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Meningitis in children
This document provides guidelines for the diagnosis and management of acute bacterial meningitis. It outlines the definition, incidence, transmission, types, signs and symptoms, investigations, treatment guidelines, and prevention including vaccination. Bacterial meningitis is most common in infants aged 1 month to 5 years. Presenting signs can include fever, headache, neck stiffness, vomiting, and altered mental status. Investigations should include lumbar puncture for cerebrospinal fluid analysis if no contraindications are present. Treatment involves prompt administration of antibiotics, and prevention focuses on vaccination programs and prophylactic antibiotics for close contacts after a confirmed case.
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Introduces the topic of bacterial meningitis, outlining the presentation content, key areas covered: definition, incidence, transmission, types, symptoms, guidelines, prevention, vaccination, and treatment.
Defines meningitis and its types, including bacterial, viral, fungal, parasitic, and non-infectious, with notable etiology for each type and age-specific considerations.
Lists common symptoms of meningitis by age, including respiratory signs, physical examination findings, and specific signs like Brudzinski and Kernig signs.
Lists common symptoms of meningitis by age, including respiratory signs, physical examination findings, and specific signs like Brudzinski and Kernig signs.
ESCMID guidelines presentation on diagnosis, including necessary investigations, lumbar puncture contraindications, CSF analysis findings, and recommendations for examinations.
Discusses methods for preventing meningitis, including vaccination protocols, types of vaccines available, and specific recommendations for children and adults.
Outlines empiric antibiotic treatment recommendations, the role of corticosteroids in management, and follow-up care strategies for hearing loss and cognitive assessment.Summarizes key takeaways from the presentation regarding age-related incidence, epidemic causes, the importance of prompt treatment, and preventive measures.
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Meningitis in children
- 1. Guideline in theDiagnosis and Management of Acute Bacterial Meningitis DR. Magdy Shafik Senior Pediatric Consultant Diploma, M.S ,Ph.D of Pediatrics
- 2. outlines • Definition, Incidence •Transmission • Types • Signs & Symptoms • ESCMID guildlines in sign and systoms • Investigations • ESCMID guildlines in Investigations • Prevention • Vaccination • Treatment guildlines
- 3. Definition Meningitis is theinflammation of the membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia matter. Encephalitis Meningioencephalitis
- 4. Incidence • Meningitis canoccur at all ages but it is commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age. • It is more common in males than females
- 8. Transmission The bacteria aretransmitted from person to person through droplets of respiratory or throat secretions. Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinkingutensils, etc.) The incubation period ranges between 2 -10 days. Average 3-5 day
- 9. Routes of Infection Nasopharynx Bloodstream Direct spread (skull fracture, meningo and encephalocele) Middle ear infection Infected Ventriculoperitoneal shunts. Congenital defects Sinusitis
- 10. Types • Bacterial • Viral(aseptic) • Fungal • Parasitic • Non-infectious
- 11. • Another classification: A) Epidemic meningitis: caused by Neiseria meningitides. وبائية تفشيات إحداث علي القادر الوحيد الميكروب وهو B) Non-epidemic meningitis: •E.Coli, L isteria monocytogens H.Influenzae type b, • S.Pneumoniae
- 12. Pyogenic Meningitis ETIOLOGY • Meningococcal’meningitis- N. meningitidis. ( A, B, C and W135) are recognized to cause epidemics. • The commonest organisms according to age groups are: E.Coli, Group B streptococci, S.Aureus, Listeria Monotocytogenes 0-2 months H.Influenzae type b, S.Pneumoniae, N.Meningitides. 2 months- 2yrs N.Meningitides (serotypes A,B,C, Y & W135) S.Pneumoniae (serotypes 1,3, 6,7) H.Influenzae 2 yrs – 15+yrs
- 14. Viral meningitis • Viralmeningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following: Enterovirus (polio virus, Echovirus, Coxsackievirus ) Herpesvirus (Hsv-1,2, Varicella.Z,EBV ) Paramyxovirus (Mumps, Measles) Togavirus (Rubella) Rhabdovirus (Rabies) Retrovirus (HIV)
- 15. Is viral encephalitiscontagious? Brain inflammation itself is not contagious. But the viruses that cause encephalitis can be. Of course, getting a virus does not mean that someone will develop encephalitis.
- 16. Is viral meningitisis contagious? • Viral meningitis is the most common type, but it's not usually life-threatening. The enteroviruses that cause meningitis can spread through direct contact with saliva, nasal mucus, or feces. ... But while you may become infected with the virus, you're unlikely to develop meningitis as a complication
- 17. Fungal Meningitis It’s rarein healthy people, but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression. The most common agents are Cryptococcus neoformans, Candida, H capsulatum.
- 18. Signs & Symptoms •The symptoms of meningitis vary and depend on the age of the child and cause of the infection. • Common symptoms are: •Flu-like symptoms •fever •lethargy •Altered consciousness •irritability •headache •photophobia •stiff neck •Brudzinski sign •Kernig sign •skin rashes •seizures
- 19. Other symptoms ofmeningitis in Neonates/infants can include: Apnea jaundice neck rigidity Abnormal temperature (hypo/hyperthermia) poor feeding /weak sucking a high-pitched cry bulging fontanelles Poor reflexes
- 20. Examination • General physical-Check for Consciousness level according to GCS scoring, jaundice or irritability. .Resuscitation: incase of septic shock, or DIC.. .Vitals: temperature , HR, B.P., R/R. • Signs of Increased ICP- Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema • Fundus: papilloedema • CN palsies: (esp. occulomotor, facial, and auditory)
- 21. Meningismus - checkfor nuchal rigidity with passive neck flexion (gives 'involuntary resistance). Brudzinski sign (hip & knee flexion with neck movement) Kernig sign (extend knee with hip flexed) Hemiparesis. Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia).
- 24.
- 25. •European Society forClinical Microbiology and Infectious Diseases (ESCMID) guildlines 2016
- 26. Strength of recommendation RecommendationGrade ESCMIDstrongly suport recommondation for use A ESCMID moderately suport recommendation for use B ESCMID marginally suport recommendation for use C ESCMID suport recommendation against useD
- 27. TABLE. Quality ofevidence Class Conclusions based on: 1 Evidence from at least one properly designed randomized controlled trial. ---------------------------------------------------------------------- 2 Evidence from at least one well- designed clinical trial, without randomization; from cohort or case– control analytic studies (preferably from >1 centre); from multiple time series; or from dramatic results of uncontrolled experiments. ---------------------------------------------------------------------------------- 3 Evidence from opinions of respected authorities, based on clinical experience, descriptive case studies.
- 28. European Society forClinical Microbiology and Infectious Diseases (ESCMID) guildlines 2016 Quality of evidence Neonates with bacterial meningitis often present with nonspecific symptoms. (Level 2) In children beyond the neonatal age the most common clinical characteristics of bacterial meningitis are fever, headache, neck stiffness and vomiting. There is no clinical sign of bacterial meningitis that is present in all patients. . (Level 2)
- 29. • The sensitivityand negative predictive value of Kernig and Brudzinski sign is low in the diagnosis of meningitis and therefore do not contribute to the diagnosis of bacterial meningitis. (Level 2)
- 30. Recommendation • Bacterial meningitisin children can present solely with nonspecific symptoms. .(Grade A) • Characteristic clinical signs may be absent. In all children with suspected bacterial meningitis ESCMID strongly recommends cerebrospinal fluid examination, unless contraindications for lumbar puncture are present.(Grade A)
- 31. • In adultswith bacterial meningitis classic clinical characteristics may be absent and therefore bacterial meningitis should not be ruled out solely on the absence of classic symptoms. .(Grade A)
- 32. Investigations CBC Blood culture LP- D/r,C/s (color, leukocyte count, differential, glucose, protein) Electrolytes PCR Coagulation profile liver and kidney function Chest X-ray CT/ MRI Blood gases EEG , ECG
- 33. Contraindication for LP .Increaseintracranial pressure. .Unstable patient. .Skin infection at site of LP. .Thrombocytopenia. .Papilloedema.
- 34. European Society forClinical Microbiology and Infectious Diseases (ESCMID) guildlines 2016 • In neonatal meningitis, CSF leukocyte count, glucose and total protein levels are frequently within normal range or only slightly elevated.(level 2) • It has been shown that in both children and adults, classic characteristics (elevated protein levels, lowered glucose levels, CSF pleocytosis) of bacterial meningitis are present in 90% of patients. A completely normal CSF occurs but is very rare. .(level 2)
- 35. • CSF lactateconcentration has a good sensitivity and specificity for differentiating bacterial from aseptic meningitis. • The value of CSF lactate is limited in patients who received antibiotic pretreatment or those with other central nervous system disease in the differential diagnosis. .(level 2) • CSF lactate level was significantly high in bacterial than viral meningitis • CSF culture is positive in 60–90% of bacterial meningitis patients depending on the definition of bacterial meningitis. Pretreatment with antibiotics decreases the yield of CSF culture by 10–20%. .(level 2)
- 36. • CSF Gramstain has an excellent specificity and varying sensitivity, depending on the microorganism. • The yield decreases slightly if the patient has been treated with antibiotics before lumbar puncture is performed. .(level 2) • In patients with a negative CSF culture and CSF Gram stain, PCR has additive value in the identification of the pathogen. .(level 2)
- 37. Recommendation • It isstrongly recommended to perform cranial imaging before lumbar puncture in patients with: • Focal neurologic deficits (excluding cranial nerve palsies). • New-onset seizures. • Severely altered mental status (Glasgow Coma Scale score <10). • Severely immunocompromised state. • In patients lacking these characteristics, cranial imaging before lumbar puncture is not recommended. (grade A)
- 38. • It isstrongly recommended to start antibiotic therapy as soon as possible in acute bacterial meningitis patients. (grade A) • The time period until antibiotics are administered should not exceed 1 hour. (grade A) • Whenever lumbar puncture is delayed, e.g. due to cranial CT, empiric treatment must be started immediately on clinical suspicion, even if the diagnosis has not been established (grade A)
- 39. • Case definition: suspected case: fever of 38 or more plus one or more of the following: 1- neck stiffness 2– bulging fontanel in children below 2 years
- 40. • Probable case: suspectedcase with turbidity of C.S.F which means: cells ↑ 80 / m3 protein ↑100 /dl sugar ↓ 40 /dL plus one or more of the following: 1- Gm staing show : -ve : N. meningiococcal (+ Epedmic ) - H.infulnza b +ve : pneumocci 2- antibodies in C .S .F by( latex antigen detection )
- 41. • Confirmed case: confirmed by lab. : 1- C.S. F culture 2- P.C.R
- 42.
- 43. المرض انتشار منالحد طرق اوال:السحائي االلتهاب من العامة الوقاية ثانيا:باالطباء خاصة وقائية اجراءت التعليمية المنشات مثل التجمعات باماكن خاصة وقائية : ثالثا
- 44. اوال:السحائي االلتهاب منالعامة الوقاية •التعليمية المنشاءات في االزدحام منع •التعليمية المنشاءات داخل الجيدة التهوية •تط يتم حيث المدارس دلخل التطعيم ببرنامج االلتزامعيم التعليمية المراحل من االولي السنة(حضانة-ابتدائي– اعدادي–ثانوي)السحائي االلتهاب يبتطعيم •من الوقائية الجرعات اخذللمخال الريفابيسين عقارطين
- 46. مؤكدة حالة اكتشافعند •1-لمدة صحيا ومراقبتهم للحالة المباشرين المخالطين جميع حصر10 ايام. •الميكرو حامل علي للقضاء يومين لمدة ريفامبيسين المخالطين اعطاءب. •مدرسة مثل تجمع داخل حالة اكتشاف عند-معسكر–حضانةاعطاء يتم المخالطين جميعريفامبيسين
- 47. How to giveRifampicin • Adult: 600 mg twice daily for 2 days • Infant more than 2 months of age: 10 mg/kg twice daily for 2 days • neonates less than one month : 5 mg/kg twice daily for 2 days N.B ciprofloxacin and cefotriaxone can be given
- 49.
- 50. Types of vaccines Live vaccines Live Attenuated vaccines Killed Inactivated vaccines ToxoidsCellular fraction vaccines Recombinant vaccines •Small pox variola vaccine •BCG •Typhoid oral •Plague •Oral polio •Yellow fever •Measles •Mumps •Rubella •Intranasal Influenza •Typhus •Typhoid •Cholera •Pertussis •Plague •Rabies •Salk polio •Intra- muscular influenza •Japanise encephalitis •Diphtheria •Tetanus •Meningococcal polysaccharide vaccine •Pneumococcal polysaccharide vaccine •Hepatitis B polypeptide vaccine •Hepatitis B vaccine
- 51. •the five mostcommon types (or serogroups) of meningococcal bacteria found are A, B, C, W and Y. No single vaccine protects against all serogroups; there are separate vaccines against meningococcal ACWY serogroups and the meniningococcal B serogroup
- 52. A smaller yetsteady rise in the occurrence of meningococcal Y disease has also been seen since 2016. Together, meningococcal W and Y disease cause approximately half of the cases of IMD in Australia. Meningococcal B, which historically caused the majority of meningococcal disease in Australia, continues to cause around half of all reported cases of IMD
- 53. • there aretwo different types of meningococcal vaccine currently available : purified capsular polysaccharide vaccines protein-polysaccharide conjugate vaccines.
- 57. Meningococcal vaccines availablefor use Quadrivalent meningococcal (MenACWY) conjugate vaccines against A, C, W and Y serogroups Registered age groupFormulationTrade name 9 month- 55 years Quadrivalent diphtheria toxoid conjugate Menactra® ≥2 monthsQuadrivalent CRM conjugate Menveo® ≥6 weeksQuadrivalent tetanus toxoid conjugate Nimenrix®
- 58. Recombinant meningococcal B(MenB) vaccines against B serogroup in infant> 2 months Meningococcal C (MenC) conjugate vaccines against C serogroup Registered for primary immunisation in infants aged 6 weeks-12 months in Austerlia
- 59. 2 types ofmeningococcal vaccine in Egypt: 1- A,C V accine : (polysaccraide) االتية العمرية للفئات اللقاح من جرعة ويعطي: الحضانة من االولي السنة ابتدائي اولي اعدادي اولي ثانوي اولي ينصحاعطاء بعدمسنتين قبل التطعيم
- 60. 2- Quadirivalent vaccineA,C,W,Y والمعتمرين والحجاج للمسافرين ويعطي
- 61. Meningococcal (Menactra) Polysaccharide DiphtheriaToxoid (D T)Conjugate Vaccine DOSAGE AND ADMINISTRATION • Primary Vaccination • Children 9 month through 23 months of age: Two doses, three months apart. • Individuals 2 through 55 years of age: A single dose Booster Vaccination: A single booster dose may be given to individuals 15 through 55 years of age at continued risk for meningococcal disease, if at least 4 years have elapsed since the prior dose.
- 63.
- 64. Nimenrix is Meningococcalpolysaccharide vaccine serogroups A, C, W-135 & Y conjugate vaccine ( TT)which is used to prevent .meningococcal infections INDICATIONS AND CLINICAL USE: active immunization of individuals from 6 weeks to 55 years of age
- 65.
- 66. Empiric antibiotic in-hospitaltreatment for community-acquired bacterial meningitis S. pneumoniae susceptible to penicillin Reduced Streptococcus pneumoniae antimicrobial sensitivity to penicillin Patient group Amoxicillin/ampicillin/penicilli n plus cefotaxime, or amoxicillin/ampicillin plus an aminoglycoside Neonates <1 month old Cefotaxime or ceftriaxone Cefotaxime or ceftriaxone plus vancomycin or rifampicin Age 1 month to 18 years Cefotaxime or ceftriaxone Cefotaxime or ceftriaxone plus vancomycin or rifampici Age >18 and <50 years Cefotaxime or ceftriaxone plus amoxicillin/ampicillin/ penicillin G Cefotaxime or ceftriaxone plus vancomycin or rifampicin plus amoxicillin/ampicillin/penicilli n G Age >50 years, or Age >18 and <50 years plus risk factors for Listeria monocytogenesa
- 67. Key Question. Does dexamethasonehave a beneficial effect on death, functional outcome and hearing loss in adults and children with bacterial meningitis
- 68. Level 1 1- Corticosteroidssignificantly reduced hearing loss and neurologic sequelae but did not reduce overall mortality. 2-Data support the use of corticosteroids in patients with bacterial meningitis beyond the neonatal age in countries with a high level of medical care. 3-No beneficial effects of adjunctive -- corticosteroids have been identified in studies performed in low-income countries. 4-The use of dexamethasone for neonates is currently not recommended.
- 69. • Does theuse of prophylactic treatment of household contacts decrease carriage or secondary cases? It is strongly recommended to treat household contacts and other close contacts of meningococcal meningitis patients with antibiotic prophylaxis consisting of ceftriaxone, ciprofloxacin or rifampicin (grade A)
- 70. Prophylactic antibiotic treatmentof household contacts of meningococcal meningitis patients prevents secondary cases and eradicates meningococcal carriage (level).
- 71. In children withbacterial meningitis, testing for hearing loss should be performed during admission (otoacoustic emission). In the case of hearing loss, patients should be referred to an ear–nose–throat specialist in a medical centre performing cochlear implants (Garde A) What follow-up of community-acquired bacterial meningitis patients should be provided (e.g. testing for hearing loss, neuropsychological evaluation)?
- 72. Routine neuropsychologic examinationis not recommended. If cognitive defects occur, neuropsychologic examination should be performed, and referral to a (neuro)psychologist/rehabilitation physician may be indicated. (Grade B).
- 73. Take Home Massage •1- Meningitis can occur at all ages but it is commonest in infancy. 95% of the cases take place between 1 month- 5 years of age. 2-Epidemic meningitis caused by Neiseria meningitides. 3- viral meningitis and viral encephalitis is not infectious. 4- Neonates with bacterial meningitis often present with nonspecific symptoms 5- It has been shown that in both children and adults, classic characteristics (elevated protein levels, lowered glucose levels, CSF pleocytosis) of bacterial meningitis are present in 90% of patients. A completely normal CSF occurs but is very rare
- 74. 6- It isstrongly recommended to start antibiotic therapy as soon as possible in acute bacterial .meningitis patients 7- Corticosteroids significantly reduced hearing loss and neurologic sequelae. 8- Prophylactic antibiotic treatment of household contacts of meningococcal meningitis patients prevents secondary cases and eradicates meningococcal carriage
- 75.