Acute Bacterial Meningitis

Clinical Features In neonates

Hyper/hypothermia, poor feeding, irritability, jaundice, convulsions, bulging fontanelle, purpura, diarrhoea, apnoea, hyperventilation. In older children: Fever, vomiting, headache, photophobia, anorexia, myalgia, arthralgia, tachycardia, petechiae, purpura, nuchal rigidity, back pain, Kernig/Brudzinski sign Papilloedema is rare in uncomplicated meningitis. Focal neurologic signs may occur due to vascular occlusion. Seizure (focal or generalized) due to cerebritis, infarction or electrolyte disturbances. Altered mental status is a feature of increased ICP, cerebritis or hypotension. Comatose patients have poor prognosis.

Investigations

1. Blood: Sugar, CBC, culture, electrolytes 2. CSF analysis: Lumbar puncture—L3-L4 or L4-L5 intervertebral space. LP is contraindicated; if: a. Evidence of raised ICP (administer mannitol and do guarded LP later) b. Severe cardiopulmonary compromise c. Infection of skin overlying site of LP. Thrombocytopenia is a relative contraindication. If CSF analysis is delayed and meningitis is clinically suspected, empiric antibiotic therapy is to be started.

• Turbid CSF: Leucocytes > 200–400/cmm.
• Normal healthy neonates: Up to 30 leucocyte/cmm.
• Normal healthy children: Upto 5 lymphocytes/cmm
• In meningitis, CSF: Leucocytosis >1000/cmm 90% neutrophils
• Gram stain of CSF will show causative organism in 70- 90% of cases.
• CSF: Sugar will be less than 50% of RBS
• CSF protein will be elevated.

Treatment

General Measures

• Control of seizures
• Control of raised ICT
• Treat shock and hypotension
• If the pneumococci in the region are sensitive to third generation cephalosporins, initial empiric antibiotic therapy is with: — Inj. Cefotaxime 200 mg/kg/day IV Q6H OR — Inj.Cetriaxone 100 mg/kg/day IV Q12H
• If pneumococci are suspected to be resistant to 3rd generation cephalosporins. — Inj.Vancomycin 60 mg/kg/day IV Q 6H
• Inj. Dexamethasone 0.15 mg/kg/dose IV Q6H × 2 day.

Assessment of Infants from 0-2 Months

Symptoms and signs of pneumonia, septicaemia or meningitis are often indistinguishable during first 2 months of life. A possible serious bacterial infection may be indicated by certain nonspecific signs. The clinical classification in this age group (2 months) divides these infants to 3 groups.

1. Possible serious bacterial infection: It is diagnosed in a sick infant when any of the following is present:

• Convulsions
• Bulging anterior fontanelle
• Lethargic or unconscious
• Fever (axillary temp. >37.5o C)
• Hypothermia (axillary temp. 60/min)
• Severe skin pustules/many pustules
• Fast breathing (RR : >60/min)
• Severe chest indrawing
• Nasal flaring
• Respiratory grunting
• Cough and severe undernutrition (Weight <2kg in first month or <2.5kg in a second month

​2. Local bacterial infection

• Red umbilicus/umbilicus draining pus
• Skin pustules

​3. No evidence of possible bacterial infection

• None of above features to suggest (1) or (2) All infants with possible serious bacterial infection are presumed to be very severely ill. They require prompt hospitalisation for parenteral broad-spectrum antibiotics and supportive care as they may deteriorate very quickly.
• Start IM/IV Ampicillin 50 mg/kg/dose Q6H +
• IM/IV Gentamicin 7.5 mg/kg OD. Continue same treatment for four days more after the child is well. Once the infant’s condition has substantially improved, change to oral, amoxycillin 15 mg/kg/dose Q8H along with IM-Gentamicin 7.5 mg/kg OD
• When meningitis is suspected, treat for 14 days or until the infant has remained well for 4 days whichever is longer.
• When staphylococcal infection is possible, (as suggested by the following): a. rapid progression of clinical disease b. empyema c. pneumothorax, pneumatocoeles in CXR d. multiple skin pustules/cellulites. Add IM/IV Cloxaciillin 50 mg/kg/dose, Q6H with IM/IV Gentamicin 7.5 mg/kg/dose OD. If there is no improvement in 48 hours or if the infants condition deteriorates, add:
• IM Chloramphenicol 25 mg/kg/dose Q8H (not used in neonates less than 7 days and in premature infants).
• Or change to IM/IV Cefotaxime 50 mg/kg/dose Q6H along with IM/IV Ampicillin 50 mg/kg/dose Q6H
• Good thermal environment is to be maintained and adequate fluids should be given (120 ml/kg/day of milk to be given by NG tube if not able to feed).

Assessment and Treatment (2 months-5 years)

• Note the following: — Age — Fever: duration — Cough: duration — Ability to drink/breast feed — Altered sensorium/Convulsions
• Two physical signs are important 1. Fast breathing: Count for 30 sec or 60 sec — 2 months–1 year: >50/minutes — 1 year–5 years: >40/minutes 2. Chest indrawing: Definite inward motion of lower chest wall on breathing in. Indications for X-ray Chest 1. Very severe and severe pneumonia to rule out empyema and pneumothorax 2. Suspected staphylococcal pneumonia 3. Nonresponse to initial antibiotic therapy 4. Cases of persistent cough (>30 days) 5. History of foreign body inhalation 6. To evaluate cardiac status. Treatment of Pneumonia
• Start cotrimoxazole 4 mg/kg/dose of TMP Q 12H Treat fever and wheezing:
• Reassess after 48 hours — Improved: Continue cotrimoxazole for a total of 5 days — No improvement: But no indicators of severe pneumonia, continue cotrimoxazole. Reassess on day five. In case of poor response, switch over to Amoxycillin or Ampicillin or Procaine penicillin.
• At 48 hours, if developing features of severe pneumonia, hospitalize and start parenteral Ampicllin.
• Advise the mother to watch for: Poor feeding—not able to drink/suck. Oxygen Therapy 1. Indication of oxygen therapy in infant and children with ALRI are:
• Central cyanosis
• Inability to drink or breastfeed
• Severe lower chest indrawing
• Head nodding
• Grunting
• Respiratory rate of 70/min or more. Indications for IV Fluids
• Cyanosis
• Restlessness
• Severe lower chest indrawing
• Grunting
• Shock and dehydration
• Poor acceptance of oral fluids. Chronic Cough Cough lasting longer than 30 days. Causes are:
• Asthma
• Foreign body inhalation
• Pertussis/Parapertussis
• Tuberculosis
• Drainage of secretion from upper airways.