Acute Bacterial Meningitis In Newborns

Neonatal Bacterial Meningitis is an inflammation of the meninges by bacteria. The symptoms include sepsis, CNS irritation such. B. lethargy, seizures, vomiting, irritability, [particularly paradoxical irritability], stiff neck, bulging fontanelle and failures of the cranial nerves. The diagnosis is made by a spinal tap. Treatment is with antibiotics.

Neonatal Bacterial Meningitis is an inflammation of the meninges by bacteria. The symptoms include sepsis, CNS irritation such. B. lethargy, seizures, vomiting, irritability, [particularly paradoxical irritability], stiff neck, bulging fontanelle and failures of the cranial nerves. The diagnosis is made by a spinal tap. Treatment is with antibiotics.

(Overview of meningitis.) The neonatal bacterial meningitis is an inflammation of the meninges by bacteria. The symptoms include sepsis, CNS irritation such. B. lethargy, seizures, vomiting, irritability, [particularly paradoxical irritability], stiff neck, bulging fontanelle and failures of the cranial nerves. The diagnosis is made by a spinal tap. Treatment is with antibiotics. The neonatal meningitis occurs at 2 / 10,000 of the newborn and 2/1000 of newborns with low birth weight, primarily boys before. 15% of newborns with sepsis ill with meningitis and occasionally it is also used in isolation before. Etiology The predominant pathogens are group B streptococci (GBS predominantly type III) Escherichia coli (especially those strains which contain the polysaccharide K1) Listeria monocytogenes Further important pathogens are enterococci, streptococci of group D outside the enterococci, ?-hemolytic streptococci, Staphylococcus aureus, coagulase-negative staphylococci and gram-negative enteric pathogens (Klebsiella, Enterobacter, Citrobacter diversus). Haemophilus influenzae type b, Neisseria meningitidis and Streptococcus pneumoniae can also be the cause. Haemophilus influenzae, Neisseria meningitidis and Streptococcus pneumoniae have been identified as causes. The neonatal meningitis most often develops as a result of a previous bacteremia on the floor of neonatal sepsis. The higher the number of bacteria in the blood cultures, the higher the risk of developing meningitis. The neonatal bacterial meningitis may also result from skin lesions on the head, especially when developmental defects lead to a compound of the skin surface with the subarachnoid space and predispose to thrombophlebitis of diploic veins. Rarely, a spread by continuity from an infectious focus in the ear (z. B. otitis media). Symptoms and discomfort often only those to recognize symptoms similar to those of sepsis same (eg., Temperature instability, respiratory distress, jaundice, apnea). Neurological abnormalities (eg. B. lethargy, convulsions [especially partial seizures], vomiting, irritability) substantiate the suspicion of a neonatal bacterial meningitis. The so-called paradoxical irritability, in tenderness and consoling the parents the newborn more irritated than calmed, is a specific index for diagnosis. A bulging or full fontanelle is found in 25%, stiff neck in 15% of children. The younger the patient, the less likely these findings. In addition, it can cause symptoms on the part of the cranial nerves come (especially III, VI and VII). Meningitis caused by group B streptococci (GBS meningitis) may occur in the first week of life and is often initially as a systemic disease with predominant respiratory symptoms. Often the GBS meningitis occurs but only after this time (usually in the first 3 months of life) on. then it manifests itself as an isolated infection with meningitis typical symptoms (fever, lethargy, seizures) and is characterized by the absence of obstetric or perinatal complications. The ventriculitis is a frequent accompaniment of bacterial meningitis, particularly when caused by gram-negative bacteria. In the context of an infection with pathogens, which calls forth a vasculitis in addition to meningitis, particularly C. diversus and Cronobacter (formerly Enterobacter) sakazakii, often form cysts and abscesses. Pseudomonas aeruginosa, E. coli K1 and Serratia are also involved in the formation of abscesses. An early symptom of brain abscesses is an elevated intracranial pressure (ICP) with vomiting, bulging fontanel and sometimes enlarged head size. A Degree of deterioration in an otherwise stable neonates with meningitis is a sign of increased ICP due to an abscess, hydrocephalus or the rupture of an abscess in the ventricular system. Tips and risks Classic symptoms of meningitis are rare; a bulging fontanelle only occurs in about 25% of newborns and neck stiffness in only 15% of newborns. Diagnosis cell count in the cerebrospinal fluid glucose and protein levels, Gram stain and culture Sometimes ultrasound or computed tomography or magnetic resonance imaging of the brain The definitive diagnosis of neonatal bacterial meningitis is secured by examining the by lumbar puncture (LP) won Liquors. This study should be performed in every newborn with suspected meningitis. However, it must be remembered that a lumbar puncture in a newborn be problematic and can induce hypoxia. In a poor performance status (z. B. respiratory distress, shock, thrombocytopenia) is increased, the LP-associated risk significantly. If the lumbar puncture moved, treating the child as a proven meningitis. Even days after the onset of the disease, even when already improved condition, the detection of inflammatory cells and pathological glucose and protein levels can give indications of the presence of the disease. For the lumbar puncture needle with a trocar should be used to avoid the spread of Epithelzellspuren into the liquor with subsequent Epitheliombildung. In any case, a culture should be created, even if the CSF should be bloody or cell-free. pathogen detection succeeds at approximately 15-35% of neonates with negative blood cultures in the cerebrospinal fluid, depending on the studied population. The LP should be repeated after 24-48 h, when the result is doubtful, and after 72 h, if Gram-negative bacteria are present in order to ensure therapeutic success. A replay of the cerebrospinal fluid analysis helps to determine the duration of therapy and prognosis. Some authors are of the opinion that with a GBS infection Rehearsal LP after 24-48 h has prognostic value. Routine LP at the end of the treatment is not required for healthy children again. Liquornormalwerte for newborns are age-dependent and also controversial. As a rule, both mature on premature infants without meningitis ? 20 WBL / ul (a fifth of it may be polymorphonuclear granulocytes) in their cerebrospinal fluid. CSF protein levels without meningitis are variable; Premature infants have Speigel of <100 mg / dl, while premature babies have concentrations of up to 150 mg / dl. Liquor blood sugar levels without meningitis are (measured at the same time) at> 75% of the serological value. These mirrors may be mg / dl (1.1-1.7 mmol / l) as low as 20-30. Bacterial meningitis through culture was identified in neonates with normal CSF indices. This shows that normal CSF values ??are not enough to rule out a diagnosis of meningitis. The suspected ventriculitis must be expressed unresponsive as expected to antibiotic therapy for each child. The diagnosis ventriculitis must be made if the leukocyte counts in Ventrikelpunktat is higher than in the lumbar puncture if a positive Gram stain of ventricular fluid a Bakterienachweis succeed, or if the ventricular pressure is increased. If ventriculitis or brain abscess is suspected, ultrasonography, magnetic resonance imaging or computed tomography with contrast medium can facilitate diagnosis; Advanced ventricle confirm ventriculitis. Prognosis Without treatment, is the lethality of neonatal meningitis 100%. With treatment, the prognosis depends on the birth weight, on the pathogens and the clinical condition. The mortality rate in newborns with neonatal bacterial meningitis is 20%. In the case of pathogens which vasculitis or brain abscesses (necrotizing meningitis) cause mortality reached almost 75%. Neurological sequelae (eg. As hydrocephalus, hearing loss, mental retardation) may occur in 20-50% of the surviving children. Particularly bad prognosis in infections with Gram-negative bacteria. In part, the prognosis depends on the number of bacteria in the CSF from time of diagnosis. The frequency of complications also directly correlated with the period over which the cultures remain positive. The cerebrospinal fluid of children with a GBS infection is usually h 24 after the start of antibiotic therapy sterile, while the corresponding interval in Gram-negative bacteria is longer with an average of 2 days. GBS meningitis has a significantly lower mortality rate than that of early-onset GBS sepsis. Empirical treatment ampicillin plus. Gentamicin, cefotaxime, or both, followed by culture-specific medication Recommended dosage selected pareneraler antibiotics for newborns. Empirical antibiotic therapy Initial empirical treatment depends on the age of the patient and is still under discussion. For newborns, many experts recommend ampicillin plus an aminoglycoside. A cephalosporin of the third generation (z. B. cefotaxime) is also added, pending culture and sensibility results if meningitis is suspected due to Gram-negative organism. However, resistance can develop quickly if cefotaxime is routinely used for empirical therapy, and prolonged use of cephalosporins of the third generation is a risk factor for invasive candidiasis. Ampicillin is effective against organisms such as GBS, enterococci and listeria. Gentamicin provides synergy against these organisms and also covers many gram-negative infections. The third generation of cephalosporins bietenteine ??adequate coverage for most Gram-negative pathogens. Hospitalized children who have already been treated with antibiotics (eg. As neonatal sepsis) may have resistant germs. Ill neonates with hospital-acquired infection should first receive vancomycin plus an aminoglycoside with or without cephalosporin 3rd generation or a carbapenem with activity against Pseudomonas aeruginosa, as cefepime or meropenem, depending on how strong the evidence of meningitis are. The antibiotic regime will be adjusted as soon as the results of the lumbar puncture are present and the pathogens and their sensitivity are known. The results of the Gram stain should not be used to limit a dosage before culture results vorliegen.Organismus-specific antibiotic therapy, the recommended dose for the initial treatment of GBS meningitis in newborns <1 week is for penicillin G 100,000- -50.000 IU / kg iv every 8 h or ampicillin 100-150 mg / kg i.v. every 8 h. In addition, gentamycin is i.v. 3 mg / kg once daily as a synergistic effect, when newborns of less than 35 weeks of pregnancy are old or 4 mg / kg i.v. once a day if newborns have an age of> 35 weeks of pregnancy. If improve the clinical findings and the cerebrospinal fluid is sterile, the gentamicin may be discontinued. For enterococci or L. monocytogenes, the treatment consists in the administration of ampicillin and gentamicin. The treatment of gram-negative bacterial meningitis is difficult. Under the usual regimen (ampicillin plus an aminoglycoside), there is, after all, to a mortality rate of 15-20% and a poor prognosis for the survivors. Instead, a cephalosporin of the third generation (z. B. cefotaxime) should be used in neonates with confirmed Gram-negative meningitis. In case of problems with resistant pathogens an aminoglycoside plus a 3rd generation cephalosporin or a broad-?-lactam antibiotic (eg. B. meropenem) may be administered until the sensitivity of the pathogen is known. The intravenous therapy for a Gram positive meningitis is at least 14 days, kept in severe cases or Gram-negative meningitis even for at least 21 days. Intraventricular instillation of antibiotics is ratsam.Zusätzliche therapeutic measures Since the meningitis can not be considered as a part of the natural history of neonatal sepsis, the supportive measures that are used for the treatment of neonatal sepsis are performed. Corticosteroids are not used in the treatment of neonatal meningitis. Patients should be closely monitored for neurological complications during early childhood, even on sensorineural hearing loss. Summary The most common causes are GBS, E. coli and L. monocytogenes. Symptoms are often non-specific (eg., Temperature instability, respiratory distress, jaundice, apnea). Although CNS findings (z. B. lethargy, seizures, vomiting, irritability) may be present, classic findings such as a bulge or full fontanelle and neck stiffness are not common. A cerebrospinal fluid culture is to be considered critical because some newborns have normal meningitis CSF indices (z. B. leukocyte, protein and blood sugar levels). An empirical treatment should be started with ampicillin, gentamicin and cefotaxime, followed by specific drugs based on the results of culture and sensitivity testing. Corticosteroids are not used in neonatal meningitis.

Health Life Media Team

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