Neonatal Meningitis

David Harvey
Professor of Paediatrics and Neonatal
Medicine
Faculty of Medicine, Imperial College
Hammersmith Hospital Campus
London

Neonatal meningitis
This lecture is based on the studies
conducted and published by the team in the
Karim Centre at Queen Charlotte's and
Chelsea Hospital in London.
We are grateful for financial support
provided by the Al-Fayed Charitable
Foundation.

Causative organisms
The organisms causing meningitis in young
infants are different from those seen in older patients.
Escherichia coli was the leading cause but this has
now been overtaken by the Group B beta-haemolytic
streptococcus, particularly in industrialised countries.
A small number of cases of viral meningitis are
also reported.

Incidence of neonatal meningitis

Meningitis is most common in infants
under one year age.
The incidence is even higher in the
first month of postnatal life, in preterm
babies, and in those of low birth weight.

Incidence (continued)
In a two-year national study conducted in
the UK in the middle 1980s, the incidence of
meningitis from all causes was 0.32/1000 live
births (bacterial meningitis 0.22/1000) 1.
Our other study in the middle 1990s
showed a similar incidence of 0.39/1000
(bacterial meningitis 0.21/1000)2.

Clinical features
The signs of meningitis in very young infants
may be very difficult to detect.
Characteristic features found in older patients,
such as neck stiffness, do not occur.
General signs of illness, including apnoeic
attacks, vomiting and lethargy are common and
significant.

Clinical features (continued)

Some features will indicate that there is an
illness affecting the brain.
Thus convulsions, which may result from
an illness of the brain, such as meningitis, or a
metabolic disturbance, such as hypoglycaemia
or hypocalcaemia, are an indication for
lumbar puncture.

Studies
The Karim Centre has studied two cohorts of
babies with neonatal meningitis who were born
in England and Wales in 1985 to 19871 and
1995 to 19962.
The first cohort was identified prospectively
using a monthly reporting card sent by the
Karim Centre to all consultant paediatricians.

Studies (continued)
The second cohort (1995-96) was identified
using the system set up by the British Paediatric
Surveillance Unit (BPSU) at the Royal College
of Paediatrics and Child Health.
All members and fellows of the College are
sent a card monthly on which they can report
uncommon conditions.

Survey details (1985-87)

566 consultant paediatricians were sent a
reporting card every month for two years.
They were asked to notify the researchers
if they had seen a case of neonatal or
postnatal meningitis in the previous month.
Clinical details were obtained from those who
reported a case.

Survey details (1995-96)

During an 18 month period from July 1995
to December 1996 monthly cards were sent
by the BPSU to 1800 paediatricians,
compliance rates for return of cards during
the period were 94%.

Survey details
In both studies further cases were
identified from the Communicable
Diseases Surveillance Centre (CDSC)
and the Meningococcal Reference
Laboratory in Manchester.
Death certificates were also obtained.

Cases of Neonatal Meningitis

(1985-87)
423 cases were identified.
Of these 118 (28%) were caused by group B betahaemolytic streptococci and 78 (18%) by E coli.
Listeria monocytogenes was identified as the cause
in 23 cases (5%).
Viral meningitis was reported in 16 cases (4%).

Cases of Neonatal Bacterial

Meningitis (1996-97)
274 cases of neonatal meningitis were
reported.
This revealed that again the Group B betahaemolytic streptococcus (42%) and
Escherichia coli (16%) were the commonest
organisms. 7% of cases were caused by
enteroviruses.

Mortality in 1980s Survey

The overall mortality from meningitis
was 19.8%, and it was 24% in bacterial
meningitis.

Mortality in 1990s
The mortality in the 1996-7 survey was lower
than in 1985-87.
It was 6.6% compared with 19.8% in the earlier
survey.
Eight of 69 babies with Group B streptococcal
infection died (12%) and 4 of 26 babies infected
with Escherichia coli (15%).

Antibiotic usage in 1980s

To our surprise, in 1980s chloramphenicol
was a commonly used antibiotic for neonatal
meningitis.
It was reported in 48% of cases.
Cefotaxime was used in 26% and gentimicin
in 40% of cases in combination with
ampicillin or penicillin.

Antibiotics in 1990s
The pattern of antibiotics used has changed
dramatically.
Chloramphenicol was used in only 1% of
cases, whereas third-generation cephalosporins,
notably cefotaxime, were used in 84%.
This may account for the improvement in
mortality.

Additional Therapy
Neonatal intensive care will be needed for these
fragile infants.
Ultrasound examination of the brain is needed to
detect the beginning of hydrocephalus.
The place of steroids needs further study.
The length of antibiotic therapy is usually 2 weeks,
but 3 weeks for E coli.

Follow-up
A five-year follow-up has been conducted
by postal survey of the parents and family
doctors of the 1985-87 cohort3.
This study showed that there was a ten-fold
increase in the risk of severe or moderate
disability in the children who suffered
meningitis.

Hearing Loss
The overall relative risk of sensorineural
hearing loss in meningitis under one year was
22.8 (95% confidence intervals 7.22 to 72.1).
Although children with neonatal meningitis
had an overall increase in hearing problems,
sensorineural hearing loss was not increased in
the neonatal group compared with meningitis
later in infancy.

Conclusions
Neonatal meningitis in industrialised countries is now
usually caused by Group B streptococci.
It is difficult to detect early.
The incidence has not changed, but the mortality has
decreased recently.
Developmental studies show that it is followed by an
increase in disability.

Bibliography
1. de Louvois J, Blackbourn J, Hurley R, Harvey D.
Infantile meningitis in England and Wales: a two year
study. Arch Dis Childhood 1991; 66: 603-607.
2. Holt DE, Halket S, de Louvois J, Harvey D. Neonatal
meningitis in England and Wales: 10 years on. Arch Dis
Child Fetal Neonatal Ed 2001; 84: F85-F89.
3. Bedford H, de Louvois J, Halket S, Peckham C,
Hurley R, Harvey D. Meningitis in infancy in England and
Wales: follow up at age 5 years. BMJ 2001; 323: 533-6

Acknowledgements
Daphne Holt
John de Louvois
Sue Halket
Helen Bedford
Catherine Peckham
Rosalinde Hurley