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Morning Report

Morning Report. December 7, 2010. Meningitis. The morbidity and mortality in the child that has bacterial meningitis has not changed in the last 15 years despite the availability of newer antibiotics and preventative strategies. Common Bacterial Pathogens. Streptococcus pneumoniae

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Morning Report

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  1. Morning Report December 7, 2010

  2. Meningitis The morbidity and mortality in the child that has bacterial meningitis has not changed in the last 15 years despite the availability of newer antibiotics and preventative strategies.

  3. Common Bacterial Pathogens • Streptococcus pneumoniae • NP colonization, subsequent bacteremia with seeding of choroid plexus • 7 serotypes • 14, 6B, 19F, 18C, 23F, 4, 9V • Vaccination has decreased incidence by 75% • Emergence of nonvaccine serotypes

  4. Common Bacterial Pathogens • Neisseriameningitidis • Fulminant presentation • High fatality rate • At risk • Flu A • Asplenia, terminal complement deficiency, lab exposure, travel to epidemic regions (Saudi Arabia or sub-Saharan Africa) • Does occur in healthy • 98% sporadic • A, B, C, W-135

  5. Less Common Bacterial Pathogens Non-neonatal Gram-negative bacilli Mycobacterium tuberculosis Borreliaburgdorferi Rickettsiarickettsii

  6. Aseptic Meningitis • Infectious • Enterovirus • Coxsackie and Echo • 1/4 an etiology is identified • HSV, arboviruses, EBV, Rabies, HHV-6 • Noninfectious • Drug-induced • NSAIDs, IVIG, OKT3, Bactrim • Vasculitis • KD or Lupus

  7. History • Infants • Fever • Lethargy • Irritability • AMS • Vomiting • Seizures • Older Children • Malaise • Myalgia • HA • Photophobia • Neck stiffness • Anorexia • Nausea

  8. Physical Exam • ABCs!!! • Neuro • AMS • Papilledema • Cranial nerve palsies • Poorly reactive pupils • Fontanelle • Focal deficits

  9. Physical Exam • Neck • Meningismus • Kernig • Brudzinski • Skin • Exanthems

  10. Work Up • Electrolytes • SIADH • CBC • Leukopenia, thrombocytopenia • High WBC • Coags • Blood Culture • CSF Culture • Consider other CSF studies

  11. The Traumatic LP Frankly bloody CSF should not be used to make clinical decisions Reattempt Do not recommend using formulas to correct!

  12. Treatment • Goals • Prompt initiation • Use of appropriate antimicrobial with correct dosing and duration • Attention to anticipated complications • Appropriate follow-up

  13. Treatment • Children older than 2 months • Vancomycin (60mg/kg/day div q 6) PLUS • Ceftriaxone (100mg/kg/day) OR • Cefotaxime (200-300mg/kg/day div q 6) • Only adjust after culture and susceptibility data are available

  14. Treatment • Duration • Depends on organism and degree of complications • F/U CSF in some children • ID specialist involved if questionable • Gram-negative • Longer course – minimum 21 days

  15. What about steroids?? • Well studied in adults • Reduce rates of mortality, severe hearing loss and neurosequelae • Children • May be beneficial for Hib meningitis • May be considered in pneumococcal meningitis • Dexamethasone (0.6mg/kg/d div q 6) x 4d

  16. Complications Shock Seizures Increased ICP Subdural effusions Focal neuro deficits Cerebral edema SIADH

  17. Meningitis Exposure • Meningococcal • Household contacts • High-risk contacts • Day care or nursery school • Intimate contact – contact with secretions or slept or eaten in same dwelling in last 7 days • Passengers on airline sitting next to patient for >8h • Rifampin • Ceftriaxone or cipro • Redbook for dosing and duration

  18. Meningitis Exposure • Hib • Unimmunized or underimmunized children<4y • Immunocompromised household contacts • 2 or more cases in child care setting • Rifampin

  19. Prognosis • Bacterial Meningitis • Mortality - 5-10% • Intellectual deficits • Hydrocephalus • Spasticity • Blindness • Hearling loss

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