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5]

Review Article

Central nervous system infection in the

pediatric population
Rabi Narayan Sahu, Raj Kumar, A. K. Mahapatra
Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Address for Correspondence: Dr. Rabi Narayan Sahu, Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh-226 014, India. E-mail: drrnsahu@gmail.com

ABSTRACT
Infection of the central nervous system is a life-threatening condition in the pediatric population. Almost all
agents can cause infection within the central nervous system and the extent of infection ranges from diffuse
involvement of the meninges, brain, or the spinal cord to localized involvement presenting as a space-occupying
lesion. Modern imaging techniques define the anatomic region infected, the evolution of the disease, and help
in better management of these patients. Acute bacterial meningitis remains a major cause of mortality and
long-term neurological disability. Fortunately, the incidence of infection after clean craniotomy is < 5%, but it
leads to significant morbidity as well as fiscal loss. The most significant causative factor in postcraniotomy
infections is postoperative CSF leak. Cerebral abscess related to organic congenital heart disease is one of
the leading causes of morbidity and mortality in the pediatric population. The administration of prophylactic
antibiotics is indicated for contaminated and clean-contaminated wounds.

Key words: Cerebral abscess, meningitis, pediatric, post-craniotomy infection, prophylactic antibiotics

Introduction of potent newer antibiotics, the mortality rate due to acute

Infection of the central nervous system is a life-threatening
condition, especially in children, that demands immediate
attention from the attending physician or surgeon and the
clinical pathologist as well as the microbiologist. Almost
all agents can cause infection within the central nervous
system and the extent of infection ranges from diffuse
involvement of the meninges, brain, or the spinal cord to
localized involvement presenting as a space-occupying
lesion. Epidemiological considerations, appreciation of the
presenting clinical syndrome (acute bacterial meningitis,
acute aseptic meningitis, chronic meningitis or space-
occupying lesions) and cerebrospinal fluid analysis facilitates
diagnosis. Modern imaging techniques define the anatomic
region that has been infected and the evolution of the disease,
help to evaluate the treatment efficacy, and can frequently
help to determine extra-central nervous system sources of
infection, such as sinusitis or mastoiditis. Acute bacterial
meningitis remains a major worldwide cause of mortality
and long-term neurological sequelae. Despite the availability
DOI: 10.4103/1817-1745.49102
Online full text at
http://www.pediatricneurosciences.com
20 / J Pediatr Neurosci / Volume 4 / Jan-Jun / 2009
bacterial meningitis remains significantly high (16–32%) in
India and other developing countries.[1-4]
Bacteriology of Infection and
Host Defenses
Almost every infective agent can cause infections within
the CNS, although agents vary in their tendency to do so.
Infective agents generally gain access to the CNS either
by the hematogenous route or by direct extensions. Most
agents that can invade the blood stream can be carried to
the CNS. The rare exceptions include rabies virus, herpes
simplex virus 1, and Naegleria fowleri. In rabies, the virus
travels along the peripheral nerves from the site of infection
to the CNS. However, in herpes and Naegleria infections,
the inoculation occurs directly through the olfactory bulbs.
Bacterial agents commonly cause infection of the CNS in
infants and children. By far, the most common presentation of
such infection is meningitis. Less often, intracranial abscesses
are found in the epidural, subdural, or intracerebral tissues.
The incidence of bacterial meningitis is high in the first few
months of life and continues to be high until two years of age,
after which it declines considerably.[5,6] Neonates usually
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derive their colonization from the maternal gastrointestinal
or genitourinary tracts. In the first two weeks of life, group
B Streptococci and Escherichia coli are the most common
infective agents, accounting for approximately 80–85%
of all cases.[7] The bulk of the remaining cases are caused
by other coliforms such as Enterobacter cloacae, Proteus
mirabilis, Citrobacter freundii, Klebsiella pneumoniae, and
Salmonella enteritidis. Group B Streptococci type-I are still
the most frequent cause of bacterial meningitis in infants
between three and six weeks of age. [8] A comprehensive
age-wise etiology of meningitis is given in the Table 1.[9]
Fortunately, the central nervous system is well protected
against most micro-organisms because of its unique location
deep in the body where it is protected by skin, muscle, bone,
and tough fibrous tissue. Surgical interventions transcend
these barriers and directly expose the CNS to the possibility
of microbiological attacks. However, the body executes a
complex series of host defenses to reduce the likelihood
that such microbiologic contaminations will proceed to
frank infection. Whether a bacterial inoculum in a wound
will proceed to a frank infection can be predicted by many
factors such as the size and virulence of the inoculum and
the level of the host defense present.
Imaging in Infection
Imaging is extremely important in the diagnosis and
management of intracranial infections. It defines the
anatomic region affected: the epidural or subdural
spaces, the pia-arachnoid, the cerebral parenchyma, or
the ventricles. It also helps to define the evolution of the
process, i.e., the transitions from meningitis to cerebritis
to abscess formation. The primary imaging techniques for
demonstrating the presence of inflammation and their
effects are computerized tomography (CT) and magnetic
resonance imaging (MRI). The intravenous injection of
an iodinated contrast agent is essential in the CT-assisted
diagnosis of cerebritis, cerebral abscess, and ventriculitis.
Similarly magnetic resonance contrast agents such as
gadolinium-DTPA cross the blood brain barrier in areas
of cerebritis or abscess.[10,11] MRI is superior to CT scans in
showing meningeal enhancement from meningitis because
of the absence of bony artifacts of adjacent skull bones
seen with CT scans. However, evidence of bony erosion
or abnormalities due to inflammation is more clearly
demarcated in CT scans than in MRI.
Table 1: Age-wise etiology of meningitis
Within 2 weeks 3 to 6 weeks
Group B Streptococcus Group B Streptococcus
Escherichia coli Haemophilus inßuenzae b
Enterococcus Streptococcus pneumoniae
Listeria monocytogenes Neisseria meningitides
Escherichia coli
Listeria monocytogenes
Sahu, et al.: Infection in pediatric population
Specific CNS Infections
Craniotomy infections
In most hospitals, the incidence of infection after clean
craniotomy is < 5%. There are several contributing factors
such as the duration of surgery, re-exploration surgery, age
of the patient, and postoperative CSF leaks.[12,13] However,
the most significant causative factor in postcraniotomy
infections is the postoperative CSF leak.[14] CSF fistulae
offer routes for bacterial entry and should be treated
promptly.[12] A few stitches in time when the skin is healthy,
solve the problem in most cases. Sometimes, repeated
lumber punctures or a spinal drain help and enables the
CSF fistula to scar.
Amongst the further complications of craniotomy infections are
postoperative meningitis, empyema, abscess formation, wound
gap, and bone flap infections. Postoperative meningitis is not
very common but it is a potentially lethal complication[15] with
Staphylococci sp. being common pathogens in such meningitis.
Lumber puncture should be done to exclude meningitis in the
postoperative period if the patients show signs of meningismus
with fever. Choosing a proper antibiotic is as important as
administering these antibiotics in proper doses.[16]
Bone flap infection
The incidence of bone flap infection following craniotomy is
greater when the bone is devascularized. Bone flap infections
are characterized by a local inflammation and a nonhealing
fistula. The standard treatment is removal of the infected
bone flap and cranioplasty at a later date.[17,18]
CSF shunt infection
CSF shunt infections are one of the most important infections
encountered by neurosurgeons. According to several studies,
the incidence varies from 5–39% of all shunts [19,20] and
the infective etiology is responsible for hydrocephalus in
a significant number of children (36%).[20] The possibility
of TORCH infection as a cause of hydrocephalus should
be considered during antenatal check-up even among the
children of screened mothers. As colonization of shunt
tubing occurs most frequently during surgery, the organisms
are usually skin pathogens, especially Staphylococci sp., both
coagulase-positive and coagulase-negative types. Staphylococci
epidermidis, (coagulase-negative) makes up the largest group
of microorganisms that colonize shunts.[21] There is some
controversy about whether antibiotic-impregnated shunts
help in preventing infection.[22,23] Sometimes, brain abscess
7 weeks to 15 years > 15 years
Haemophilus inßuenzae b Streptococcus pneumoniae
Streptococcus pneumoniae Neisseria meningitides
Neisseria meningitides Streptococcus
Staphylococcus
Listeria monocytogenes
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Sahu, et al.: Infection in pediatric population

and other uncommon complications can occur due to shunt begins subsequently with capsulation consolidating around
insertion.[24,25] the necrotic center. The late capsule phase occurs around
14 days with dense collagen capsulation surrounded by a
gliotic pseudocapscule.[33] The treatment of the brain abscess
Intracranial Abscess is usually nonsurgical, but surgical aspiration or excision of
the whole abscess in necessary in most cases.[34] Occasionally,
The incidence of brain abscess is higher in India. Bhatia et spontaneous evacuation of intracranial abscesses has been
al, reported that abscess comprised 8% of all intracranial reported through normal or abnormal pathways.[35]
spinal space-occupying lesions.[25] Brain abscess is initiated
when micro-organisms are introduced as a result of trauma,
contiguous infection, or hematogenous dissemination. Neurosurgical Infections in the
Sometimes, the abscess confines itself to subdural spaces
and is then known as subdural empyema [Figure 1]. The
Immunocompromised Host
source of infection is frequently found and the cause
Infection involving the CNS is often devastating in patients
remains obscure in 10–37% of patients. [26] Suppurative
with compromised immune function. The incidence of
infections of the paranasal sinus, middle ear, and mastoid
CNS infection in immunocompromised patients is 0.6–14%
are the most common sources of underlying infection in
with a mortality rate of 42–77%. Sometimes, intracranial
most clinical series.[27-29] Metastatic abscesses occur through
infections harbor unusual organisms such as Nocardia sp.
hematogenous dissemination of micro-organisms from a
etc. [36] Meningitis and encephalitis represent most CNS
remote site of infection. Common primary foci include skin
infections in immunocompromised patients and do not usually
pustules, pulmonary infections (empyema, bronchiectasis,
require neurosurgical attention. The developments of brain
abscess and pneumonia), osteomyelitis, dental abscess, and
abscess in the compromised host signals a neurosurgical
subacute bacterial endocarditis. Metastatic abscesses occur in
emergency. Organ transplantation and cancer patients
multiples and tend to occur at the cortico-medullary junction
comprise the majority of immunocompromised patients
where the blood flow is slowest.[30] Cerebral abscess related to
who are prone to brain abscess formation.[37] The duration
organic congenital heart disease is one of the leading causes
of immunosuppressant therapy is a major determining
of morbidity and mortality in the pediatric population.[31]
factor for the development of CNS infection. After organ
Tubercular brain abscess (TBA) is a rare manifestation of
transplantation, the maximal risk of CNS infection for
CNS tuberculosis. It is characterized by an encapsulated
transplants recipients is for the first four months. Potential
collection of pus containing viable tubercular bacilli without
infections including Pseudomonas sp, E. coli, and Proteus sp
any evidence of tubercular granuloma.[32] Britt et al, divided
are more common. Among fungal infections, Aspergillus sp
abscess formation into four stages based on histopathologic
is common.[38,39]
data.[33] The early celebrities (days one to three) stage is
characterized by the presence of a necrotic center accompanied Tubercular abscess formation has been described in some
by a local inflammatory response surrounding the adventitia cases.[40]
of blood vessels [Figure 2]. In the late celebrities phase
(days four to nine), pus formation occurs leading to the
enlargement of the necrotic center, which is surrounded by Antibiotic Prophylaxis in Neurosurgery
a zone of inflammatory cells and macrophages; maximum
edema occurs during this phase. Early encapsulation phase Due to a low risk of infection (2–3%), prophylactic use of

Figure 1: Brain abscess in contrast-enhanced CT scan Figure 2: Interhemispheric subdural empyema

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antibiotics in neurosurgery is a controversial issue. Some
neurosurgeons believe that there are strong arguments
against the use of antimicrobials (promotion of antibiotic-
resistant strains of bacteria, superinfection, and adverse
drug reactions) and meticulous aseptic techniques could
be more useful than prophylactic antibiotics. On the
other hand, despite being rare, the consequences of a
neurosurgical infection can be dramatic and may result
in rapid death caused by meningitis, cerebritis, abscess
formation, or sepsis.[41,42] Ideally, a prophylactic antibiotic
should achieve high peak tissue concentrations at the site of
the wound before the first incision and should be maintained
until the time of closure. Currently, the administration of
prophylactic antibiotics is indicated for contaminated and
clean-contaminated wounds. Clinical studies emphasized
that the most important factors influencing the choice of
antibiotic prophylaxis in neurosurgery is the patient’s immune
status, virulence of the pathogens, and the type of surgery
(“clean contaminated”--procedure that crosses the cranial
sinuses, “clean nonimplant”--procedure that does not cross
the cranial sinuses, CSF shunt surgery, skull fracture). Despite
the proven effectiveness of antibiotic prophylaxis, many
researchers would argue that contemporary dosing regimens
should be re-evaluated. The debates concerning the dosage
and timing of ideal prophylactic administration are likely to
continue.[42]
Discussion
Almost all agents can cause infection within the central
nervous system and the extent of infection ranges from
diffuse involvement of the meninges, brain, or the spinal
cord to localized involvement presenting as a space-
occupying lesion. Infection of the central nervous system
is a life-threatening condition in the pediatric population.
Modern imaging techniques define the anatomic region
that has been infected, the evolution of the disease, and
help in improved management of these patients. Acute
bacterial meningitis remains a major cause of mortality and
long-term neurological disability. Fortunately, the incidence
of infection after clean craniotomy is < 5%, but it leads
to significant morbidity as well as fiscal loss. The most
significant causative factor in postcraniotomy infections is
the postoperative CSF leak. CSF shunt infection is one of
the most important infections encountered by neurosurgeons.
Staphylococci epidermidis (coagulase-negative) makes up the
largest group of microorganisms colonizing shunts. Cerebral
abscess related to organic congenital heart disease is one of
the leading causes of morbility and mortality in the pediatric
population. The administration of prophylactic antibiotics
is indicated for contaminated and clean-contaminated
wounds. The most important factors influencing the choice
of antibiotic prophylaxis in neurosurgery are the patient’s
immune status, the virulence of the pathogens, and the type
of surgery performed.
Sahu, et al.: Infection in pediatric population
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Source of Support: Nil, Conflict of Interest: None declared.

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