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 causes 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� 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, � Aseptic meningitis is caused by viral, neoplastic, protozoal, spirochetal or other non septic causes.

34 %

4.5 %

1 %

30 %

6 %

8 %

4%

E coli

Listeria spp

Other gram negative

Other streptococci

Staphylococci

Salmonella spp

Group B strep

Pooled information from 1853 case of meningitis

3 %

2 %

3 %

1 %

3 %

2 %

Pseudomonas spp

Haemophilus

Pneumococcus

Meningococcus

Others

Salmonella spp

Fig. Distribution of the most common causes of neonatal meningitis

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

Haemophilus Streptococcus Neiseria Group B

Age group influenzae pneumoniae meningitis Streptococcus Listeria

< 1 mo 0 15.7 0 125.0 39.2

1-23 mo 0.7 6.6 4.5 2.8 01-23 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 days.

� The other is more acute and fulminant. Usually with severe � 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 fontanelFull fontanel

Irritability

Stiff neck

Seizures

Headache

Focal neurologic deficits

Petechial skin rash

Table 3. Clinical signs of neonatal bacterial meningitis

Symtoms Percentage Sign Percentage

Lethargy 50 Fever or hypothermia 61

Anorexia Respiratory distress 47

Vomiting 49 Irritability 32

Diarrhea Jaundice 28Diarrhea 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 & Marcy (1995)

Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL MENINGITIS

Children

Incidence Mortality rate

Organism (%) (%)

S. pneumoniae 10-20 8S. 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 avilable

EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS

BACTERIAL CELL WALL COMPONENTS

Endothelial Cells CNS-Macrophages Endotoxin Shock

IL-1

PGE2

TNF,IL-1,

PAF

Thrombosis CSF pleocytosis

Impaired BBB Infarction Hydrocephalus Perfusion

Edema

ICP CBFMicrocirculatory

Failure

PGE2

CSF Examinations in SuspectedBacterial Meningitis

Routine testGram’s stain (60 – 90%)

Bacterial culture and sensitivities (70 – 85%)

Cell count and differential

GlucoseGlucose

Protein

Bacterial antigen (50 –100%)

Special test

Culture for tuberculosis, fungus, virus

Additional bacterial antigen studies

Serology

Cryptococcus antigen

India ink

Coccidioidomycosis antibody

Polymerase chain reaction

Table 3. CEREBROSPINAL FLUID FINDINGS IN BACTERIAL MENINGITIS

Normal Bacterial meningitis

Opening pressure 50-195 mm CSF > 200 mm CSF

(3,8-15 mm Hg)

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

(15% neutrophils (86% neutrophils)(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; NL = normal

Treatment

� Two critical decisions must be consider:

� The first concern the choice of antibiotic

therapytherapy

� The second, the benefits versus the risk of doing a lumbar puncture.

EVALUATION OF THE PATIENT WITH ACUTE BACTERIAL MENINGITIS

Mild• Irritibility

• Lethargy

• Headache

• Vomiting

• Nurchal rigidity

Moderate• Seizures

LumbarPuncture;

Start

AntibioticsAnd Steroids

ICP

NL ICP

CT or MRI Scan and Treat

Observe

• Seizures

• Focal deficit

• Consciousness

• Papilledema

Severe• Status epilepticus

• Persistent deficit

• Coma

• Herniation

Start

AntibioticsAnd Steroids

And Do

CT or MRIScan

Lumbar

Puncture

ICP

NL ICP

Treat

Observe

Delayed LP

� Intravenous antibiotics used for 2 to 3 days prior to lumbar puncture do not alter the CSF cell count, or protein or glucose concentrations

� Substantially decrease the chance of demostrating bacteria on Gram stain or culture

TABLE 3. RECOMMENDATIONS FOR ANTIBIOTIC THERAPYIN PATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIA CHOICE OF ANTIBIOTIC

On Gram’s staining

Cocci

Gram-positive Vancomycin plus broad-spectrum cephalosporin

Gram-negative Penicilin G

Bacilli

Gram-positive Ampicillin (or penicillin G) plus aminoglycoside

Gram-negative Broad-spectrum cephalosporin plus aminoglycoside

TABLE 3. RECOMMENDATIONS FOR ANTIBIOTIC THERAPYIN PATIENTS WITH BACTERIAL MENINGITIS

TYPE BACTERIA CHOICE OF ANTIBIOTIC

On culture

S. pneumoniae Vancomycin plus broad-spectrum cephalosporinS. pneumoniae Vancomycin plus broad-spectrum cephalosporin

H. influenzae Ceftriaxone

N. meningitidis Penicillin G

L. monocytogenes Ampicillin plus gentamicin

S. agalactiae Penicillin G

Enterobacteriaceae Broad-spectrum cephalosporin plus aminoglycoside

Pseudomonas aeru- Ceftazidime plus aminoglycoside

ginosa, acineto-bacter

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

0-7 hari Ampisilin 150 mg/kg/hari dibagi setiap 8 jam IV plus

cefotaksim 100 mg/kg/hari setiap 12 jam IV

atau

Ceftriaxone 50 mg/kg/hari diberikan setiap 24 jam IV

atau

Empiric therapy for acute bacterial meningitis in

neonatus

atau

Ampisilin 150 mg/kg/hari dibagi setiap 8 jam IV plus

gentamisin 5 mg/kg/hari IV setiap 12 jam.

> 7 hari Ampisilin 200 mg/kg/d divided dose every 6 hours IV

AND

Cefotaxime 150 mg/kg/d divided dose every 8 hours IV

oror

Cetriaxone 75 mg/kg every 24 hours IV

Table 2. Empiric therapy for acute bacterial meningitis

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

6 hours IV AND6 hours IV AND

Cefotaxime 200 mg/kg/d divided dose every 6

hours IV or

Cetriaxone 100 mg/kg/d divided dose every 12

hours IV or 80 mg/kg daily IV/IM;

Add vancomycin 60 mg/k/d IV divided dose every

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 IV/IM every day OR12 hours IV or 80 mg/kg IV/IM every day 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 vancomycin 60 mg/kg/d divided dose

every 6 hours IV if penicillin-resistant S pneu-

mococcus suspected

TABLE 4. GUIDELINES FOR THE DURATION OF ANTIBIOTIC

THERAPY

PATHOGEN SUGGESTED DURATION

OF THERAPHY

(DAYS)(DAYS)

H. influenzae 7

N. meningitis 7

S. Pneumoniae 10 – 14

I. monocytogenes 14 – 21

Group B streptococci 14 – 21

Gram – negative bacilli (other than 21

H. influenzae

Complications during Acute Bacterial Meningitis

Common

Increased intracranial pressure

SIADH

Ventriculomegaly

SeizuresSeizures

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

SCAN RESULTS INCREASED

Normal Hyperventilate to reduce increased cerebral

blood volume

INTRACRANIAL PRESSURE MEASUREMENT

Table Treatment of the Seriously III Patient with Meningitis

blood volume

Edema Do not hyperventilate; use furosemide or

mannitol and restrict fluids

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

hydrocephalus or en- crease CSF production (Diamox or digo

larged subarachnoid xin); increase CSF reabsorption (stero -

spaces ids)

Subdural effusions Subdural drainage

Infarcts Steroids to reduce peri-infarct edema

Fundamental principles to the management of meningitis

� Antibiotic therapy should be prompt and appropriate

� 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

CSF

Antibiotics Normal meninges Meningitis

Penicillins

Penicillins G Poor Fair-good

Ampicillin Poor Fair-good

Methicillin Poor -

Nafcillin - Fair

CephalosporinsCephalosporins

Cefazolin Poor Fair-good

Cefotaximes Good Good

Ceftriaxone Good Good

Ceftazidime Good Good

Tetracyclines

Tetracycline - Fair

Oxytetracycline - Fair

Chlortetracycline - Poor

Sources : Infectious Disease in Emergency Medicine. 1998. Judith C. Brillman

& Ronald

Table. Complication and outcome of patient with acute bacterial meningitis

Children

(%)

Complications

Acute seizures 31

Cranial nerve palsies 3 – 5

Deafness 10

Focal neurologic deficits 4 – 15

Hydrocephalus 2 – 20

Cerebrovascular Involvement 2 – 12Cerebrovascular Involvement 2 – 12

Cerebral edema 2 – 8

Central nervous system hemorrhage 2

Herniation 2 – 6

Mental retardartion 4 – 6

Epilepsy 4 – 7

Outcome

Good recovery/mild disability 84 – 88

Severe/moderate disability 8 – 14

Persistent vegetative state 1 – 2

Dead 2 – 5

Penetration of antibacterials into CNS

CSF

Antibiotics Normal meninges Meningitis

Aminoglycosides

Gentamycin Poor Fair

Amikacin - Poor

Rifampin Fair Good

Cyprofloxacin Fair Fair

Miscellaneus antibacterials

Chloramphenicol Good Good

Clindamycin Poor Fair

Metronidazole - Good

Trimetrophin Good Good

Vancomycin Poor Good

Sources : Infectious Disease in Emergency Medicine. 1998. Judith C. Brillman

& Ronald

Guidelines for acceptable CSF values

At the end of therapy

1. The percentage of polymorphonuclear leukocytes

(PMNs) in the CSF is more important than the

absolute white blood cell (WBC) count and is 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 conco-

mitantly obtained serum glucose.

Table 1. INCIDENCE AND MORTALITY RATES IN ACUTE BACTERIAL

MENINGITIS

Children

Incidence Mortality rate

Organism (%) (%)

S. pneumoniae 10-20 8S. 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 avilable

Cell damage

Bacteria

Peptidoglycan

Teichoic acid

Endotoxin

Immune

modulators

Permeability

blood-brain

barrier

Edema

Glucose

Lactate Blood flow

Intracranial

pressure

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 � 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 and untreated, can lead to significant morbidity or death.

Table 33.3 clinical signs of bacterial meningitis

Symtoms Percentage Sign Percentage

Lethargy 50 Fever or hypothermia 61

Anorexia Respiratory distress 47

Vomiting 49 Irritability 32

Diarrhea Jaundice 28Diarrhea 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 & Marcy (1995)

Table 1. Complication and Outcome In Acute Bacterial Meningitis

Children

(%)

Complications

Acute seizures 31

Cranial nerve palsies 3 – 5

Deafness 10

Focal neurologic deficits 4 – 15

Hydrocephalus 2 – 20

Cerebrovascular Involvement 2 – 12Cerebrovascular Involvement 2 – 12

Cerebral edema 2 – 8

Central nervous system hemorrhage 2

Herniation 2 – 6

Mental retardartion 4 – 6

Epilepsy 4 – 7

Outcome

Good recovery/mild disability 84 – 88

Severe/moderate disability 8 – 14

Persistent vegetative state 1 – 2

Dead 2 – 5

TABLE 1. chronic complications of

bacterial meningitis

Hearing loss

Behavior disorders

Mental retardation

Neuropsychiatric dysfunction

SeizuresSeizures

Auditory dysfunction

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-spectrum

L. monocytogenesL. monocytogenes cephalosporin

Age, 3 mo to < 18 yr N. meningitidis, S. pneumoniae Broad-spectrum cephalosporin

H. influenzae

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

negative bacilli

With head trauma, neuro Staphylococci, gram-negative Vancomycin plus ceftazidime

surgery, or cerebrospi bacilli, or S pneumoniaenal fluid shunt

The American Academy of Pediatrics (AAP)

recommended in 1997 :

Vancomycin plus Cefotaxim or ceftriaxoneVancomycin plus Cefotaxim or ceftriaxone

should be administered initially to all children

older than 1 month with definite or probable

bacterial meningitis.