Bacterial Meningitis In Infants 3 Months Old

Bacterial meningitis is a serious infection of meninges and subarachnoid space in children. Toddlers can nonspecific symptoms and signs (eg. As lethargy, irritability, poor diet, fever or hypothermia) have. The diagnosis is made by a CSF. Treatment includes antimicrobials and in selected infants, dexamethasone.

For an overview of the Meningitis see overview of meningitis. For acute bacterial meningitis in older children and adults see Acute bacterial meningitis and in children <3 months See Neonatal bacterial meningitis. For viral meningitis, including for infants and children, see Viral meningitis.

Bacterial meningitis is a serious infection of meninges and subarachnoid space in children. Toddlers can nonspecific symptoms and signs (eg. As lethargy, irritability, poor diet, fever or hypothermia) have. The diagnosis is made by a CSF. Treatment includes antimicrobials and in selected infants, dexamethasone. For an overview of the Meningitis see overview of meningitis. For acute bacterial meningitis in older children and adults see Acute bacterial meningitis and in children <3 months See Neonatal bacterial meningitis. For viral meningitis, including for infants and children, see Viral meningitis. Etiology The etiology and incidence of bacterial meningitis are closely related to age and whether the children received a routine immunization with Haemophilus influenzae type b and Streptococcus pneumoniae conjugate vaccines. In infants who did not receive routine vaccinations, are among the most common causes of bacterial meningitis Neisseria meningitidis (serogroup B particular, but occasionally groups A, C, Y or W135) S. pneumoniae (serotypes Many, especially in infants without recording of S. pneumoniae conjugate vaccine) H. influenzae type B (especially in children without proven conjugate vaccine against H. influenzae type B) symptoms and complaints the younger the patient, the non-specific symptoms and discomfort of meningitis are. The first manifestations of bacterial meningitis can an acute febrile illness with respiratory or gastrointestinal symptoms to be later followed by signs of serious illness. Young children may have a bulging fontanelle, but rarely stiff neck or other classic meningeal signs (z. B. Kernig characters or Brudzi?ski characters), typically present in older children. In children <12 months, the lack of neck stiffness must not be used to exclude meningitis. Tips and risks in children <12 months, the lack of neck stiffness must not be used to exclude meningitis. However, if present, neck stiffness should not be ignored. With the progression of bacterial meningitis children develop CNS manifestations, sometimes very quickly. The degree of CNS disorder ranging from irritability to coma. 15% of children who have bacterial meningitis, are comatose or semikomatös at the time of hospitalization. Seizures sometimes occur with bacterial meningitis, but only at about 20% of children in general in those who are already toxic, awareness disturbed or comatose. In infants who are attentive and after a brief, non-partial seizure with fever appear normal, it is unlikely that they have bacterial meningitis (see febrile seizures). Papilledema is very rare in children of all ages with viral meningitis. When a papilledema is present, should be sought for the papilledema for other causes; bacterial meningitis is progressing so fast that not enough time in the rule that a papilledema can develop. Diagnosis GRF analysis generally should be performed a lumbar puncture if the diagnosis of meningitis in an infant is known or suspected. However, it may be too late for a Lumbalpunktiont following reasons: Clinically important cardiorespiratory compromise (most common in young infants) signs of a significant increase in intracranial pressure, including changes in the retina; altered pupil responses; Hypertension, bradycardia and respiratory depression (Cushing triad) and focal neurological symptoms Suspected intracranial injury, including presence of visible injuries, especially on the head, or past injury that is not an accident comes infection at the site of the lumbar puncture is suspected or past bleeding disorders ( z. B. hemophilia, severe thrombocytopenia) In these circumstances, blood cultures are created and antibiotics are given empirically without lumbar puncture. In cases of suspected increased intracranial pressure, arrangements for an imaging study (z. B. brain CT with and without contrast enhancement) can be performed immediately after the antibiotic administration during or should. If the results of the imaging study suggest that it is safe to do a lumbar puncture can be done. However, it is not necessary to routinely perform a CT before lumbar puncture in young children with suspected meningitis, although all patients with meningitis have a slightly increased intracranial pressure. Liquor is sent for analysis, usually cell count, protein, glucose, Gram stain, culture and - in certain infants, PCR tests for enteroviruses (for example, in infants with meningitis during the late summer and autumn in the US) or herpes simplex - virus (. eg infants <3 months). Simultaneously, a blood sample should be taken and sent to determine the CSF-blood glucose ratio. (Editor's note: This is not done in Germany so because the CSF lactate is determined.) Typical Liquorbefunden with bacterial meningitis include high leukocyte count (> 500 leukocytes / ul [range 10,000 to 20,000 Leuckozyten] with a predominance of neutrophils granulocytes [> 80%]) Increased protein (> 100 mg / dl) Low glucose (<40 mg / dl, often <10 mg / dl and CSF: blood sugar ratio typically <0.33) Gram stain shows organisms often the CSF in bacterial meningitis. Although the findings may vary somewhat, infants have with bacterial meningitis rarely a normal CSF in the investigation. Small children should also have two sets of blood cultures (if possible) have serum electrolytes, blood count and differential, and a urinalysis and urine culture. Differential diagnosis symptoms and signs of bacterial meningitis can also be caused by other CNS infections, including viral meningitis (typically enteroviral), HSV encephalitis (almost exclusively in infants <3 months) and brain abscess. Other causes of CNS infections that affect older children and adults (. Eg neuroborreliosis, fungal meningitis, tuberculous meningitis; Bartonella infection, chemical meningitis due to use of NSAIDs, trimethoprim / sulfamethoxazole, or intravenous immunoglobulin; cancer) occur rare in children <12 months on and should be distinguishable based on the medical history, physical examination and testing of the CSF. These other causes of meningitis, CSF findings include most <500 leukocytes / ul with <50% neutrophils, protein <1 00 mg / dl, normal glucose and a negative Gram stain of organisms. Prognosis In older infants and children is the mortality rate in bacterial meningitis is about 5 to 10%, and a neurological morbidity (eg. B. sensorineural hearing loss, mental retardation, spasticity and paralysis, seizures) occurs at 15 to 25%. Sensorineural hearing loss is most common after pneumococcal meningitis. Therapy Antimicrobial therapy Once bacterial meningitis is diagnosed, intravenous access should be obtained and an appropriate antimicrobial drugs (and possibly corticosteroids) are added. Empirical antimicrobial therapy for infants> 3 months is aligned with the common pathogens: pneumococcal, meningococcal and H. influenzae type B A typical drug treatment includes ceftriaxone or cefotaxime plus vancomycin cefotaxime and ceftriaxone are extremely effective against the organisms that usually a bacterial cause meningitis in infants> 3 months. The main difference between these drugs is that ceftriaxone has a much longer serum half-life than cefotaxime. Vancomycin is given because some pneumococcal strains are not vulnerable in certain areas of cephalosporins of the 3rd generation. In the regions (and institutions), where most pneumococcal are penicillin-sensitive, vancomycin may not be necessary, especially if no gram-positive cocci are seen on the CSF Gram stain; withhold the decision vancomycin, should be made generally in consultation with an infectious disease specialist. Once the pathogen has been identified, medications are used more specifically; For example, vancomycin is no longer needed. Organism Specific Antimicrobial Therapy After began immediately empirical antimicrobial drugs, the results of the CSF and / or used by blood cultures in order to select a more targeted drug, while the Empfindlichkeitstes is waited for microbial identification and the results. When S. pneumoniae is thought (eg. Because as gram-positive cocci in pairs seen on a Gram stain of the CSF), the empirical vancomycin should be continued are available to test for susceptibility results. Vancomycin is stopped when the isolate is susceptible to penicillin or against third-generation cephalosporin; If the isolate is not sensitive, vancomycin continues (and some doctors add rifampicin). Since dexamethasone CSF penetrance (and thus the effectiveness of) decrease of vancomycin may recommend some experts that either dexamethasone should not be given, or if it is given that rifampicin is added simultaneously. When H. influenzae type b is suspected or detected, the disease can be treated with ceftriaxone or cefotaxime either reliable; Ampicillin can be used only if the sensitivity of the isolate is proved. If treatment with ampicillin is used, it is followed by a 4-day application of once daily rifampin to clear the carrier status and to prevent relapse (rifampicin is not necessary if the third-generation cephalosporin used to complete the therapy). Diseases caused by N. meningitidis are treated reliably with penicillin G or ampicillin at high doses, or alternatively by a third-generation cephalosporin. When a penicillin or ampicillin therapy is applied, followed by a 2-day course of twice daily rifampin to clear the vehicle status and prevent a relapse (rifampicin is not necessary if a third-generation cephalosporin is used to complete the therapy ). From other causes of bacterial meningitis in infants and children> 3 months was reported, but are very rare. Listeria monocytogenes, S. agalactiae and E. coli cause disease in infants <3 mo of age; They rarely are found in extremely premature infants who have survived to become> 3 mo of age. S. aureus meningitis can occur in infants who had a trauma or neurological surgery. Specific antimicrobial therapies for this type of rare infections should be selected in consultation with an infectious disease specialist. Specific therapy for bacterial meningitis in infants over 3 months after identification and susceptibility results are known. Excitation treatment Streptococcus pneumoniae penicillin MIC ? 0.06 g / ml and ceftriaxone or cefotaxime MIC ? 0.5 ug / ml penicillin G or ampicillin for 10-14 days; Ceftriaxone or cefotaxime are also acceptable penicillin MIC ? 0.12 g / ml and ceftriaxone or cefotaxime MIC ? 0.5 ug / ml: ceftriaxone or cefotaxime for 10-14 days penicillin MIC ? 0.12 g / ml and ceftriaxone or cefotaxime MIC followed ceftriaxone or cefotaxime) and vancomycin with or without rifampin for 10-14 days Neisseria meningitidis penicillin G or ampicillin (for 7 days must of rifampin to eliminate carrier state) alternatives: ? 1.0 ug / ml of cefotaxime, ceftriaxone or Haemophilus influenzae type B ceftriaxone or cefotaxime Alternatively, for 10 days: ampicillin if the isolate (must be followed by rifampin, to eliminate the carrier state) is vulnerable MIC = minimum inhibitory concentration (= minimum inhibitory concentration). Recommended doses of antimicrobial drugs for infants and children with bacterial meningitis drug infants and children ampicillin 50-75 mg / kg every 6 h cefotaxime 50-75 mg / kg every 6 h ceftriaxone 40-50 mg / kg every 12 h or 80-100 mg / kg every 24 h penicillin G 50.000 to 66.667 units / kg every 24 h or 75,000-100,000 units / kg i.v. every 6 h rifampicin 10 mg / kg every 12 h vancomycin 10-15 mg / kg every 6 h corticosteroids in bacterial meningitis The use of corticosteroids (eg., dexamethasone) as adjunctive therapy in bacterial meningitis is investigated for decades and is still controversial. The positive effect of corticosteroids in reducing neurological morbidity seems to vary with the age of the patient (child or adult), with the specific bacterial etiology and even if the patient lives in a developed country or in developing countries. Currently, there is some evidence that dexamethasone in infants and children in developed countries, the bacterial meningitis caused by H. influenzae type B have hearing impairments reduced. The efficacy of dexamethasone in meningitis caused by other organisms remains unproven, although some studies in adults in industrialized countries with meningitis caused by S. pneumoniae report improved neurological outcomes and reduced mortality. Dexamethasone does not seem to help children or adults with bacterial meningitis who live in developing countries still seem to benefit newborns with meningitis. Thus, it should i.v. dexamethasone 0.15 mg / kg be given before or within 1 h after antimicrobial therapy in children> 6 weeks with meningitis caused by H. influenzae type B The drug is continued every 6 h for 4 days at confirmed H. influenzae type B meningitis. Some experts also recommend the same dexamethasone therapy in children with pneumococcal meningitis, which are> 6 weeks old. For optimal efficacy must be started with dexamethasone at diagnosis; this is not always possible unless Gram stain of the liquid or epidemiological factors (eg. as illness contact history) can provide an immediate etiological diagnosis. In regions where children were routinely given H. influenzae type B and pneumococcal conjugate vaccines caused by these organisms bacterial meningitis will be rare. For these reasons, along with the contradictory statements about the benefits of treatment with dexamethasone, be many experts in pediatric infectious diseases not routinely corticosteroids in infants with meningitis. Prevention For prevention of bacterial meningitis are vaccination and chemoprophylaxis sometimes available. Vaccinations A conjugate pneumococcal vaccine that is effective against 13 serotypes, which> 90% of pneumococcal stereotype include that causes meningitis in children, is recommended for all children from 2 months of age (see table: Recommended vaccination scheme for old age 0-6. routine vaccination with H. influenzae type b conjugate vaccine in the second month of life is very effective. the Advisory Committee on immunization practices (ACIP) recommends that children> 6 weeks, have a risk for meningococcal disease received a meningococcal conjugate vaccine for infants not a high risk, routine meningococcal conjugate vaccine is aged 11 or 12 years is recommended (see table: recommended vaccination schedule for the age of 7-18 years).. Among the children with high risk include have functional or anatomic asplenia have persistent shortcomings of Komplementkomponentenwegs Travel to a high-risk area (eg. B. Sub-Saharan Africa, Saudi Arabia during the Hajj) Two meningococcal vaccines serogroup B were approved by the ACIP for use in children ? 10 years who are at high risk for meningococcal disease group B (same categories as above ); a routine vaccination for meningococcal B is not administered to date. For more information, s. current ACIP meningococcal vaccine for meningitis recommendations.Chemoprophylaxe Antimicrobial chemoprophylaxis is necessary for N. meningitidis: All close contacts H. influenzae meningitis: Selected contacts close contacts of children who have meningitis caused by other bacteria that do not require chemoprophylaxis. In meningococcal meningitis, close contacts are at risk for infection, the 25 to be 500 times higher than in the general population can. Close contacts are defined as household members, particularly children <2 years old contacts exposed in day care centers in the 7 days before onset of symptoms who directly mouth secretions of the patient (eg., By kissing, sharing toothbrushes or utensils, mouth-to mouth resuscitation, intubation, Endotrachealtubus- management) is exposed in the 7 days before onset of symptoms Not every doctor who has cared for a child with meningitis, is considered a close contact. Health personnel should only receive chemoprophylaxis if they provide the respiratory tract of the patient or are directly exposed to the secretions of the patient's airways. Chemoprophylaxis should be given (ideally within 24 h after the identification of the index patient) as soon as possible; chemoprophylaxis, given> 2 weeks after exposure, probably has little or no value. Rifampin, ceftriaxone and ciprofloxacin are appropriate medication depending on the age of the contact (see table: Recommended chemoprophylaxis for high-risk contacts * of children with meningococcal or H. influenzae meningitis type b). In young children, oral rifampin or injectable ceftriaxone is preferred. H. influenzae meningitis type B risk of infection upon contact is less than with a meningococcal disease, but may in young, unvaccinated infant or toddler contacts who live in the household of an index patient, be significant. Also, household contacts could asymptomatic carriers of H. influenzae type B to be. Close contacts are more explicitly defined as for meningococcal prophylaxis because caregivers who spend time in the home, but do not live there yet with H. influenzae type B may have been colonized. Therefore, for this organism, household contacts are defined as follows: people living with the index patient people who ? 4 hours spent with the index patients for ? 5 of the 7 days preceding the hospitalization of the index patient chemoprophylaxis is then recommended for each member of a household, as just defined, although the following happens in this household least one contact <4 years, which is incompletely immunized or not immunized. One child <12 months, that has not completed the primary Hib conjugate vaccine series A immunsupprimiertes child (regardless of dermvorangegangenen immunization status) A complete immunization against H. influenzae type b is defined as at least 1 dose of Hib conjugate vaccine at the age of ? 15 months, or 2 doses of between 12 to 14 months or 2- or 3-dose primary series for children <12 months with a booster dose at ? 12 months. In addition, if a preschool or daycare ? has 2 cases of invasive Hib disease within 60 days among its members, many experts recommend chemoprophylaxis for all participants and employees to prevent asymptomatic nasal delivery, regardless of immunization status. The biggest risk with close contacts for a secondary infection is <4 years immunized incomplete against H. influenzae type B in children. Chemoprophylaxis should be <24 h are given after the identification of the index patient; chemoprophylaxis, given> 2 weeks after exposure, probably has little or no value. Oral rifampin or injectable ceftriaxone and ciprofloxacin are preferred for older contacts acceptable (see Table: Recommended chemoprophylaxis for high-risk contacts * of children with meningococcal or H. influenzae meningitis type b). Recommended chemoprophylaxis for high-risk contacts * of children with meningococcal or H. influenzae type b meningitis from drugs and indications age dose duration Rifampin † (N. meningitidis) <1 mo 5 mg / kg i.v. or p.o. every 12 h 2 days ? 1 Month 10 mg / kg i. v. or p.o. every 12 h (a maximum of 600 mg p.o. every 12 h) rifampin 2 days † (to H. influenzae) <1 mo 10 mg / kg i.v. or p.o. once / Day 4 ? 1 month 20 mg / kg iv or p.o. once / day (maximum 600 mg po once / day) four days ceftriaxone (for both excitation) <15 years 125 mg i.m. Single dose ? 15 years 250 mg i.m. Ciprofloxacin single dose ‡ (for both excitation)> 1 m 20 mg / kg p.o. (Maximum 500 mg) Single dose * See text for definitions of close contacts at high risk. † rifampin is not recommended for pregnant women. ‡ Ciprofloxacin is not routinely recommended for children <18 years; However, it can be used for certain children> 1 month, if the risks and benefits were evaluated. If fluoroquinolone-resistant strains were identified by meningococcal in a community, ciprofloxacin should not be used for chemoprophylaxis. Important points infants with bacterial meningitis can first non-specific symptoms and discomfort (eg. As disease of the upper respiratory or GI disease) have, but then quickly decompensation. The most common bacterial causes of meningitis Neisseria meningitidis, Haemophilus influenzae type B and Streptococcus pneumoniae. If meningitis is suspected, perform a lumbar puncture and apply as soon as possible an empirical antimicrobial therapy (and possibly dexamethasone). Empirical antimicrobial therapy in infants> 3 months carried out with cefotaxime or ceftriaxone and vancomycin. For more information Meningococcal Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP)

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