningitis S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
• Altered sensorium • Bulging fontanelle • Headache • Convulsions • Nuchal rigidity • Opisthotonus • Hypothermia • Coma Symptoms in infants and children • Fever • Irritability • Excessive fussiness • Altered Behaviour • Refusal of feeds • Lethargy • Anorexia • Nausea • Vomiting • Photophobia S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
General Physical Examination  Breathing, Airway &Circulation : Adequate/Compromised  Altered Sensorium and Severity , Coma Scale  Vital Parameters: Temperature,Pulse,BP, Respn: Rate,Type, Regularity, CFT, Hydration Status  Skin : Mottling, Color change,of vascular compromise Purpura, Infections, Dermal sinus, & other stigma of Spina Bifida Occulta, S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Skin in Acute Bacterial Meningitis Complications S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Examination for signs of Meningeal Irritation neck – crossed Meningismus Nuchal stiffness / rigidity Kernig’s Sign Brudzinski’s leg sign Brudzinski’s leg sign Higher Functions  Cranial Nerves Motor- coordination Neurological Signs S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Elicitation of Meningeal Signs S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Brudzinski’s contralateral reflex sign The childt’s hip and knee are passively flexed on one side  Contralateral leg bends in reflex response
Investigations in Acute Bacterial Meningitis Complete Blood Count LP: CSF Examination  Microscopy- Colour, Cells, opening Pressure  Biochemistry: Glucose, Proteins  Gram staining  Blood & CSF Culture  Electrolytes; ABG in severe cases Chest x-ray CT/MRI Scans EEG PCR Others S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
CONTRAINDICATIONS FOR PERFORMING LUMBAR PUNCTURE IN CHILDREN S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Increased ICP Papilloedema Unstable Child – Shock, Resp.depression, low GCS  Infection in the local site Severe Thrombocytopenia / DIC
CSF Findings in CNS Infections infection Pressure WBC /µL Glucose Protein Ac Bacterial meningitis 200-300 100-5000; > 50%PMN < 40mg/dl > 100 mg/dl TBM 100 - 300 100 – 500 Lymphocytes Low; <40 mg/dl Elevated; >100mg/dl Viral meningitis 90-200 10-300; Lymphocytes Normal or Less in Mumps /LCM Normal or slight rise Aseptic Meningitis 50 - 200 10 – 300 Lymphocytes Normal Normal or slight rise Cryptococcal 100-300 <500; Lymphocytes Low 50-200 NORMAL 80-200 <5 Lympho- cytes 50-75mg/dl 15-40mg/dl S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Non-motile Gram-negative, coccobacillary, facultatively anaerobic bacterium, and it’s Oxidase and Catalase postive S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS- 19TH February2016
Other Investigations S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry Detects Latex Particle Agglutination Of C.S.F Specific Bacterial Antigen H.influenzae, S.pneumoniae, N.memingitidis, E.coli , etc Countercurrent ImmunoElectrophoresis Smears from purpuric spots –Grams staining S.pneumoniae,N.memingitidis, DNA Sequencing Advanced centers Bacterial identification 8th &9th SEMESTER UNDERGRADUATE CLASS INPAEDIATRICS - 19TH February2016 S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry th th TH
Acute Bacterial Meningitis - DIFFERENTIAL DIAGNOSIS  Partially treated Meningitis  Viral Encephalitis Cerebral Malaria Tuberculous Meningitis Enteric Encephalopathy Leptospirosis Metabolic/ Toxic Encephalopathies Dengue Haemorrhagic Fever S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Acute Complications • Increased Intracranial tension & coning pressure effects • Subdural Effusion • Septicaemia & Septic Shock • Seizures • SIADH • Acute Hydrocephalus • Cranial Nerve paralysis • DIC • Purpura Fulminans and Gangrene S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
? Complication S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Complications Commoner after bacterial meningitis than after viral meningitis Sensorineural hearing loss: partial or total Seizure and Epileptic State Cognitive problems: Memory and concentration; Learning difficulties and behavioural problems Motor Problems involving co-ordination and balance Speech problems Visual disturbances Cerebral Palsy S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Greatest risk for hearing loss 1 Males 2 Nuchal Rigidity 3 Increased ICP 4 Low CSF glucose levels 5 S Pneumoniae Infection 6 Abnormal CT Scan Findings S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
 S pneumoniae :  Hib :  N meningitidis : 26.3-30% 7.7-10.3%; 5-10.3%. Overall mortality for bacterial meningitis 5-10% Neonates: Older children: S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 15-20% 3-10%. Neurologic Sequelae : 30%
Age: Neonates, Preterms Organisms: Pneumococci> H.imfluenzae> Meningococci Gm –ve Organisms, Salmonellae and Enterobacteriaceae DIC Endotoxic shock Neural tube Anomalies Immunosuppresse individuals. S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Poor Prognostic Factors
Poor Prognosis for Bilateral Sensoryneural Hearing Loss  Males Increased Nuchal Rigidity Prolonged Sezures Low Coma Score  Low CSF glucose levels S pneumoniae infection Abnormal CT findings S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
1 in 4 survivors had :  Serious and disabling sequelae  Functionally important behavior disorder or neuropsychiatric problem  Auditory dysfunction that impaired their performance in school Prognosis
Empiric Antibiotic Treatment in childhood Acute Bacterial Meningitis S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Organism Age Group Antibiotic Unknown Infants less Ampicillin Cefotaxime than 1 month Gentamicin month of age and Adults Children over 1 Ampicillin Cefotaxime Vancomycin Unidentified bacilli Children and Gram-negative Adults Cefazidime Gentamicin -Unidentified S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 organisms Children and Gram positive Adults Ceftriaxone Vancomycin Ampicillin
Haemophilus influenzatype b S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Ceftriaxone Meningococci Penicillin G plus ceftriaxone
STREPTOCOCCI Vancomcin Nafcillin (with or without rifampin) LISTERIA SP Ampicillin Gentamicin Trimethoprim- sulfamethoxaxzole ENTERIC GRAM- NEGATIVE CHIA COLI, PROTEUS SP , KLEBSIELLA SP) BACTERIA(ESCHERI Ceftriaxone Gentamicin PSEUDOMONAS STAPHYOCOCCI Ceftazidime Cefepime *These may be used with the addition of aminoglycoside Vancomycin Nafcillin *May be prescribed with or without rifampin S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Acute Bacterial (Pyogenic) Meningitis in Children Treatment of Complications 1) Convulsions: I.V.Diazepam 2) Cerebral Oedema: Mannitol ; i.v.dexamethasone 3) Drainage of Subdural Empyema 4)Surgical management of Hydrocephalus S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Acute Bacterial (Pyogenic) Meningitis in Children S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Supportive Treatment 1) Correction of Fluid and Electrolyte Disturbances 2) Control & Maintenance of normal body temperature 3) Control of Convulsions ( Anticonvulsant drugs) 4) Control of increased intracranial pressure and cerebral odema 5) Care of comatose /unconscious child ( Skin, Eyes, Bladder , Bowel, Lungs )
Acute Bacterial (Pyogenic) Meningitis in Children Supportive Treatment 6) Protocol based Management of Septic Shock with Fluids, Electrolyte & Inotropes 7) Management of Disseminated Intravascular Coagulation 8) Nutritional Support 9) Monitoring of head circumference, vital parameters, Intracranial tension, response to drugs S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Acute Bacterial (Pyogenic) Meningitis in Children S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Supportive Treatment 10) Treatment of Complications like hydrocephalus, subdural empyema, etc.,
Immunization Routine Immunization with available vaccines against Haemophilus, Pneumococcus Meningococcus ( Routine or in, High Risk Children) Vaccination before travelling to endemic areas S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016
Prevention of Acute Bacterial Meningitis S.Srinivasan, Professor of Paediatrics, MGMCRI, Pillayarkuppam, Puducherry 8th &9th SEMESTER UNDERGRADUATE CLASS IN PAEDIATRICS - 19TH February2016 Antibiotic Chemoprophylaxis with Antibiotics given to close contacts H.influenzae type B Rifampicin 20mg/kg/day for 4 days N. Meningitidis Rifampicin 20mg/kg/day or 600mg oral for 2 days in older children Ceftriaxone single dose Ciprofloxacin single dose

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