pediatric pyogenic meningitis

1. Pediatric pyogenic meningitis
pyogenic meningitis

2. Pyogenic meningitis
•Meningitis is defined as inflammation of
membranes surrounding the brain and spinal cord
•Meningoencephalitis is inflammation of meninges
and brain cortex
pyogenic meningitis

4. pyogenic meningitis

5. Incidence and etiology
•Bacterial meningitis is commonest in infancy
•May result in death within hours of onset if not treated
•Responsible for 3% hospital admissions
•More frequent in infant males
•Any organism can cause meningitis
•Great risk during 6-12 months and 95% cases occur
between 1month and 5years
pyogenic meningitis

6. Causative agents for different ages
pyogenic meningitis
Age Causative agents
0 – 2 months •Escherichia coli
•Group B streptococci
•Staphylococcus aureus
•Listeria monocytogenes
2months – 2 years •Haemophilus influenzae type b
•Streptococcus pneumoniae
•Neisseria meningitides
2 years – 21 years •Neisseria meningitides
(serotypes A, B, C, Y and W 135)
•Streptococcus pneumoniae
(serotype 1, 3, 6, 7, 14, 19, 21, 23)
•Haemophilus influenzae

7. Streptococcus pneumoniae

8. Pathogenesis
•Causative agent enter CNS via blood or direct
invasion
•Anatomic or congenital defect can also cause
invasion
•Inflammation of meninges initiated when cell
elements of organism disrupt blood brain barrier
•Followed by outpouring of polymorphs and fibrin
pyogenic meningitis

9. •Release of cytokines and chemokines in CNS
stimulated by bacteria
•Meninges become swollen, inflamed and covered
in exudates
•Early in illness cerebral edema present and
ventricles reduced in size
•Pressure on peripheral nerves may lead to motor or
sensory deficit
•Communicating hydrocephalus due to adhesive
thickening of arachnoid in basal cisterns
pyogenic meningitis pathogenesis

10. •Obstructive hydrocephalus due to fibrosis
blocking aqueduct of sylvius or foraminas
•Affected cranial nerves cause deafness and
vestibular problem
•Cerebral vessels and cranial nerves can be
involved and may lead to permanent neurologic
damage
•Cerebral atrophy by thrombosis of small cortical
veins
pyogenic meningitis pathogenesis

11. •Inflammation involving veins crossing subdural
space lead to increase in vascular permeability
and loss of albumin into subdural space
•Hypoglycorhacia by decreased transport of
glucose across the inflamed choroid plexus and
increased use by host
•Seizures by electrolyte imbalance ultimately
depolarization of neuronal membranes
pyogenic meningitis pathogenesis

12. Clinical features
Meningitis always must be considered in any
young infant whose temperature is greater
than 100.7°F (38.2°C) and who has no obvious
site of infection
pyogenic meningitis

14. Neonates and infants
•Gram negative organisms are commonly
responsible
•Infective illness in mother, prolonged rupture of
membranes or difficult delivery put the newborn at
risk
•Premature infants have low level of antibodies
•Predisposing factor is spina bifida or dermal sinus
pyogenic meningitis

15. •Initial signs are subtle
•Fever occurs in 50% of cases
•Infant is ill looking and feeds poorly
•May develop vomiting, hypothermia, lethargy,
convulsions
•Has bulging anterior fontanelle, head retraction
and high pitch cry
pyogenic meningitis neonates and infants

17. Older children
•Classic signs preceded by upper respiratory or GIT
symptoms
•High grade fever, head ache and projectile vomiting
•Seizures are common
•Increased CSF pressure leads to bulging fontanelle
and diastasis of sutures
pyogenic meningitis

18. •Neck stiffness, positive kerning's sign and
brudzinski’s sign
•Cranial nerve palsies and papilledema
•Hemiplegia in cases late reported, ataxia may also
be present
•Patient may be semi comatose or comatose
•Meningococcal meningitis is characterized by the
presence features of Waterhouse Friderichsen
syndrome
pyogenic meningitis older children

19. •Otitis media and mastoiditis is likely to lead
streptococcal or pneumococcal meningitis
•Staphylococcal infection is likely following surgical
procedures, skull fractures or skin infections
•If there is no specific sign between 6months – 2years
then H. influenzae is the cause
•Onset of clinical signs is sudden in meningococcal
and S. pneumoniae infection
pyogenic meningitis in older children

21. Investigations
Lumbar puncture
•CSF pressure should be noted, fundi checked for
papilledema
•Xanthochromia due to jaundice, bilirubin from
hemorrhage or increased protein
•If lumbar puncture is traumatic; one leukocyte
per 700 RBC in CSF is subtracted and 1 additional
mg protein is added in CSF protein for 800 RBC
pyogenic meningitis

22. •CSF glucose should be compared to blood
glucose, CSF glucose is 2/3 of blood glucose
•In CSF of neonates normally there are up to 30
lymphocytes and 150mg/dl protein
•Gram stain is important to recognize the
causative agent
pyogenic meningitis investigations LP

24. pyogenic meningitis investigations LP
CSF findings in various CNS disorders
Conditon Color Leucocytes Protein mg/dl Glucose mg/dl
Normal Clear 0 – 5
60 – 70%
lymphocytes
20 – 45 >50 or 75% of
blood glucose
Acute bacterial
meningitis
Opalescent
to purulent
100 – 20000
PMN predominate
100 – 500 <40
May be none
Tuberculous
meningitis
Opalescent 10 – 2000
PMN early but
lymphocyte later
>50 <40
May be none
Viral
encephalitis
Clear 5 – 500
Mostly
lymphocytes
PMN early
30 – 150 30 – 70

25. pyogenic meningitis investigations LP
Gram staining
Meningococci Gram negative intracellular diplococci
Pneumococci Gram positive diplococci
H. Influenzae Gram negative coccobacilli
E. Colli Gram negative bacilli

26. Contraindications for immediate LP
•Increased ICP especially with focal neurologic
deficits
•Severe cardio pulmonary compromises
•Infection of skin overlying the site of LP
•Bleeding or clotting disorder
pyogenic meningitis investigations LP

27. Recommendation for repeat LP
at 24 – 36 hours
•All neonates
•Meningitis caused by S. pneumoniae and gram
negative enteric bacilli
•Lack of cranial improvement in 24 – 36hours
after therapy
•Prolonged or second fever
•Recurrent meningitis
•Immunocompromised patients
pyogenic meningitis investigations LP

28. CSF culture
The yield of CSF culture decreases soon after
antibiotic therapy has been started. More
sensitive technique, polymerase chain reaction
may help to diagnose cases of bacterial
meningitis in patients treated by antibiotics
Blood culture
90% H. influenzae and 80% S. pneumoniae
pyogenic meningitis investigations

29. Blood counts
Total and differential leukocyte count; generally
there is leucocytosis with predominant
polymorphs
X – ray chest
To rule out TB and pneumonia
CT scan
pyogenic meningitis investigations

30. Indications for CT scan
•Newborn except for disease caused by listeria
•Prolonged comatose condition
•Seizures 72 hours after start of treatment
•Continued excessive irritability
•Focal neurologic findings
•Persistently abnormal CSF findings
•Relapse or recurrence
pyogenic meningitis investigations

31. Rapid diagnostic tests
•Concurrent immuno electro phoresis
•Latex particle agglutination
•ELISA to detect bacteria antigen in CSF
•CSF lactate level
•Enzyme radioisotope to detect activity of ß
lactamase in CSF
Gram staining
Smears of petechial or purpuric lesions on skin
pyogenic meningitis investigations

32. Differential diagnosis
•Tuberculous meningitis
•Aseptic meningitis
•Brain abscess
•Brain tumor
•Cerebral malaria
pyogenic meningitis

33. Management
Supportive measures
•Vitals recorded every 15 – 30 minutes until patient
is stable
•Neurologic examinations and seizure evaluation
•Measure head circumference in children <18
months
•Intake and output record
pyogenic meningitis

34. •Body weight, serum electrolytes monitored 12
hourly
•For fever sponge and give antipyretics
•Feeding continued and give tube feeding if necessary
•Fluid restricted to 60%, not indicated in hypotension
•Care of comatose patient
•IV diazepam for seizures, phenobarbitone for
recurrent seizures
pyogenic meningitis management supportive

35. Specific measures
Antibiotics
•Appropriate antibiotic given by culture report
•Term infants in 1st month given combo of
ampicillin with gentamicin or cefotaxime
•Low birth weight preterm infants presenting late
should be given vancomycin and an
aminoglycoside
pyogenic meningitis management

36. •1 – 2 month infants given ampicillin ad ceftriaxone
•Resistant strains treated with vancomycin
alternatively meropenem
•Duration of therapy is 7 – 10 days
Steroids
•Dexamethasone for 2 – 4 days
•Given before antibiotic is started for good result
pyogenic meningitis management specific

37. Treatment of complications
Cerebral edema and raised ICP
•Head elevated about 30°
•Steroids for reducing inflammation and brain water
content
•Mannitol
Subdural effusion
•Symptomatic effusion should be aspirated
pyogenic meningitis management

38. Subdural effusion

39. Inappropriate ADH secretion
•Hyponatremia, coma, seizures, weight gain,
puffiness of face, decreased urine output
•Treated with fluid restriction and diuretics
Waterhouse Friderichsen syndrome
•Patient in shock with hypotension petechial rash
•Give normal saline/plasma, steroids and
dopamine infusion
pyogenic meningitis management treatment of complications

40. Waterhouse Friderichsen syndrome

41. Complications of meningitis
pyogenic meningitis
Increased ICP Cranial nerve palsies
Seizures Stroke
Ataxia Inappropriate ADH
Prolonged fever >10days Rapidly increasing head
circumference
Subdural effusions Spastic paraparesis
Blindness Cerebral infarcts
Anemia Cerebral herniation
Long term neurologic abnormality Epilepsy
Deafness Spasticity
Visual handicap Repeated episode

42. Prognosis
•Worse prognosis in young children with higher
bacterial colony counts, intractable seizures,
subdural effusion, bacteremia and prolonged fever,
thrombocytopenia, low ESR, absence of
leukocytosis, DIC, rapidly progressive purpura in
12hours, hypotension or coma
•Mortality rate is 8 – 25%
•35% have permanent deficit
pyogenic meningitis

43. Prevention
Vaccination
•Vaccines available against S. pneumoniae, N.
meningitides and H. influenza type b
•Pneumococcal polysaccharide vaccine available
•Meningcoccal vaccine for high risk group and
children
•H. influenza vaccine given for all >2months infants
pyogenic meningitis

44. Antibiotic prophylaxis
Meningococcal
The dose of rifampicin recommended is 10mg/kg
given 12hourly for 2days
H. Influenzae
Rifampicin 20mg/kg/day for 4 days
For all house contacts and patient
Streptococcus pneumoniae
No prophylaxis
pyogenic meningitis

45. THANKYOU
pyogenic meningitis