ACUTE BACTERIAL MENINIGITIS

Dr. A. T. Olayinka Dept of Medical Microbiology ABUTH - ZARIA

Introduction

Infection of the meninges and CSF. Could be acute or chronic Caused by a variety of organisms

Acute forms
In neonates Group B Streptococci Listeria monocytogenes Escherihia coli & other coliforms Salmonella spp Klebsiella pneumonia Staphylococcus aureus Staph epidermidis In the older ages Neisseria meningitidis Haemophilus influenza Streptococcus pneumonia Listeria monocytogenes Burkholderia psuedomallei Fusobacterium necrophorum

Neonatal factors
Deficient immunity (humoral and CMI) Ineffective phagocytes Complement activity is 50% of adult activity IgM production less than 20% of adult level IgG production about 5% of adult levels IgA production begins at birth

Epidemiology
Typically occurs in the dry season Meningitic belt: Senegal Sudan, Ethiopia, also some parts of East/South Africa. Mean annual rainfall 300-1100mm Epidemics occur in 5-10year cycles. In epidemics 400/100,000 population Hyperendemic rate 40/100,000 population.

Bacteriology: N. meningitidis
GNDC with contiguous sides flattened (beanshaped) Capsulated and piliated 9 capsular sero-groups at least: A, B, C, D, X, Y, Z, W-135, 29-E Serotypes B, C and Y a(resource rich countries) A (especially clones III I) andW-135 - common in less developed countries. Groups A and C are associated with epidemics Group B in sporadic endemic cases.

Virulence factors
Capsule IgA protease Pili Endotoxin Outer membrane proteins

Clinical Features
Sore throat, fever, neck stiffness, headache, photophobia; haemorrhagic skin rash with petechiae 35% develop fulminant septicaemia with DIC, endotoxaemic shock and or renal failure. Addisonian crisis - bleeding into the brain & adrenal glands producing the Waterhouse Friedreichsen syndrome.

Bacteriology: H. influenzae
Pleomorphic non-motile Gram negative coccobacillus 6 types designated a-f, Capsular type b produces invasive disease in the immune-competent host. It possesses a polyribitol phosphate capsule. requires X-haematin, V-NAD factors

Related factors
Maternal antibodies protect the baby till 3 4months of age Rare above 7 years of age though may occur in adults

Bacteriology - Streptococcus pneumoniae

Lanceolate gram positive capsulated cocci usually occurring in pairs. draughtsman appearance and -haemolysis More than 85 capsular types, Sensitive to optochin Produce exotoxin - pneumolysin

Predisposing factors
Children less than 2yrs of age or the elderly. Splenectomized patients Sickle cell disease Following previous head trauma Debilitation

Clinical features
Signs of meningeal irritation More associated with focal signs on admission Symptoms and signs tend to be worse than for meningococcus and H. influenzae

Pathogen N. meningitidis H. Influenzae S. Pneumoniae

Host Children & adolescents Children < 5yrs All ages esp <2yrs, elderly

Impt CF

Mortality

Sequelae <1 9 15-20

Acute (6-24hrs) 7 10 Less acute (12ds) 5

Usu 20 to ilness 2 0- 30

Virulence factor N. meningitidis Capsule IgA Protease Pili Endotoxin OMPs + + + + +

Bacterial Pathogen H. Influenzae + + + + + S. Pneumoniae + + -

Bacteriology -Listeria monocytogenes

Small Gram positive motile rods -Haemolytic on sheep or horse blood agar Grow at selective incubation temp of 40C Organism is motile at 250C and non-motile at 370C In immunocompromised adults, renal transplants, cancer patients

Transmission - Generally

Facilitated by droplet contact Saliva exchange Close household contacts

Pathogenesis
Colonization of the nasopharynx Pili by which it attaches to the mucosa Capsule allows evasion of phagocytic killing enabling longer survival of the organism Translocates to enter the circulation. Localizes in the pia and arachnoid mater and sets up an inflammatory response in the meninges & CSF.

Diagnosis
Gram stain Culture: selective media CSF chemistry and cell count Agglutination (latex or haem) CCIE Molecular diagnosis PCR Serology not useful acute disease

NORMAL Appearance Pressure mm/H20 Protein g/l Neutrophils( 106/l) Mononuclear cells Glucose (mmol) Clear <180-200 0.15 0.4 0 05 2.2 3.3

PURULENT Turbid Raised 0.5 6.0 100-6000 Can be raised 0 2.2

ASEPTIC Clear/Opalescnt Normal 0.5 1.0 <15 15 500 2.2 3.3

Pathogen N. meningitidis H. Influenzae S. Pneumoniae

Capsule Polysaccharide Polysaccharide Polysaccharide

Important types A,B,C,Y,W-135 B Many

Vaccine A&C good B-poor Hib vaccine <1yr olds Pneumovax (23valent)

Grp B Streptococcus
E. Coli

Polysaccharide rich (Ia,Ib,II) III in in sialic acid neonatal meningitis

KI in meningitis

Treatment
Empirical important Penicillin Chloramphenicol Cephalosporins

Prevention
Chemoprophylaxis
Preemptive therapy Eradication of NP carriage

Vaccination
Hib Conjugate group A/Conjugate Group C Conjugate polysaccharide 23-valent pneumococcal polysaccharide vaccine

Questions?