MENINGITIS

HAFIIDHATURRAHMAH
MS-PPDS ILMU KESEHATAN ANAK FK UGM

Modul Ilmiah RSUD Banyumas

November, 2015
DEFINITION
• Bacterial meningitis is an infection of the surface of the brain
(meninges) by bacteria that have usually travelled there from
mucosal surfaces via the bloodstream. (NICE, 2015)

• Meningitis is a clinical syndrome characterized by inflammation

of the meninges. (Medscape, 2014)

• Meningitis is an inflammation of a membrane, called the

meninges, that covers the brain and spinal cord. Damage to
the meninges produces a variety of problems, ranging from a
high fever with headaches to unconsciousness and death
(Brian R.Shmaesfsky, WHO,2004)
EPIDEMIOLOGY
• Most common in:
• Children < 4 years
(peak: 3-8 months)
• Viral > bacterial

Medscape,
2014
 ETIOLOGY
• > 2 months of age :
 Streptococcus pneumonia
 Neisseria meningitidis
 Haemophilus influenzae type B
(in unimmunised children)
• < 2 months of age :
 Group B streptococcus
 E. coli and other Gram-negative
 Listeria monocytogenes
 SIGNS AND SYMPTOMS
• The classic triad
of bacterial meningitis
Fever
Headache
Neck stiffness

Medscape,
Medscape, 2014
2014 www.anglocelt.ie
SIGNS AND SYMPTOMS
• 0 – 3 months
Fever or hypothermia
Bulging fontanelle
Irritability
High pitched cry
Lethargy
Altered mental state

Seizures

Apnoea

Poor feeding

Vomiting
 • ≥3 months
SIGNS AND SYMPTOMS  Fever 50%
 Bulging fontanelle
 Neck stiffness
 (60 - 80% > 3 years)
 Kernig’s sign in older children
 Brudzinki’s sign in older
children
 Irritability or lethargy
 Altered mental state (highly
variable)

meningococcal-septicaemia.com
Clinical signs of meningeal irritation
RISK FACTORS
• Age
• Head trauma
• Splenectomy
• Chronic disease
• Children with facial cellulitis, periorbital cellulitis, sinusitis, and septic arthritis
have an increased risk of meningitis.
• Maternal infection and pyrexia at the time of delivery are associated with
neonatal meningitis
• Use of Hib and pneumococcal vaccines decreases the likelihood of infection
from these agents.
DIAGNOSIS
• Definitive diagnosis is based on the following:
• Bacteria isolated from the CSF obtained via
lumbar puncture
• Meningeal inflammation demonstrated by
increased pleocytosis, elevated protein level,
and low glucose level in the CSF

Medscape,
2014
Bacterial meningitis score
• Positive CSF Gram stain
• CSF absolute neutrophil count 1000/µL or higher
• CSF protein level 80 mg/dL or higher
• Peripheral blood absolute neutrophil count 10,000/µL or
higher
• History of seizure before or at the time of presentation
• Specific hematologic, radiographic (CT and MRI may
reveal ventriculomegaly and sulcal effacement)
Contraindication for Lumbal Puncture
• Unstable patients with hypotension or respiratory distress who may not be
able to tolerate the procedure
• Brain abscess, brain tumors or other cause of raised intracranial pressure
• Occasionally infection at the lumbar puncture site.
NSW 2014
 INITIAL MANAGEMENT
• Airway
• Breathing
• Circulation
• Disability (level of consciousness)
• Exposure (rash assessment and environmental control),
• Fluids
• Glucose
AIRWAY and BREATHING
• Ensure that the airway is patent and adequate ventilation
is established;
• Supplemental oxygen should always be administered
• If ventilation or oxygenation is inadequate, then respiratory
support should be commenced in the form of bag and
mask technique, followed by endotracheal intubation.
CIRCULATION
• Fluid restriction is not an issue in the initial stabilisation of children
with meningitis;
 DISABILITY
• If there are signs of cerebral edema
(decreasing level of consciousness,
bulging fontanelle, papilloedema, rising
blood pressure with falling heart rate),
mannitol 0.25 g/kg/dose IV, infused
over 30 mins (dose range up to 1.0 g/kg)
should be given.
EXPOSURE
• The presence of a rash may be indicative of
meningococcal sepsis;
• Regulation of temperature is important in the acute
management of children presenting with sepsis.
FLUID
• Fluid restriction is not an issue in the initial stabilisation of
children with meningitis
• Urea and electrolytes must be checked early in the
management process and corrected if necessary
• Ensure patient is adequately hydrated (but not overloaded)
by closely monitoring input/output and physical
assessment.
GLUCOSE
• Blood glucose levels must be checked early in the
management process and corrected if necessary.
 SEIZURES
• Treat immediately with a rapid injection of a
benzodiazepine (e.g. midazolam, 0.15 mg/kg/dose IV);
• Alternative: midazolam (0.15 – .2 mg/kg/dose IM) or rectal
diazepam (0.5 mg/kg/dose rectal)
• Loading dose of phenytoin (20 mg/kg IV in 0.9% sodium
chloride, over 20 minutes).
• Phenobarbitone (loading dose of 20 mg/kg IV or IM) is
often used to treat seizures in neonates with suspected
meningitis.

NSW 2014
ANTIBIOTIC SELECTION
OUTCOME MENINGITIS BACTERIA

Dewi Sutriani Maharini, 2014, PKB

NSW, 2014
Antibiotics for suspected bacterial meningitis
• ≥ 3 months  Ceftriaxone
• ≤ 3 months  Cefotaxime and either Ampicillin or Amoxicillin

• Do not administer Ceftriaxone at the same time as calcium containing

infusions. Instead, use cefotaxime.
• Ceftriaxone should not be used in premature babies or in babies with jaundice,
hypoalbuminaemia or acidosis as it may exacerbate hyperbilirubinaemia.

NICE, 2015
Treatment for specific infections in confirmed
bacterial meningitis
• Children and young people aged 3 months or older
Treat H influenzae type b meningitis  Ceftriaxone for 10 days
Treat S pneumoniae meningitis  Ceftriaxone for 14 days

*unless directed otherwise by the results of antibiotic sensitivities

NICE, 2015
• Children younger than 3 months
Treat Group B streptococcal meningitis  Cefotaxime for at least
14 days.
Treat bacterial meningitis due to L monocytogenes  Amoxicillin
or ampicillin for 21 days in total, plus gentamicin for at least the first
7 days.
Treat bacterial meningitis due to Gram-negative bacilli 
Cefotaxime for at least 21 days

NICE, 2015
Treatment of unconfirmed bacterial meningitis
•≥ 3 months with unconfirmed, uncomplicated but clinically
suspected bacterial meningitis  Ceftriaxone for at least 10 days
depending on symptoms and signs and course of the illness.

• ≤ 3 months with unconfirmed but clinically suspected bacterial

meningitis  Cefotaxime plus either Ampicillin or Amoxicillin for at
least 14 days.

NICE, 2015
NSW, 2014
 STEROIDS

• In children ≥3 months of age with suspected bacterial

meningitis, steroids (dexamethasone) should be given
early, just before or at the time of antibiotics
• The dosing regimen is 0.15 mg/kg/dose IV, every 6
hours for 4 days.

NSW, 2014
 COMPLICATIONS
• Septic shock
• Disseminated intravascular coagulopathy (DIC)
• Purpura fulminans
• Waterhouse-Friderichsen syndrome
• Cerebral herniation

• 83% of appropriately treated children will have an uncomplicated recovery.

• Later complications: cerebrovascular events, subdural effusions, hearing
deficits and a range of neurological sequelae.
Bacterial meningitis and meningococcal septicaemia, NICE, February 2015
Pediatric Bacterial Meningitis, Medscape, 2014
Infants and Children: Acute Management of Bacterial Meningitis:
Clinical Practice Guideline, NSW Government, July 2014

Meningitis: Deadly diseases and epidemics, Brian R. Shmaefsky, WHO 2004

Meningitis-Encephalitis, Clinical Practice Guidelines, The Royal Children's Hospital

Melbourne, September 2012

Dewi Sutriani Maharini, PKB Ilmu Kesehatan Anak Sanglah, November 2014