Infective meningitis is an inflammation of the arachnoid and pia mater

associated with the presence of bacteria, viruses, fungi or protozoa in the

CSF.
 https://www.youtube.com/watch?v=CIkgQcmv0Xs

 https://www.youtube.com/watch?v=9e9Lo0OPON4
 Infective meningitis is associated with significant mortality and risk of serious sequelae in
survivors.

 Every year, too, an estimated 23,000 children die of bacterial meningitis in Pakistan.
Meningococcus is a germ that causes meningitis in children and adults. We do not know if
this is a common cause of meningitis in Pakistan or not as epidemiological studies have
not been conducted.
Causative Agents

Bacteria Haemophilus inluenzae type b (Hib), Streptococcus pneumoniae and

Neisseria meningitidis, S. pneumoniae, Escherichia coli, Staphylococcus
aureus, Listeria monocytogenes

Viruses Human enteroviruses, such as echoviruses and Coxsackie viruses, Herpes

simplex and varicella zoster viruses

Fungal Candida species, Cryptococcus neoformans, Histoplasmosis

Mycobacterium tuberculosis
 Bacterial meningitis occurs in all age groups, it is predominantly a disease of young
children, with 40–50% of all cases occurring in the first 4 years of life.

 Two bacteria, N. meningitidis and S. pneumoniae, account for about 75% of cases. However,
the pattern of micro-organisms causing meningitis is related to the age of the patient and
the presence of underlying disease.

 N. meningitidis is the most common cause of bacterial meningitis from infancy through to
middle age, with peaks of incidence in the under-5-year age group and in adolescents.
 Human enteroviruses such as echoviruses and Coxsackie viruses account for about 70% of
cases of viral meningitis in the UK.

 Herpes simplex and varicella zoster viruses account for most other cases.

 Occasional causes of viral meningitis include mumps virus and human immunodeficiency
viruses.
 Candida species are an occasional cause of shunt-associated meningitis.

 Cryptococcus neoformans has emerged as an important cause of meningitis in patients with

late-stage HIV infection and other severe defects of T-cell function. With greater use of
fluconazole for oral candidiasis, and especially the advent of highly active antiretroviral
therapy, cryptococcosis has become much less common in developed countries.

 However, in sub-Saharan African countries with the highest HIV prevalence, cryptococcus is
the leading cause of infective meningitis. In certain other areas of the world, infections
with fungi such as Coccidioides immitis and Histoplasma capsulatum are endemic.
 Direct spread from the nasopharynx
 In susceptible individuals, (e.g. physical barriers, local immunity, phagocytes)
 Blood-borne spread from other foci of colonisation or infection
 Abnormal communications with the skin or mucous membranes, for example, skull
fractures, anatomical defects or a meningocoele
 Spread from an infected adjacent focus, for example, brain abscess, tuberculoma,
infected paranasal air sinus or infection of the middle ear
 Acute bacterial meningitis usually presents with sudden-onset headache, neck
stiffness, photophobia, fever and vomiting.
 On examination, Kernig’s sign and Brudzinski’s may be positive.
 Haemorrhagic skin rash, development of seizures, focal cerebral signs and cranial
nerve palsies.
 In infants with meningitis, the early physical signs are usually non-specific and
include fever, diarrhoea, lethargy, feeding difficulties and respiratory distress.
Focal signs such as seizures or a bulging fontanelle usually only occur at a late
stage.
CHILDREN LESS
THAN 1 YEAR
OLD:
Sign Symptoms
 Neck retracted and arched  Fever • Irritability •
backwards • Bulging Refusal to eat • Vomiting •
fontanelle (bulging soft Drowsiness and weak cry
spot in skull of baby)•  • Convulsions after which
Coma • Hypotonia/ the child is sleepy • neck
hypertonia • Convulsion stiffness • Lethargy • Coma

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Hypotonia

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 Adults and older children:

Severe neck stiffness causing a

Inability to straighten the leg when the hip is
patient's hips and knees to flex
flexed to 90 degrees
when the neck is flexed
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 The definitive diagnosis of meningitis is established by detection of the causative
organism and/or demonstration of biochemical changes and a cellular response
in CSF.
 CSF is obtained by lumbar puncture,

“where a needle is inserted between the posterior space of the third and fourth
lumbar vertebrae into the subarachnoid space”
Parameter Value
Color Colorless, clear Liquid
Cells 5 cells/Microlitre
Protein Concentration up to 0.4 g/L
Sugar Concentration 60% of blood glucose
 CSF and Blood Culture Gold standard
 PCR - Viral loads
 Cryptococcal Antigen Testing
The antimicrobial therapy of meningitis requires attainment of adequate levels of
bactericidal agents within the CSF
Antimicrobials fall into three categories according to their ability to penetrate the
CSF:
• those that penetrate even when the meninges are not inflamed, for example,
chloramphenicol, metronidazole, isoniazid and pyrazinamide;
• those that generally penetrate only when the meninges are inflamed, and are
used
in high doses, for example, most β-lactam antibiotics, the quinolones and
rifampicin;
• those that penetrate poorly under all circumstances, including the
aminoglycosides, vancomycin and erythromycin.
 The passage of antibiotics into CSF is dependent on the degree of meningeal inflammation and integrity
of the blood–brain barrier created by capillary endothelial cells, as well as the following properties of
the antibiotic:
 lipid solubility (the choroidal epithelium is highly
 impermeable to lipid-insoluble molecules)
 ionic dissociation at blood pH
 protein binding
 molecular size
 concentration of the drug in the serum.
 The third-generation cephalosporins, cefotaxime or ceftriaxone, have a broad
spectrum of activity that encompasses not only the three classic causes of bacterial
meningitis, but also many other bacteria that are infrequent causes of meningitis.
 Cephalosporins are inactive against L. monocytogenes, and amoxicillin or
ampicillin should be added where it is possible that the patient may
have listeriosis.
 Cryptococcal meningitis is treated with liposomal amphotericin B 3 mg/kg OD
+flucytosine 25 mg/kg QDS for at least 2 weeks, followed by consolidation therapy
with fluconazole 400 mg O D for at least 8 weeks. In patients with HIV, secondary
prophylaxis with oral fluconazole 200 mg O D is indicated until CD4 count >100
cells/mm3 for at least 3 months with undetectable viral load.
 Usually self limiting
 treated with high-dose aciclovir 10 mg/kg three times daily for at least 10 days
(adults and children aged ≥12 years).
 For younger children, the recommended dosages are 20 mg/kg three times daily
for infants up to age 3 months and 500 mg/m2 three times daily for those aged
3 months to 12 years.
 Post-exposure prophylaxis should ideally be given within 24 hours and consists of
one dose of ciprofloxacin 500 mg (adults) or 250 mg (children 5 to 11 years) or
rifampicin 600 mg twice daily for 2 days for adults. For children aged 1–11
years, the rifampicin dose is 10 mg/kg BD for 2 days (maximum dose 600 mg).
Azithromycin 500 mg single dose may be considered for pregnant women.
 SUPPORTIVE TREATMENT
 Corticosteroids If the patient's meningitis is causing pressure
in the brain, corticosteroids, such as dexamethasone, may be
administered to adults and children.
 Dexamethasone 0.15 mg/kg per dose to be given four times
daily for 4 days.

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 SUPPORTIVE TREATMENT CONT..
 Antipyretic: Acetaminophen effective in bringing the patient's temperature
down. Other methods for reducing the patient's fever may include a cool sponge
bath, cooling pads, plenty of fluids, and good room ventilation.

 Anti-convulsants: If the patient has seizures (fits), he/she will be given an

anti-convulsant, such as phenobarbital or dilantin.

 Diuretic: i.e mannitol (1g/kg initial and then 50g every 2-3 hours) to
decrease
intracranial pressure

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 Prevention

 Prophylactic antibiotics (Short term prevention)

 Preventative treatment in close contacts, with antibiotics (e.g. rifampicin 600mg twice for
two days, ciprofloxacin (500mg oral once) or ceftriaxone (250mg IM once) .

 Vaccines (Long term prevention)

 Meningococcal vaccine

 Haemophilus vaccine (HiB) is used in childern (3 doses by 6 months of age and a

booster between 12-18 months of age)

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