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CONTENTS
Prevention and Treatment of Bacterial Meningitis
EDITORIAL BOARD
Board Members
DIAGNOSIS
Examination of cerebrospinal fluid
(CSF) is the gold standard diagnostic test in
BM. In many resource poor settings, despite
lack of laboratory support, clinicians should
have a low threshold for doing a lumbar puncture. The appearance and Gram stain of CSF
assist diagnosis. If there is no laboratory, a
multistix urine dipstick test will identify low
glucose, high protein and white cells (a positive leucocyte esterase patch) in CSF.
GENERAL MANAGEMENT
Children with BM are often managed
with limited resources against a background of
other diseases or ill health that compromise the
outcome even when optimal care is provided.
The ESPID Reports and Reviews of Pediatric Infectious Diseases series topics, authors and contents are chosen and approved
independently by the Editorial Board of ESPID.
The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015
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The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015
TABLE 1. Empirical Antibiotic Treatment for Bacterial Meningitis in Resource Poor Settings
Age
<7 days
>7 days,
<2 months
Main Causes
Ceftriaxone 50mg/kg/bd
Streptococcus pyogenes
Enterobacteriae
Listeria
monocytogenes*
S. agalactiae
S. pyogenes
Enterobacteriae
Nontyphoidal
salmonellae spp
Staphylococcus aureus
L. monocytogenes
223 months
25 years
Streptococcus agalactiae
Streptococcus
pneumoniae
Haemophilus influenzae
Neisseria meningitidis
Nontyphoidal
salmonellae spp
Enterobacteriae
S. pneumoniae
H. influenzae
>514 years
N. meningitidis
S. pneumoniae
>14 years
N. meningitidis
S. pneumoniae
N. meningitidis
Alternative Treatment
Benzylpenicillin
50,000 iu/kg bd
+ Gentamicin 7.5mg/kg od
(smaller doses for prems)
IV/IM 1421 days
21 Days for Gram negative
Benzylpenicillin
50100,000 iu/kg qds
+ Gentamicin 7.5mg/kg od
Benzylpenicillin
100.000 iu/kg qds
+ Chloramphenicol 25 mg/kg qds
IV/IM 1014 days
IV/IM 710 days
Based on the WHO Pocket Book of Hospital Care for Children.6 Known local susceptibilities must guide first choice of antimicrobial therapy. If the bacterial agent is unidentified use
the longer course of antibiotics. If complications such as a cerebral abscess are suspected or the child is HIV positive a longer course of antibiotics may be needed. A repeat lumbar puncture
may be done after 23 days to assess bacterial erasure and should be repeated if there is clinical deterioration.
*Listeria monocytogenes is uncommon where unpasteurized dairy products and processed meats are unavailable to pregnant women.
Enterobacteriae may be best treated with daily ceftriaxone doses divided and given 12 hourly.
Salmonella meningitis requires prolonged treatment of 46 weeks of antibiotics usually ceftriaxone and ciprofloxacin. A repeat lumbar puncture at the end of treatment is necessary if
there is any doubt about complete infection eradication.
Tds indicates 8 hourly; qds, 6 hourly; bd, twice daily; od, once daily.
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DURATION OF ANTIBIOTIC
THERAPY
A large multicountry study (n = 1004)
in resource poor settings compared the outcome of 5 versus 10 days of ceftriaxone for
BM caused by one of the 3 most common
etiological agents, S. pneumoniae, Neisseria meningitidis and Hib.10 Randomization
was on day 5 and only in stable patients with
no complications. Children receiving 5 days
ADJUVANT TREATMENT
Dexamethasone
Corticosteroids as adjuvant treatment
in BM remain controversial. In a large study,
in African children dexamethasone conferred
no benefit.11 A Cochrane review of adjuvant
steroid therapy found no benefit to outcome
in poorly resourced centers.12
Glycerol
Glycerol has been used to reduce
intracranial pressure. A multicountry South
American study reported encouraging
results; when severe neurological sequelae
The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015
and death were combined, glycerol was beneficial compared with placebo (OR: 0.44; 95%
CI: 0.250.76; P = 0.003).13 In a Malawian
study in which paracetamol and glycerol
were the active adjuvant therapies, there was
no benefit or harm by adding glycerol or paracetamol to standard antibiotic therapy.14
SUPPORTIVE CARE
Supportive care is critical and the
importance of good nursing care and monitoring cannot be over-emphasized. Fluids should
be monitored, seizures controlled, adequate
calorie intake ensured and serum glucose and
electrolytes kept within normal limits.
A Cochrane review found no evidence
for fluid restriction and some evidence to
support maintenance intravenous fluids in the
first 48 hours in settings with high mortality
rates and late presentations.15 Where children
present early and mortality is lower, evidence
is insufficient to guide practice.
Seizures must be controlled promptly.
WHO recommends rectal diazepam and/or
paraldehyde followed by phenobarbitone if
convulsions continue. Intractable seizures are
difficult to manage without mechanical ventilator support and loading doses of anticonvulsant drugs such as phenobarbitone have
to be repeated despite the risk of respiratory
failure. Neonatal seizures are usually managed with phenobarbitone.
PROGNOSIS
Case fatality rate is as high as 37%
depending on the cause, age and other cofactors.13 The prognosis is worse in infants, in
children with low CSF white cell counts or
low glucose, low blood pressure, anemia,
persistent convulsions and those who arrive
COMPLICATIONS
Acute complications other than those
mentioned already include subdural empyema
or intracranial abscess. If fever does not settle
an ultrasound scan of the head should be done
in children with an open fontanelle. Large subdural collections and intracranial abscesses can
be drained trans-fontanelle by experienced personnel. Antibiotic therapy should be prolonged.
Fever may also be caused by infected injection
or cannula sites, joints or chest infections.
Long-term neurological sequelae are
frequent and often devastating. Some hearing
loss occurs in up to 30% of survivors, especially following pneumococcal or Salmonella
spp. meningitis. Hydrocephalus may present
after weeks or months. Therefore, all survivors should have their hearing tested and
head size monitored after discharge. Followup should include physical, neurological and
developmental assessments.
FUTURE RESEARCH
1. Pentavalent vaccine support. Available at:
www.gavialliance.org/support/nvs/pentavalent.
Accessed October 1, 2014.
2. Delrieu I, Yaro S, Tameklo TA, et al. Emergence
of epidemic Neisseria meningitidis serogroup X
meningitis in Togo and Burkina Faso. PLoS One.
2011;6:e19513.
3. Emergence of W135 Meningococcal Disease - libdoc.who.int ... whqlibdoc.who.int/hq/2002/WHO_
CDS_CSR_GAR_2002.1.pdf WHO/CDS/CSR/
GAR/2002.1. Emergence of W135 Meningococcal
Disease. Report of a WHO Consultation Geneva
1718 September 2001. Accessed October 2014.
4. CDC. Updated recommendation from the
Advisory Committee on Immunization Practices
(ACIP) for revaccination of persons at prolonged increased risk for meningococcal disease.
MMWR. 2009;58:10421043.
5. Everett DB, Mukaka M, Denis B, et al. Ten years
of surveillance for invasive Streptococcus pneumoniae during the era of antiretroviral scale-up
and cotrimoxazole prophylaxis in Malawi. PLoS
One. 2011;6:e17765.
6. Pocket Book of Hospital Care for Children: guidelines
for the management of common childhood illnesses.
2nd edition. 2103. WHO: Geneva. http://apps.who.
int/iris/bitstream/10665/81170/1/9789241548373_
eng.pdf. Accessed July 29, 2014.
7. Falade AG, Lagunju IA, Bakare RA, et al. Invasive
pneumococcal disease in children aged <5 years
admitted to 3 urban hospitals in Ibadan, Nigeria.
Clin Infect Dis. 2009;48(Suppl 2):S190S196.
8. Kisakye A, Makumbi I, Nansera D, et al.
Surveillance for Streptococcus pneumoniae meningitis in children aged <5 years: implications
for immunization in Uganda. Clin Infect Dis.
2009;48(Suppl 2):S153S161.
9. Swann O, Everett DB, Furyk JS, et al. Bacterial
meningitis in Malawian infants <2 months of
age: etiology and susceptibility to World Health
Organization first-line antibiotics. Pediatr Infect
Dis J. 2014;33:560565
10. Molyneux E, Nizami SQ, Saha S, et al; CSF 5
Study Group. A double blind randomised study
comparing 5 vs 10 days of ceftriaxone therapy
for bacterial meningitis in children. The Lancet.
2011; 377:18371845.
11. Molyneux EM, Walsh AL, Forsyth H, et al.
Dexamethasone treatment in childhood bacterial
meningitis in Malawi: a randomised controlled
trial. Lancet. 2002;360:211218.
12. Brouwer MC, McIntyre P, Prasad K, et al.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev. 2013;6:CD004405.
13. Peltola H, Roine I, Fernndez J, et al. Adjuvant
glycerol and/or dexamethasone to improve the
outcomes of childhood bacterial meningitis: a
prospective, randomized, double-blind, placebocontrolled trial. Clin Infect Dis. 2007;45:
12771286.
14. Molyneux EM, Kawaza K, Phiri A, et al. Glycerol
and acetaminophen as adjuvant therapy did
not affect the outcome of bacterial meningitis in Malawian children. Pediatr Infect Dis J.
2014;33:214216.
15. Maconochie IK, Bhaumik S. Fluid therapy for
acute bacterial meningitis. Cochrane Database
Syst Rev. 2014;5:CD004786.
16. Roine I, Weisstaub G, Peltola H; LatAm
Bacterial Meningitis Study Group. Influence
of malnutrition on the course of childhood
bacterial meningitis. Pediatr Infect Dis J.
2010;29:122125.
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