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Evauation of Meningitis and Management. Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri. Evauation of Meningitis and Management. Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri. What is meningitis? …….

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Dr k prashanth kumar consultant physician oxygen hospitals vikrampuri

Evauation of Meningitis and

Management

Dr. K. Prashanthkumar

Consultant Physician

Oxygen hospitals , Vikrampuri.


Evauation of meningitis and management
Evauation of Meningitis and Management

Dr. K. Prashanthkumar

Consultant Physician

Oxygen hospitals , Vikrampuri.


What is meningitis
What is meningitis?……

  • The brain and spinal cord are covered by connective tissue layers collectively called the meninges which form the blood-brain barrier.

    1-the pia mater (closest to the CNS)

    2-the arachnoid mater

    3-the dura mater (farthest from the CNS).

    The meninges contain cerebrospinal fluid (CSF).

    Meningitis is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain.


What is meningitis1
What is Meningitis?

  • Meningitis can be caused by many different organisms including viruses and bacteria.

  • Meningitis, caused by a bacteria, is life threatening and requires urgent medical attention and treatment with antibiotics.

  • Meningitis caused by a virus is very rarely life threatening but can cause the body to become very weak.

  • When bacteria invade the body they can cause meningitis, septicaemia or meningitis and septicaemia together


Causes of meningitis
Causes of Meningitis

-Bacterial Infections

-Viral Infections

-Fungal Infections

(Cryptococcus neoformans

Coccidiodes immitus)

-Inflammatory diseases

(SLE)

Cancer

-Trauma to head or spine.


N. meningitides

G-ve diplococci

E.Coli

G-ve bacilli

Streptococci-GBS

G+ve cocci

Strep. pneumoniae

G+ve diplococci


Bacterial meningitis etiological agents
Bacterial meningitis…..Etiological Agents:

  • Pneumococcal, Streptococcus pneumoniae (38%)

  • Meningococcal, Neisseria meningitidis (14%)

  • Haemophilus influenzae (4%)

  • Staphylococcal, Staphylococcus aureus (5%)

  • Tuberculous, Mycobacterium tuberculosis


Bacterial meningitis
Bacterial Meningitis

Potentially life threatening disease.

One million cases per year world wide. 200,000 die annually.

Can affect all age groups but some are at higher risk.

Treatment available : antibiotics as per causative organism

Humans are the reservoir .

Pneumococcal meningitis is the most common type. Approximately 6,000 cases/yr

Haemophilus meningitis: Since 1985 Incidence has declined by 95% due to the introduction of Haemophilus influenza b vaccine.

Other bacterial meningitis caused by E-Coli K-1, Klebsiella species and Enterobacter species are less common overall, but may be more prevalent in newborns, pregnant women, the elderly and immunocompromised hosts.


What is meningococcal disease
What is Meningococcal disease?

Etiological Agent: Neisseria meningitidis

Clinical Features: sudden onset. F,H,N,V

Reservoir: Humans only. 5-15% healthy carriers

Mode of transmission: direct contact with patients oral or nasal secretions. Saliva.

Incubation period: 1-10 days. Usually 2-4 days

Infectious period: as long as meningococci are present in oral secretions or until 24 hrs of effective antibiotic therapy

Epidemiology:

Sporadic cases worldwide.

“Meningitis belt” –sub-Saharan Africa into India/Nepal.

In US most cases seen during late winter and early spring.

Children under five and adolescent most susceptible. Overcrowding e.g. dormitories and military training camps predispose to spread of infection.


Aseptic meningitis
Aseptic Meningitis

Definition: A syndrome characterized by acute onset of meningeal symptoms, fever, and cerebrospinal fluid pleocytosis, with bacteriologically sterile cultures.

Laboratory criteria for diagnosis:

CSF showing ≥ 5 WBC/cu mm

No evidence of bacterial or fungal meningitis.

Case classification

Confirmed: a clinically compatible illness diagnosed by a physician as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis

Comment

Aseptic meningitis is a syndrome of multiple etiologies, but most cases are caused by a viral agent


Viral meningitis
Viral Meningitis

Etiological Agents:

Enteroviruses (Coxsackie's and echovirus): most common.

-Adenovirus

-Arbovirus

-Measles virus

-Herpes Simplex Virus

-Varicella

Reservoirs:

-Humans for Enteroviruses, Adenovirus, Measles, Herpes Simplex, and Varicella

-Natural reservoir for arbovirus birds, rodents etc.

Modes of transmission:

-Primarily person to person and arthopod vectors for Arboviruses

Incubation Period:

-Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days

Treatment: No specific treatment available.

Most patients recover completely on their own.


Non polio enteroviruses
Non Polio Enteroviruses

Types:62 different types known:

-23 Coxsackie A viruses,

-6 Coxsackie B viruses,

-28 echoviruses, and 5 other

How common?

-90% of all viral meningitis is caused by Enteroviruses

-Second only to "common cold" viruses, the rhinoviruses.

-Estimated 10-15 million/ more symptomatic infections/yr in US

Who is at risk?Everyone.

How does infection spread?Virus present in the respiratory secretions & stool of a patient.

Direct contact with secretions from an infected person.

Parents, teachers, and child care center workers may also become infected by contamination of the hands with stool.


The difference between meningitis and septicaemia
The difference between Meningitis and Septicaemia

When bacteria cause disease i.e. meningococcal disease the body can be affected in different ways:

Meningitis - bacteria enter the blood stream and travel to the meninges and cause inflammation.

Septicaemia - when bacteria are present in the blood stream they can multiply rapidly and release toxins that poison the blood. (The rash associated with meningitis is due to septicaemia.)

Meningitis and septicaemia often occur together.


Symptoms of meningitis and septicemia
Symptoms of Meningitis and Septicemia

Meningitis and meningococcal septicaemia may not always be easy to detect, in early stages the symptoms can be similar to flu.  They may develop over one or two days, but sometimes develop in a matter of hours.It is important to remember that symptoms do not appear in any particular order and some may not appear at all.


Symptoms for meningitis and meningococcal septicaemia
Symptoms for meningitis and meningococcal septicaemia:

:Babies and Young Children

-High temperature, fever, possibly with cold hands and feet

-Vomiting or refusing feeds

-High pitched moaning, whimpering cry

-Blank, staring expression

-Pale, blotchy complexion

-Stiff neck

-Arched back

-Baby may be floppy, may dislike being handled, be fretful

-Difficult to wake or lethargic

-The fontanelle (soft spot on babies heads) may be tense or bulging.


Older children and adults
Older Children and Adults

-High temperature, fever, possibly with cold hands and feet.

-Vomiting, sometimes diarrhoea.

-Severe headache.

-Joint or muscle pains, sometimes stomach cramps.

-Neck stiffness (unable to touch the chin to the chest)

-Dislike of bright lights.

-Drowsiness.

The patient may be confused or disorientated. Fitting may also be seen.

A rash may develop.


One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.


Another physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.


In the early stages, signs and symptoms can be similar to many other more common illnesses, for example flu. Early symptoms can include fever, headache, nausea (feeling sick), vomiting and general tiredness.

The common signs and symptoms of meningitis and septicaemia are shown above. Others can include rapid breathing, diarrhoea and stomach cramps. In babies, check if the soft spot (fontanelle) on the top of the head is tense or bulging.


One sign of meningococcal septicemia is a rash that does not fade under pressure (see ‘Glass test’)

-This rash is caused by blood leaking under the skin. It starts anywhere on the body. It can spread quickly to look like fresh bruises.

-This rash is more difficult to see on darker skin. Look on the paler areas of the skin and under the eyelids.


Glass test
‘Glass Test’ fade under pressure (see ‘Glass test’)

A rash that does not fade under pressure will still be visible when the side of a clear drinking glass is pressed firmly against the skin.

If someone is ill or obviously getting worse, do not wait for a rash. It may appear late or not at all.

A fever with a rash that does not fade under pressure is a medical emergency.


Be fade under pressure (see ‘Glass test’)aware, be prepared

Meningitis and meningococcal septicaemia (blood poisoning) are serious diseases that can affect anyone at any time. Teenagers and studentsin particular, are at increased risk.Most young people in the UK have already had the MenC vaccine. If you haven’t or can’t remember, gettingvaccinated now is a good way to protect yourself.

But remember, vaccines can’t preventall forms of meningitis and septicaemia.So it is very important that you are aware of the signs and symptoms so that you can get medical help urgently if you become ill.


Public health importance
Public Health Importance fade under pressure (see ‘Glass test’)

Challenges:

-Educating public

-Timely reporting and records keeping

-Updating information daily.

-Alleviating public anxiety and concerns

-Collaborating with health partners

Opportunities:

-Educating public

-Communication

-Strengthening partnerships


Demography and epidemiology
DEMOGRAPHY AND EPIDEMIOLOGY fade under pressure (see ‘Glass test’)

  • The highest incidence is among neonates, who are usually infected by bacteria found in the birth canal at the time of parturition.

    • Group B streptococci (Streptococcus agalactiae) account for the majority of cases; other causes include Listeriamonocytogenes, E.coli, other Gram-negative bacilli, and enterococci.

  • From age 1 to 23 months, the most common organisms are Streptococcus pneumoniae and Neisseria meningitidis


  • Children from the second to the fifth year used to have a high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • From age 2 through 18, N. meningitidis is the most common cause, accounting for more than one-half of cases, followed by S. pneumoniae

  • In adults up to age 60, S. pneumoniae is most common followed by N. meningitis

  • Over age 60, most cases are due to S. pneumoniae and less often L. monocytogenes


Etiology - in Adults high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • S. pneumoniae 30-50%

  • N. meningitidis 10-35%

  • H. influenzae 1-3%

  • G -ve bacilli 1-10%

  • Listeria species 5%

  • Streptococci 5%

  • Staphylococci 5-15%


Predisposing factors
Predisposing factors high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • Most cases of meningitis occur when colonization by potential pathogens is followed by mucosal invasion of the nasopharynx

  • However, some patients develop disease by direct extension of bacteria across a skull fracture in the area of the cribriform plate

  • Other patients develop meningitis following systemic bacteremia as with endocarditis or a urinary tract infection or pneumonia

  • Other predisposing conditions include asplenia, complement deficiency, corticosteroid excess, and HIV infection


Etiology and epidemiology of meningitis
Etiology and epidemiology of high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infectionmeningitis

  • Lack of immunity ( IgM or igG anti capsularantibody ) to specific pathogens with young age.

  • recent colonization with pathogenic bacteria .

  • Close contact with invasive disease ( respiratory tract secration)

  • Crowding , poverty , black race , male .

  • Defect in complement (C5- C8 ) associated with recurrent meningococcal infection .


Etiology and epidemiology of meningitis con
Etiology high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection and epidemiology of meningitis(con)

:

C

  • Open neural tube defect : Meningomyelocele and lumbosacral dermal sinus associated with Staphylococci aureus and gram – negative

  • head trauma or neurosurgical procedures ( staphylococci )


Clinical features
CLINICAL FEATURES high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • The overwhelming majority of patients with bacterial meningitis have fever and headache

  • Most patients have high fevers, but a small percentage have hypothermia

  • CNS symptoms

    • Some patients will have significant photophobia and/or clouding of the sensorium

    • Changes in mentation and level of consciousness, seizures, and focal neurologic signs tend to appear later in the course of disease


Clinical features1
CLINICAL FEATURES high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • Nuchal rigidity

    • Passive or active flexion of the neck will usually result in an inability to touch the chin to the chest

  • Tests to illustrate nuchal rigidity

    • The Brudzinski sign refers to spontaneous flexion of the hips during attempted passive flexion of the neck

    • The Kernig sign refers to the inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees


Clinical features2
CLINICAL FEATURES high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • Other findings

    • Some infectious agents, particularly N. meningitidis, can also cause characteristic skin manifestations, petechiae and palpable purpura

    • If meningitis is the sequela of an infection elsewhere in the body, there may be features of that infection still present at the time of diagnosis of meningitis eg, otitis or sinusitis


Differential Dx high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • Viral- 40 % of meningitis

  • Fungal

  • Tuberculous

  • Spirochete

  • Chemical / Drug induced

  • Collagen Vascular Disease

  • Parameningeal infection: brain abscess, epidural abscess

  • Subarachnoid hemorrhage

  • Neuroleptic Malignant Syndrome


Laboratory features
LABORATORY FEATURES high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • Most often the WBC count is elevated with a shift toward immature forms

  • Platelets may be reduced if disseminated intravascular coagulation is present or in the face of meningococcal bacteremia

  • Blood cultures are often positive, and can be very useful in the event that CSF cannot be obtained before the administration of antimicrobials

    • At least one-half of patients with bacterial meningitis have positive blood cultures, with the lowest yield being obtained with meningococcus


Laboratory features1
LABORATORY FEATURES high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection

  • CSF analysis – every patient with meningitis should have CSF obtained unless the procedure is contraindicated

  • Chemistry and cytologic findings highly suggestive of bacterial meningitis include a CSF glucose concentration below 45 mg/dL, a protein concentration above 500 mg/dL, and a white blood cell count above 1000/mm3

  • A Gram stain should also be obtained

  • The Gram stain is positive in up to 10 percent of patients with negative CSF cultures and in up to 80 percent of those with positive cultures


Opening pressure>180 mmH2O high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection White blood cells10/ L to 10,000/ L; neutrophils predominate Red blood cells Absent in no traumatic tap Glucose <2.2 mmol/L (<40 mg/dL)CSF/serum glucose <0.4Protein>0.45 g/L (>45 mg/dL)

Gram's stain Positive in >60%CulturePositive in >80%

Latex agglutination May be positive in patients with meningitis due to S. pneumoniae, N. meningitidis, H. influenzae type b, E. coli, group B streptococci 

Limulus lysate positive in cases of gram-negative meningitis PCR Detects bacterial DNA



Complications of meningitis
Complications of Meningitis Bacterial Meningitis

One of the most common problems resulting from meningitis is hearing loss.Anyone who has had meningitis should take a hearing test.

  • Young children:

  • Babyish behavior

  • Forgetting recently learned skills

  • Reverting to bed-wetting

  • Babyish behavior


  • Older people: Bacterial Meningitis

  • Lethargy

  • Recurring headaches

  • Difficulty in concentration

  • Short-term memory loss

  • Clumsiness

  • Balance problems

  • Depression


Serious complications
Serious complications Bacterial Meningitis

  • Other serious complications can include:

  • Brain damage

  • Epilepsy

  • Changes in eye sight


Vaccine for meningitis
Vaccine for meningitis Bacterial Meningitis~~

  • There are vaccines against Hib and against some strains of N. meningitidis and many types of Streptococcus pneumoniae. The vaccine against haemophilus influenze (Hib) has reduced Hib meningitis cases by 95 percent since 1985.

  • There are vaccines to prevent meningitis due to S. pneumoniae. The pneumococcal polysaccharide vaccine is recommended for all persons over 65 years of age and younger persons at least 2 years old with certain chronic medical problems.


Treatment and prevention of bacterial meningitis
Treatment and prevention of bacterial meningitis Bacterial Meningitis

  • Suspected bacterial meningitis is a medical emergency and immediate diagnostic steps must be taken to establish the specific cause

  • The mortality rate of untreated bacterial meningitis approaches 100 percent and, even with optimal therapy, there is a high failure rate

  • Empiric treatment should be begun as soon as the diagnosis is suspected using bactericidal agent(s) that achieve significant levels in the CSF


Use of bactericidal agents Bacterial Meningitis

  • Bactericidal therapy is generally necessary to cure meningitis

  • Bacteriostatic drugs, such as clindamycin and tetracycline, are inadequate for meningitis

  • Chloramphenicol is a bacteriostatic drug for most enteric Gram negative rods; however, it is usually bactericidal for H. influenzae, N. meningitidis, and S. pneumoniae and has been extensively and successfully used to treat meningitis caused by these organisms


Choice of agent Bacterial Meningitis

  • Selected third generation cephalosporins such as cefotaxime and ceftriaxone, have emerged as the beta-lactams of choice in the empiric treatment of meningitis

  • These drugs have potent activity against the major pathogens of bacterial meningitis with the notable exception of listeria

  • Ceftazidime, another third generation cephalosporin, is much less active against penicillin-resistant pneumococci than cefotaxime and ceftriaxone


Treatment - Empiric Bacterial Meningitis

  • Ceftriaxone 2 gm IV q12h or Cefotaxime 2 gm IV q4-6h

  • plus Vancomycin 15 mg/kg q6h

  • If > 50 years, also add Ampicillin 2 gm IV q4h (for Listeria)


Therapy for specific pathogens
THERAPY FOR SPECIFIC PATHOGENS Bacterial Meningitis

Streptococcus pneumoniae

  • The conventional approach to the treatment of pneumococcal meningitis was the administration of penicillin alone for two weeks at a dose of four million units intravenously every four hours

  • Good results have also been obtained with third generation cephalosporins

  • However, the problem of treating pneumococcal meningitis has recently been compounded by the widespread and increasingly common reports of pneumococcal strains resistant to penicillin


    • Cefotaxime or ceftriaxone can be used if the MIC for these drugs is less than 0.5 µg/mL

    • It is recommended that vancomycin (2 g/day) should be given with cefotaxime or ceftriaxone in the initial treatment of pneumococcal meningitis if there has been beta-lactam resistance noted locally

    • Vancomycin should be continued if there is high level penicillin resistance and an MIC >0.5 µg/mL to third generation cephalosporins

    • If corticosteroids are given, rifampin should be added as a third agent since it increases the efficacy of the other two drugs

    • The usual duration of therapy is two weeks


    Haemophilus influenzae drugs is less than 0.5 µg/mL

    • A third generation cephalosporin is the drug of choice for H. influenzae meningitis

    • Patients with H. influenzae meningitis should be treated for five to seven days

    • For adults, a dose of 2 g every six hours of cefotaxime and 2 g every 12 hours of ceftriaxone is more than adequate therapy

    • Pharyngeal colonization persists after curative therapy and may require a short course of rifampin if there are other children in the household at risk for invasive Haemophilus infection

    • The recommended dose is 20 mg/kg per day (to a maximum of 600 mg/day) for four days


    Neisseria meningitidis drugs is less than 0.5 µg/mL

    • This infection is best treated with penicillin

    • Although there are scattered case reports of N. meningitidis resistant to penicillin, such strains are still very rare

    • A third-generation cephalosporin is an effective alternative to penicillin for meningococcal meningitis

    • A five day duration of therapy is adequate

    • However, when penicillin is used, there may still be pharyngeal colonization with the infecting strain. As a result, the index patient may need to take rifampin, a fluoroquinolone, or a cephalosporin


    Listeria monocytogenes drugs is less than 0.5 µg/mL

    • Listeria has been traditionally treated with ampicillin and gentamicin, as resistance to these drugs is quite rare

    • Ampicillin is given in typical meningitis doses (2 g intravenously every four to six hours in adults) and gentamicin is used for synergy

    • An alternative in penicillin-allergic patients is trimethoprim-sulfamethoxazole (dose of 10/50 mg/kg per day in two or three divided doses)

    • The usual duration of therapy is at least three weeks


    Enteric Gram negative rods drugs is less than 0.5 µg/mL

    • Prior to the availability of third generation cephalosporins, it was often necessary to instill an aminoglycoside antibiotic such as gentamicin directly into the cerebral ventricles

    • It is now possible to cure these infections with high doses of third generation antibiotics

    • A repeat CSF sample should be obtained for culture two to four days into therapy to help assess the efficacy of treatment

    • The duration of therapy should be at least three weeks


    Prevention of meningitis vaccines
    PREVENTION OF MENINGITIS drugs is less than 0.5 µg/mLVaccines

    A spectacular reduction in H. influenzae meningitis has been associated with the near universal use of a vaccine against this organism in developed countries since 1987

    • There has been a 94 percent reduction in H. influenzae meningitis between 1987 and 1995

    • Pneumococcal vaccine administered to the chronically ill and elderly is probably useful in reducing the overall incidence of pneumococcal infections. However, its role in the prevention of meningitis is as yet undetermined


    Vaccines
    Vaccines drugs is less than 0.5 µg/mL

    • Meningococcal vaccines are active against many strains of N. meningitidis

    • However, the majority of meningococcal infections in the United States are caused by type b meningococcus for which there is no vaccine

    • Vaccines for other types (notably type a) are recommended for travelers and American military personnel to countries with epidemic meningitis

    • Immunization against meningococci is not warranted as postexposure prophylaxis


    Chemoprophylaxis
    Chemoprophylaxis drugs is less than 0.5 µg/mL

    • There is a role for chemoprophylaxis to prevent spread of meningococcal and haemophilus meningitis but not for pneumococcal disease

    • The use of antimicrobial therapy to eradicate pharyngeal carriage of meningococci is widely accepted to prevent development of disease in close contacts and to eradicate pharyngeal carriage

    • Rifampin 600 mg PO every 12 h for a total of four doses is recommended

    • Ciprofloxacin, in a single dose of 500 mg PO, is equally effective and can be used in patients over the age of 18


    Role of steroids
    Role Of Steroids drugs is less than 0.5 µg/mL

    • The addition of antiinflammatory agents has been attempted as an adjuvant in the treatment of meningitis

    • Early administration of corticosteroids such as dexamethasone for pediatric meningitis has shown no survival advantage, but there is a reduction in the incidence of severe neurologic complications and deafness

    • A meta-analysis of five such studies in children showed a relative risk of bilateral deafness of 4.1 and of late neurological sequelae of 3.9 in controls compared to children treated with steroids


    • A second meta-analysis of trials of meningitis in children evaluated the findings according to organism

    • For H. influenzae type b meningitis, dexamethasone therapy was associated with a significant reduction in deafness

    • For pneumococcal meningitis, dexamethasone was effective only if given early ; in this setting, there was a significant reduction in hearing loss

    • Two days of therapy was as effective and less toxic than longer courses of steroid administration

      Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA 1997; 278:925


    • There is no consensus regarding the utility of corticosteroid therapy in adults

    • The Infectious Disease Society of America considers adjuvant corticosteroids for meningitis to be unsupported for routine use in adults but supports them for H. influenzae infections in children

      Guidelines for the use of systemic glucocorticoids in the management of selected infections.

      J Infect Dis 1992; 165:1


    Mortality rate and late sequelae
    MORTALITY RATE AND LATE SEQUELAE corticosteroid therapy in adults

    • The prognosis of meningitis is linked to age and the presence of underlying disease

    • Bacterial meningitis accompanying advanced liver disease, HIV infection, or organ transplantation is likely to be associated with more morbidity and mortality

    • In addition, the prognosis and complications differ in children and adults


    • The mortality rates are lowest in children corticosteroid therapy in adults

    • A meta-analysis of prospectively enrolled cohorts of children in developed countries showed a 4.8 percent mortality from 1955 to 1993

    • The mortality rate varied by organism, ranging from 3.8% for H. influenzae to 7.5 percent for N. meningitidis to 15.3% for S. pneumoniae

    • 83.6 percent of the surviving children had apparently complete recovery

    • The most common sequelae were

      • Deafness – 10.5 percent.

      • Bilateral severe or profound deafness – 5.1 percent.

      • Mental retardation – 4.2 percent.

      • Spasticity and/or paresis – 3.5 percent.

      • Seizures – 4.2 percent.


    • Complications are more common in adults corticosteroid therapy in adults

    • A series of 86 adults with meningitis, for example, showed a mortality rate of 18.6 percent with a complication rate of 50 percent

    • The most common problems were:

      • Cerebrovascular involvement – 15.1 percent.

      • Cerebral edema – 14 percent.

      • Hydrocephalus – 11.6 percent.

      • Septic shock – 11.6 percent.

      • Disseminated intravascular coagulation – 8.1 percent.

      • Acute respiratory distress syndrome – 3.5 percent.

        Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study. Arch Neurol 1993; 50:575


    • A second review of bacterial meningitis in adults from 1962 to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • As in children, there was a higher rate of death due to S. pneumoniae (37 percent) as compared to N. meningitidis (13 percent) and listeria (10 percent)

      Acute bacterial meningitis in adults.

      N Engl J Med 1993; 328:21.


    Selected bedside signs of meningitis
    Selected Bedside Signs of Meningitis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Chemoprophylaxis regimens for meningococcal disease
    Chemoprophylaxis Regimens for Meningococcal Disease to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Bacterial meningitis organisms
    Bacterial Meningitis - Organisms to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Birth - 4 wks: GBS, E.coli

    • 4 - 12 wks: GBS, E.coli, Pneumococcus Salmonella, Listeria, H. Influenza

    • 3 mths - 3 yrs: Pneumococcus, Meningococcus

      H. Influenza

    • 3 yrs+ adult: Pneumococcus, Meningococcus


    Bacterial meningitis pathogenesis
    Bacterial Meningitis - Pathogenesis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Infection of upper respiratory tract

    • Invasion of blood stream (bacteraemia)

    • Seeding & inflammation of meninges


    Meningitis clinical features
    Meningitis: Clinical features to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    Newborn & Infants: non-specific

    • Fever

    • Irritability

    • Lethargy

    • Poor feeding

    • High pitched cry, bulging AF

    • Convulsions, opisthotonus


    Acute meningococcaemia
    Acute Meningococcaemia to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Neisseria meningitidis: serotype Grp B commonest

    • Endotoxin causes vascular damage vasodilatation, third spacing, severe shock

    • Severe complication:

      Waterhouse-Friderichsen syndrome: massive haemorrhage of adrenal glands secondary to sepsis: adrenal crisis-low B.P, shock, DIC, purpura, adreno-cortical insufficiency


    Septicaemia
    Septicaemia to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Purpura fulminans
    Purpura fulminans to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Clinical features3
    Clinical features to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Clinical features4
    Clinical features to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Clinical features5
    Clinical features to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


    Diagnosis
    DIAGNOSIS to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Hx & PE

      Investigations:

    • FBC

    • R/L/B

    • CRP

    • Coag

    • Blood gas

    • Glucose

    • Blood C/S

    • Skin scrapings

    • PCR

    • CXR+ Mantoux if TB suspected


    Diagnosis1
    Diagnosis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    LP


    Csf findings
    CSF FINDINGS to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    ·  Bacterial Viral TB

    ·Cells 10-100,000 <2,000 250-500

    ·polyslymphslymphs

    ·Glucoselow normal very low

    ·ProteinN-INC N-INC N-INC

    ·G-Staingen +ve -ve +ve Zn


    Bacterial meningitis management
    Bacterial Meningitis Management to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    •  Medical emergency

    •  Early diagnosis essential

    • Immediate optimum treatment

    • Intensive supportive therapy

    • Rehabilitation

    • Prophylaxis to family

    • Notification to GP & Public Health


    Bacterial meningitis meningococcaemia management
    Bacterial Meningitis/Meningococcaemia Management to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • ABC

    • PICU

    • Fluid management: aggressive resuscitation

    • Dexamethasone: only in Pneumococcal and HiB, given before antibiotics

    • Inotropes: increasing aortic diastolic pressure and improving myocardial contractility


    Antibiotics
    Antibiotics to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    Less than 2 months of age:

    • Ampicillin + Cefotaxime+/- Gentamicin

    • Treat for 3 weeks (neonate)

      Over 2 months:

    • Cefotaxime

    • Treat for 7-10 days


    Prophylaxis
    Prophylaxis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Rifampicin:

      Children 5mg/kg bd x 2/7

      Adults: 600 mg bd x 2/7

      Pregnant contact:

      Cefuroxime IM x 1 dose

      OR

      Just do T/S and await result


    Meningitis complications
    Meningitis - Complications to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Septic shock - DIC

    • Cerebral oedema

    • Seizures

    • Arteritis/venous thrombosis

    • Subdural effusions

    • Hydrocephalus . Abscess . Brain damage

    • Deafness


    Meningococcaemia poor prognosis
    Meningococcaemia - poor prognosis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Onset of Petechiae within 12 hrs

    • Absence of meningitis

    • Shock (BP 70 or less)

    • Normal or low WCC

    • Normal or low ESR


    Subdural effusion
    Subdural Effusion to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Failure of temp to show progressive reduction after 72 hours

    • Persistent positive spinal cultures after 72 hr

    • Occurrence of focal/ persistent convulsions

    • Persistence/recurrence of vomiting

    • Development of focal neurological signs

    • Clinical deterioration after 72 hr especially ICP


    Partially treated meningitis
    Partially treated meningitis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • 50% cases prior antibiotic - alters the findings in bacterial meningitis -

    • Accurate history vital

    • CSF mainly lymphocytic [not usual polys]

    • Can have normal glucose

    • +ve cultures reduced by 30%

    • Gram stain reduced by 20%


    Viral meningitis1
    Viral meningitis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Most common infection of CNS especially in <1yr

    • Causes: enterovirus (commonest, meningitis occurring in 50% of children <3mth ) herpes, influenza, rubella, echo, coxsackie, EBV, adenovirus

    • Mononuclear lymphocytes in CSF

    • Symptomatic treatment. Complications associated with encephalitis and ICP


    Tb meningitis
    TB Meningitis to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Usually insidious: difficult to diagnose in early stages (fever 30%, URTI 20%)

    • Rare in children in developed countries

    • If untreated is usually fatal

    • Meningitis usually occurs 3-6mths after primary infection

    • 1 stage-lasts 1-2wk, fever malaise, headache

    • 2 stage-+/- suddenly, meningeal signs

    • 3 stage-worsening neurological condition, death


    Mortality morbidity
    Mortality/Morbidity to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Bac meningitis: Overall mortality 5-10%

    • Neonatal meningitis: 15-20%

    • Older children: 3-10%

    • Strep. pneumonia: 26-30%

    • H. influenza type B: 7-10%

    • N. meningitidis: 3.5-10%

    • 30% neurological complications

    • 4% Profound b/l hearing loss (sensorineural) in all bac meningitis


    Mortality morbidity1
    Mortality/Morbidity to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study

    • Viral meningoencephalitis: Enteroviral fewer complications

    • Tuberculous meningitis: related to stage of disease

    • Stage I-30% morbidity

    • Stage II- 56%

    • Stage III-94%


    THANK YOU to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study


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