Meningitis in children

By:- Destaye Guadie (Bsc, Msc )

University of Gondar College of

Medicine & Health Science School of

Nursing Department of Pediatrics and

Child Health ,2009 E.C

E-mail-dstgd32@gmail.Com .
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 Learning Objectives
After the end of this session the students should be able to:
Define Meningitis in children.
Describe the anatomy & physiology of Meningitis in children
Explain Epidemiology and etiology of Meningitis in
children
Describe the pathogenesis of Meningitis in children.
Identify the clinical manifestations of Meningitis in
children.
Recognize the RX,DX & DDX of Meningitis in children.
Describe the nursing care of a patient with Meningitis.
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List the complications of Meningitis in children.
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 Presentation outlines
Anatomy & physiology Mode of transmition
Introduction Clinical feture
Etiology Dx & DDX
Epidemiology Rx
Pathophysiology Nursing
Risk factors of meningitis
managements
Types of meningitis
Preventions

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 Anatomy and Physiology
Meningitis, in general, is the inflammation of the
protective membranes surrounding the brain and spinal
cord. 
In order to inflame these protective membranes,
the bacteria must somehow enter the bloodstream and
bypass the blood-brain barrier.

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 Anatomy and….

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 Physiology
The intracranial compartment is protected by the
skull, a rigid structure with a fixed internal volume.
Brain parenchyma — 80 %
CSF — 10 %
Blood — 10 %
Because the overall volume of the cranial vault
cannot change, an increase in the volume of one
component, or the presence of pathologic components,
necessitates the displacement of other structures, an
increase in ICP, or both.
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 BLOOD-BRAIN BARRIER / BBB

The BBB mainly consists of tight junctions, which

seals the endothelial cells that line the brain capillaries. 
Astrocytes, a type of neuroglia from the brain, closely
attached to the endothelial cells and release chemicals to
regulate the permeabilities of the tight junctions.

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 Introduction
Infection of the central nervous system is the most
common cause of fever associated with signs and
symptoms of CNS disease in children.
Bacteria meningitis is one of the most potentially
serious infections occurring in infants and older
children.
This infection is associated with a high rate of acute
complications and risk of long term morbidity.
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 Introduction…
Annual incidence in the developed countries is
approximately 5-10 per 100,000.
Approximately 90 per cent of cases occur in
children during the first 5 years of life.
Despite the effectiveness of current antibiotics in
clearing bacteria from the cerebrospinal fluid (CSF),
bacterial meningitis continues to cause significant
morbidity and mortality worldwide. Up to date

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 Defnitiion of terms
Meningitis – inflammation of the
meninges
Encephalitis – infection of the brain
parenchyma
Meningoencephalitis – inflammation
of brain + meninges
Aseptic meningitis – inflammation of
meninges with sterile CSF
 Etiology
Generally could be Bacteria, viruses, fungi,
parasites.Bacterial meningitis categorize
by age 2. I2mth-2yrs
Hib,
1.Neonates -infants Strep pneumoniae &
Neisseria meningitis
Escherichia coli
3. 2-21yrs
Listeria monocytogenes Neisseria meningitis
A, B, C, Y, and W 135,
B-haemolytic streptococci Hib and
Strep pneumoniae
Staphylococcus aureus
The 3 main bacterial species
Staphylococcus epidermidis that contribute to this
disease

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 Epidemiology
After the introduction of the Hib and pneumococcal
conjugate vaccines to the infant immunization schedule, the
incidence of bacterial meningitis declined in all age groups
except children younger than two months.
The peak incidence continues to occur in children
younger than two months.

Thigpen MC, Whitney CG, Messonnier NE, et al 2011

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 Epidemiology …

The highest incidence is among neonates, who are usually

infected by bacteria found in the birth canal at the time of
parturition.

 90% of cases occur before 5 yr.

 Mortality 20-40% in neonates

 Mortaility 5-10% in infants and children.

Group B streptococci account for the majority of cases (50%),

followed by E. coli (25%)
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 Pathogenesis
Susceptibility of bacterial infection on CNS in the
children:
Insufficient barrier (Blood-brain barrier)
Immaturity of immune systems
Insufficient complement activity
Insufficient chemotaxis of neutrophils
Insufficient function of monocyte-macrophage system
Diminished Blood levels of interferon (INF) –γ and
interleukin
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 Pathogenesis…
Specific immune
Immaturity of both the cellular & humoral
immune systems
Insufficient antibody-mediated protection
Diminished immunologic response

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 Pathogenesis…
Bacterial virulence-Offending bacterium from
blood invades the meninges.
Bacterial toxins and Inflammatory mediators are
released.
Bacterial toxics:
Lipopolysaccharide, LPS
Teichoic acid
Peptidoglycan
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 Pathophysiology
The causative organism enters the bloodstream,
crosses the blood–brain barrier, and triggers an
inflammatory reaction in the meninges. Independent of
the causative agent, inflammation of the subarachnoid
and pia mater occurs. Increased intracranial pressure
(ICP) results.
Meningeal infections generally originate in one of
two ways: either through the bloodstream from other
infections (cellulitis) or by direct extension (after a
traumatic injury to the facial bones).
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 Risk factors of meningitis
Extremes of age (< 5 or >60 years)
Immunosuppression, which increases the risk of
opportunistic infections and acute bacterial meningitis.
HIV infection, which predisposes to bacterial
meningitis caused by encapsulated organisms,
Crowding (such as that experienced by military
recruits and college dorm residents), which increases the
risk of outbreaks of meningococcal meningitis
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 Risk factors
Recent exposure to others with meningitis.
Contiguous infection (eg, sinusitis)
Dural defect (eg, traumatic, surgical, or congenital)
Bacterial endocarditis
Modes of transmission
Close contact with a person who is sick with the
disease
Contact with carriers
Living in close quarters, such as college dormitories
Being in crowded situations for prolonged periods of time
Sharing drinking glasses, water bottles, or eating utensils
Kissing, sharing a (MENINGITIS
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 Types of meningitis
1. Bacterial meningitis bacterial infection.
2. Viral meningitis caused by viruses (enterovirus)
3. Tuberculosis meningitis: Tuberculosis infection due to M.
tuberculosis.
4.Cryptococcal meningitis: Infection from a yeast called
Cryptococcus. Often associated with AIDS.
5. Neoplastic meningitis: spread of solid tumors to the brain
or spinal cord.
6. Syphilitic meningitis: due to infection with the bacterium
that causes syphilis.
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 Clinical feature
High grade fever , Feeding problems & Irritability

High-pitched crying

Bulging fontanels & Severe persistent headache.

Neck stiffness : infants may not develop a stiff neck

Seizures: is correlative with the inflammation of

brain parenchyma, cerbral infarction and electrolyte

disturbances.
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 Clinical features…
Nausea and vomiting, sometimes along with
diarrheal
Confusion and disorientation can progress to stupor,
coma, and death
Drowsiness or sluggishness
Eye pain or sensitivity to bright light
Numbness and tingling

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 Clinical features…
Increased intracranial pressure
Headache
Projectile vomiting
Hypertension
Bulging fontanel
Cranial sutures diastasis/separation
Coma
Cerebral hernia
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 Clinical features…

BRUDZINSKI
SIGN is +ve

The Kernig sign is +ve

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 Selected Bedside Signs of Meningitis
Bedside Test Description
Nuchal rigidity
Inability to flex the head forward due to
or neck stiffness
rigidity of the neck muscles; however,

nuchal rigidity is absent if flexion of the neck

is painful but there is full range of motion

Inability to flex the head forward due to
rigidity of the neck muscles; however,
Kernig's sign nuchal rigidity is Extension in the knee is
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 Diagnosis
CM
INVESTIGATIONS(Lab)

CSF analysis (LP - A thin needle is inserted between L4/L5 to

withdraw a sample of CSF).
Blood test

Chest X-ray
CT scan or MRI

Cultures of samples of CSF, blood, urine, mucus from the nose

and throat, and pus from
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skin infections.
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 Laboratory Findings
Examination of cerebrospinal fluid (CSF):
Cloudiness
Evident increased protein level
Evident decreased glucose (<1.1mmol/l)
Increased pressure of cerebrospinal fluid
Evident increased total WBC count (>1000×109/L)
Evident increased neutrophils in leukocyte differential
count
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 Differential Dx

Cerebral malaria Bacterial infections

TBc meningitis Viral infections
Aseptic meningitis Trauma
Brain abscess Malignancy
Brain tumer

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 Prevention

Immunization
Prophylaxis

Reduced over crowded

Health education

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 Treatment antibiotic therapy

Therapeutic principle
Good permeability for Blood-brain barrier
Drug combination
Full dosage
Full course of treatment

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 Treatment of acute bacterial meningitis in
children
Suspected bacterial meningitis is a medical emergency,
and immediate diagnostic steps must be taken to establish the
specific cause so that appropriate antimicrobial therapy can be
initiated.
The mortality rate of untreated bacterial meningitis
approaches 100 % and, even with optimal therapy, morbidity
and mortality may occur.
Neurologic sequelae are common among survivors.
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 Treatment of acute bacterial Cont…
Despite the effectiveness of current antibiotics in
clearing bacteria from the CSF, bacterial meningitis
continues to cause significant morbidity and mortality
worldwide.
Empiric treatment should be begun as soon as the
diagnosis is suspected using bactericidal agent(s) that
achieve significant levels in the CSF

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 Empiric treatment
Ceftriaxone 50-100 mg/kg/day IV/IM q12 hr
Vancomycin 60 mg/kg/day IV q6h.
Convulsive management

Diazepam

Phenobarbital

Treatment of increased intracranial pressure

Dehydration therapy

• 20%Mannitol 5ml/kg iv q6h

• Lasix 1-2mg/kg iv
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 General and Supportive Measures
Treatment of septic shock and DIC
Volume expansion
Dopamine
Corticosteroids
Heparin
Fresh frozen plasma
Platelet transfusions
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 Therapy for specific pathogens
Microorganism Recommended Duration of
therapy treatment

Penicillin G or Ampicillin 2 weeks

Streptococcus OR
pneumoniae Vancomycin + Third-generation
cephalosporin (eg, ceftriaxone or
cefotaxime)
Penicillin G 7 days
Neisseria OR
meningitidis Third-generation cephalosporin
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ceftriaxone
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 Therapy for specific …
Haemophilus Third-generation 7 days
influenzae cephalosporin (eg,
ceftriaxone or cefotaxime)

Listeria Ampicillin or Penicillin G 3 weeks

monocytogenes
Escherichia coli Third-generation 21 days or 2 weeks
cephalosporin (eg,
ceftriaxone or cefotaxime)
Group B Ampicillin or Penicillin G 14-21 days
streptococci
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Drug of choice according to the culture isolates
Organism Drug of choice
Gr. B strep coccus Cefotaxim
Ceftriaxone and Gentamicin
L. Monocytogenes Ampicillin
H.Influenzae Cefotaxim
Ceftriaxone and CAF
N.Meningitides Benzile pens, Ceftriaxone
S.pneumoniae Vancomicin, Benzile pens,
Ceftriaxone
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 Prognosis
Prognosis depends largely on the supportive care
provided.
Appropriate antibiotic therapy reduces the mortality
rate for bacterial meningitis in children, but mortality
remain high.
Overall mortality in the developed countries ranges
between 5% and 30%.
50 percent of the survivors have some sequelae of the
disease.
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 Prognosis…
Prognosis depends upon many factors:
Age
Causative organism
Number of organisms and bacterial virulence
Duration of illness prior to effective antibiotic
therapy
Presence of disorders that may compromise host
response to infection
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 Complications of bacterial meningitis

Can be divided into acute and late.

1. Acute Complications
Increased ICP severe vomiting
Hydrocephalus Internal bleeding
Hypoglycemia Low blood pressure
Myocarditis Shock
Brain damage Death

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 Late complications:

Development delay Hemiparesis

Cerebral palsy Hearing loss
Microcephaly Blindness
Seizure disorder

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 Nursing Management
Assess neurologic status and vital signs constantly.
Determine oxygenation from arterial blood gas values
and pulse oximetry.
Insert cuffed endotracheal tube (or tracheostomy), and
posi-position patient on mechanical ventilation as
prescribed.
Assess blood pressure (usually monitored using an
arterial line) for incipient shock, which precedes cardiac or
respiratory failure.
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 Nursing Management…

Protect the patient from injury secondary to seizure

activity or altered level of consciousness (LOC).

Monitor daily body weight; serum electrolytes; and

urine volume, specific gravity, and osmolality, especially if

syndrome of inappropriate antidiuretic hormone (SIADH)

is suspected.

Prevent complications associated with immobility, such

as pressure ulcers and(MENINGITIS

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 Nursing Management…

Rapid IV fluid replacement may be prescribed, but

take care not to overhydrate patient because of risk of
cerebral edema.
Reduce high fever to decrease load on heart and
brain from oxygen demands.
Inform family about patient’s condition and permit
family to see patient at appropriate intervals.

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 Summary

Definition
Etiology
Clinical manifastation
Management
Complication
Nursing management
Prevention

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 Any questions?

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 References

Nelson Textbook of Pediatrics, 19th ed.

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 Thanks for your attention

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