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Good Morning! 

Good Morning! . Morning Report: Thursday, April 5 th. The LP…. Bacterial Meningitis in the Neonate. Some Background Info…. Bacterial meningitis is more common in the first month than at any other time in life Mortality rate has declined from 50% in the 1970s to 10-15% currently

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Good Morning! 

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  1. Good Morning! Morning Report: Thursday, April 5th

  2. The LP…

  3. Bacterial Meningitis in the Neonate

  4. Some Background Info… • Bacterial meningitis is more common in the first month than at any other time in life • Mortality rate has declined from 50% in the 1970s to 10-15% currently • BUT, the morbidity rate is relatively unchanged • Incidence 0.25-0.32/1000 live births • Occurs in up to 15% of neonates with bacteremia

  5. Risk Factors for Neonatal Sepsis and Meningitis • LBW (<2500g) • Preterm birth (<37 wga) • PROM • Septic or traumatic delivery • Fetal hypoxia • Maternal peripartum infection • Galactosemia • Urinary tract abnormalities

  6. Etiology • Early-onset infections (first 3-6 days after birth) • Reflect vertical transmission from maternal genital tract flora • Late-onset infections (after first week of life) • Suggest nosocomial or community acquisition • (Maternal flora may still be a source)

  7. Etiology • The “bugs” • GBS • E.Coli • Other gram-negative bacilli • Other gram positive organisms constitute a higher portion of disease burden among VLBW infants • Enterococcus • Coagulase-negative staphylococci • S. aureus • L. monocytogenes • Alpha-hemolytic streptococci

  8. Clinical Features • Temperature instability (60%) • Term infants: temp> 38C • Preterm infants: temp< 36C • Neurologic symptoms • Irritability/ lethargy (60%) • Poor tone • Tremors/twitching/seizures (20-50%) • Focal • More common presentation in gram-negative meningitis • Full fontanelle

  9. Clinical Features • Other • Poor feeding/ vomiting (50%) • Respiratory distress (33-50%) • Apnea (10-30%) • Diarrhea (20%)

  10. Laboratory Work-up • Full septic work-up • CBC • BCx • UA/ UCx (if > 6 days of age) • LP • Glucose • Protein • Cell count and differential • Gram stain • Culture

  11. CSF Findings in Meningitis PEARLS OF CSF WISDOM: CSF WBC ct may be lower with gram-positive organisms In 20% of patients with culture-confirmed meningitis, the gram stain will be negative (especially with L. monocytogenes) Adjustment of WBC in the setting of a traumatic LP can result in loss of sensitivity with only a marginal gain in specificity

  12. Diagnosis • CSF culture • Negative cultures rely on cell count and protein • LP was delayed until after antibiotic administration • IAP

  13. Treatment- Empirics • Empiric therapy • Early-onset • Ampicillin and gentamicin OR • Ampicillin and cefotaxime OR • If Listeria and Enterococcus are unlikely • Ampicillin and gentamicin and cefotaxime • If a gram-negative organism is strongly suspected • Late-onset • Non-hospitalized neonates • Ampicillin and gentamicin OR • Ampicillin and gentamicin and cefotaxime • Hospitalized neonates • Vancomycin, gentamicin, cefotaxime • Vancomycin, ampicillin, gentamicin

  14. Treatment- Specifics • Specific therapy • GBS: Ampicillin or PCN+ Gentamicin sterility PCN G monotherapy • Gram-negative enterics: Ampicillin (for amp-susceptible strains), Cefotaxime+ Gentamicin sterility 7-14 days of continued combination therapy Cefotaximemonotherapy • Listeria: Ampicillin and Gentamicin • Coagulase-negative staphylococci: Vancomycin

  15. Treatment-Duration • Positive CSF culture • Gram-positives (uncomplicated course): 14 days • Gram-negatives: 21 days (minimum) • Ventriculitis, abscess, multiple areas of infarction: up to 8 weeks

  16. Complications • Acute • Ventriculitis • Abscess • Infarction • Hydrocephalus • Subdural effusion • Chronic • Developmental delay (25%) • Late-onset seizures (20%) • CP (20%) • Hearing loss (10%) • Cortical blindness (<10%)

  17. Noon is free!! Thanks for your attention!!

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