CNS INFECTIONS IN PEDIATRICS

 MENINGITIS 

 What is Meningitis?

Brief description 

 Meningitis is acute inflammation of the meninges (the membranes covering the brain). 

Bacterial meningitis is a notify able disease. 

 This is an acute and one of the most potentially serious infections in infants and children that affects the central nervous system.

Causes Of Meningitis

  Most common bacterial: S. pneumoniae. H. influenza type b (mainly in young children), N meningitides and Enteric bacilli. 

 Viral (HSV, enteroviruses, HIV, VZV etc.)

 Cryptococcus neoformans (in the immune-suppressed)

Mycobacterium tuberculosis

Clinical Features

 In infants whose cranial sutures are still open, budged fontanel

 Rapid onset of fever

 Projectile Vomiting

 Irritability, lethargy, convulsion, coma

 Bulging of the anterior fontanel

 Haemorrhagic rash (N. meningitidis infection)

 In older children focal neurologic signs, such as: A sixth nerve palsy, may be more prominent

 Signs of meningeal irritation, such as nuchal rigidity, kerning‘s sign or Brudziniski sign are usually present. 

Differential diagnosis  Brain abscess

 Space-occupying lesions in the brain

 Drug reactions or intoxications

 Cerebral malaria

 Viral meningitis

 Poisoning

Investigations

 If bacterial meningitis is suspected, a LP should be performed unless  there is evidence of cardiovascular instability or of increased intracranial pressure (due to the risk of herniation).

 

 CSF: Increased number of white cell count, low level  of CSF glucose and elevated protein level are the usual findings. 

  Indian-ink staining (for Cryptococcus), gram stain, culture and sensitivity will reveal the microorganism.

 Blood: For serological studies and full blood count

 Neuroimaging u/s of brain, CT or MRI

Treatment

    Objectives

 Decrease the risk of grave complications and mortality

 Avoid residual sequelae

 Shorten hospital stay 

Non-pharmacologic

 Restrict fluid intake to 70% of calculated maintenance.

 Monitor urine output and daily weight

 Support feeding (NGT if necessary)

 Monitor vital signs

Pharmacologic

First line

Ceftriaxone, 100mg/kg, IV once daily for 10 days for all cases

Alternative

 Cefotaxime, 225-300mg/kg/ day divided every 6 or 8 hrs

N.B. Antibiotic treatment may be modified when culture and sensitivity results are collected.

Causative organisms identified

 Streptococcus pneumoniae (10 to 14-day course; up to 21 days in severe case)

 Benzyl penicillin 100,000 IU/kg per dose IV or IM every 4 hours Or ceftriaxone 100 mg/kg daily dose IV or IM every 12 hours

 Haemophilus influenzae (10-day course) Ceftriaxone 100 mg/kg per dose

 IV or IM every 12, only if the isolate is reported to be susceptible to the particular drug 

Or ampicillin Child: 50 mg/kg per dose 

 Neisseria meningitidis (5-7 day course)

 Benzylpenicillin 100,000-150,000 IU/kg every 6 hours Or Ceftriaxone 100 mg/kg daily dose

Note: Consider prophylaxis of close contacts (especially children < 5 years): Ceftriaxone 125mg IM stat.

 Listeria mono cytogenes (at least 3 weeks course)

o Common cause of meningitis in neonates and immunosuppressed children

o Ampicillin 50mg/kg IV every 6 hours.

Adjunct to treatment with antibiotics

 Dexamethasone 0.6mg/kg/day divided QID for two-four days in 

cases of suspected H. influenza meningitis. 

o It should be administered just before or with antibiotics

Note:

 Because of the potential severity of the disease, refer all patients to hospital after pre-referral dose of antibiotic.

 Carry out lumbar puncture promptly and initiate empirical antibiotic regimen

Prevention

 Avoid overcrowding

 Improve sanitation and nutrition

 Prompt treatment of primary infection (e.g., in respiratory tract)

 Immunization as per national schedules

 Mass immunization if N. Meningitis epidemic