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1、Bacterial meningitis,Bacterial meningitis,Introduction,Bacterial meningitis is an inflammation of the leptomenings, usually causing by bacterial infection.Bacterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours), subacutely (symptoms evolving over 1-7days), or chronically
2、 (symptoms evolving over more than 1 week).,IntroductionBacterial meningit,Introduction,Annual incidence in the developed countries is approximately 5-10 per 100000. 30000 infants and children develop bacterial meningitis in United States each year. Approximately 90 per cent of cases occur in childr
3、en during the first 5 years of life.,IntroductionAnnual incidence i,Introduction,Cases under age 2 years account for almost 75% of all cases and incidence is the highest in early childhood at age 6-12 months than in any other period of life.There are significant difference in the incidence of bacter
4、ial meningitis by season.,IntroductionCases under age 2,Etiology,Causative organisms vary with patient age, with three bacteria accounting for over three-quarters of all cases:Neisseria meningitidis (meningococcus)Haemophilus influenzae (if very young and unvaccinated)Streptococcus pneumoniae ( pneu
5、mococcus),EtiologyCausative organisms va,Etiology,Other organisms Neonates and infants at age 2-3 months Escherichia coliB-haemolytic streptococciStaphylococcus aureusStaphylococcus epidermidisListeria monocytogenes,EtiologyOther organisms,Etiology,Elderly and immunocompromisedListeria monocytogenes
6、Gram negative bacteriaHospital-acquired infectionsKlebsiellaEscherichia coliPseudomonasStaphylococcus aureus,EtiologyElderly and immunocomp,Etiology,The most common organisms Neonates and infants under the age of 2monthsEscherichia coli Pseudomonas Group B StreptococcusStaphylococcus aureus,Etiology
7、The most common organi,Etiology,Children over 2 monthsHaemophilus influenzae type bNeisseria meningitidisStreptococcus pneumoniaeChildren over 12 yearsNeisseria meningitidisStreptococcus pneumoniae,EtiologyChildren over 2 months,Etiology,Major routes of leptomening infectionBacteria are mainly from
8、blood.Uncommonly, meningitis occurs by direct extension from nearly focus (mastoiditis, sinusitis) or by direct invasion (dermoid sinus tract, head trauma, meningo-myelocele).,EtiologyMajor routes of leptom,Pathogenesis,Susceptibility of bacterial infection on CNS in the children Immaturity of immun
9、e systemsNonspecific immuneInsufficient barrier (Blood-brain barrier)Insufficient complement activityInsufficient chemotaxis of neutrophilsInsufficient function of monocyte-macrophage systemBlood levels of diminished interferon (INF) -and interleukin -8 ( IL-8 ),PathogenesisSusceptibility of,Pathoge
10、nesis,Susceptibility of bacterial infection on CNS in the childrenSpecific immuneImmaturity of both the cellular and humoral immune systemsInsufficient antibody-mediated protectionDiminished immunologic responseBacterial virulence,PathogenesisSusceptibility of,Pathogenesis,A offending bacterium from
11、 blood invades the leptomeninges. Bacterial toxics and Inflammatory mediators are released.Bacterial toxicsLipopolysaccharide, LPSTeichoic acidPeptidoglycan Inflammatory mediatorsTumor necrosis factor, TNFInterleukin-1, IL-1Prostaglandin E2, PGE2,PathogenesisA offending bacter,Pathogenesis,Bacterial
12、 toxics and inflammatory mediators cause suppurative inflammation.Inflammatory infiltrationVascular permeability alterTissue edema Blood-brain barrier detroyThrombosis,PathogenesisBacterial toxics a,Pathology,Diffuse bacterial infections involve the leptomeninges, arachnoid membrane and superficial
13、cortical structures, and brain parenchyma is also inflamed.Meningeal exudate of varying thickness is found.There is purulent material around veins and venous sinuses, over the convexity of the brain, in the depths of the sulci, within the basal cisterns, and around the cerebellum, and spinal cord ma
14、y be encased in pus. Ventriculitis (purulent material within the ventricles) has been observed repeatedly in children who have died of their disease.,PathologyDiffuse bacterial inf,Pathology,Invasion of the ventricular wall with perivascular collections of purulent material, loss of ependymal lining
15、, and subependymal gliosis may be noted. Subdural empyema may occur.Hydrocephalus is an common complication of meningitis.Obstructive hydrocephalus Communicating hydrocephalus,PathologyInvasion of the ventr,Pathology,Blood vessel walls may infiltrated by inflammatory cells.Endothelial cell injuryVes
16、sel stenosisSecondary ischemia and infarctionVentricle dilatation which ensues may be associated with necrosis of cerebral tissue due to the inflammatory process itself or to occlusion of cerebral veins or arteries.,PathologyBlood vessel walls ma,Pathology,Inflammatory process may result in cerebral
17、 edema and damage of the cerebral cortex.Conscious disturbanceConvulsionMotor disturbance Sensory disturbance Meningeal irritation sign is found because the spinal nerve root is irritated.Cranial nerve may be damaged,PathologyInflammatory process,Clinical manifestation,Bacterial meningitis may prese
18、nt acutely (symptoms evolving rapidly over 1-24 hours) in most cases.Symptoms and signs of upper respiratory or gastrointestinal infection are found before several days when the clnical manifestations of bacterial meningitis happen.Some patients may access suddenly with shock and DIC.,Clinical manif
19、estationBacteria,Clinical manifestation,Toxic symptom all over the body HyperpyrexiaHeadachePhotophobiaPainful eye movementFatigued and weak Malaise, myalgia, anorexia, Vomiting, diarrhea and abdominal painCutaneous rashPetechiae, purpura,Clinical manifestationToxic sy,Clinical manifestation,Clinica
20、l manifestation of CNSIncreased intracranial pressureHeadacheProjectile vomiting Hypertension Bradycardia Bulging fontanel Cranial sutures diastasisComa Decerebrate rigidity Cerebral hernia,Clinical manifestationClinical,Clinical manifestation,Clinical manifestation of CNSSeizuresSeizures occur in a
21、bout 20%-30% of children with bacterial meningitis.Seizures is often found in haemophilus influenzae and pneumococal infection.Seizures is correlative with the inflammation of brain parenchyma, cerbral infarction and electrolyte disturbances.,第一课件网站 ,Clinical manifestationClinical,Clinical manifesta
22、tion,Clinical manifestation of CNSConscious disturbanceDrowsiness Clouding of consciousness ComaPsychiatric symptom Irritation Dysphoria dullness,Clinical manifestationClinical,Clinical manifestation,Clinical manifestation of CNSMeningeal irritation signNeck stiffnessPositive Kernigs signPositive Br
23、udzinskis sign,Clinical manifestationClinical,Clinical manifestation,Clinical manifestation of CNSTransient or permanent paralysis of cranial nerves and limbs may be noted. Deafness or disturbances in vestibular function are relatively common.Involvement of the optic nerve, with blindness, is rare.
24、Paralysis of the 6th cranial nerve, usually transient, is noted frequently early in the course.,Clinical manifestationClinical,Clinical manifestation,Symptom and signs of the infant under the age of 3 monthsIn some children, particularly young infants under the age of 3 months, symptom and signs of
25、meningeal inflammation may be minimal.Fever is generally present, but its absence or hypothermia in a infant with meningeal inflammation is common. Only irritability, restlessness, dullness, vomiting, poor feeding, cyanosis, dyspnea, jaundice, seizures, shock and coma may be noted. Bulging fontanel
26、may be found, but there is not meningeal irritation sign.,Clinical manifestationSymptom,Complication,Subdural effusionSubdural effusions occur in about 10%-30% of children with bacterial meningitis.Subdural effusions appear to be more frequent in the children under the age of 1 year and in haemophil
27、us influenzae and pneumococal infection.Clinical manifestations are enlargement in head circumference, bulging fontanel, cranial sutures diastasis and abnormal transillumination of the skull.Subdural effusions may be diagnosed by the examination of CT or MRI and subdural pricking.,Complication Subdu
28、ral effusio,Complication,Ependymitis Neonate or infant with meningitis Gram-negative bacterial infection Clinical manifestation Persistent hyperpyrexia, Frequent convulsion Acute respiratory failure Bulging fontanel Ventriculomegaly (CT) Cerebrospinal fluid by ventricular punctureWBC50109/LGlucoseo.
29、4g/L,ComplicationEpendymitis,Complication,Cerebullar hyponatremiaSyndrem of inappropriate secretion of antidiuretic hormone (SIADH)Hyponatremia Degrade of blood osmotic pressureAggravated cerebral edemaFrequent convulsion Aggravated conscious disturbance,ComplicationCerebullar hyponat,Complication,H
30、ydrocephalus Increased intracranial pressureBulging fontanelAugmentation of head circumferenceBrain function disorder Other complicationDeafness or blindnessEpilepsyParalysis Mental retardationBehavior disorder,ComplicationHydrocephalus,Laboratory Findings,Peripheral hemogramTotal WBC count 20109/L
31、40109/L WBCDecreased WBC count at severe infectionLeukocyte differential count80%90% Neutrophils,Laboratory FindingsPeripheral,Laboratory Findings,Rout examination of cerebrospinal fluid (CSF) Increased pressure of cerebrospinal fluid Cloudiness Evident Increased total WBC count (1000109/L)Evident I
32、ncreased neutrophils in leukocyte differential countEvident Decreased glucose (1.1mmol/l) Evident Increased protein level Decreased or normal chloridateCSF film preparation or cultivation : positive result,Laboratory FindingsRout examin,Laboratory Findings,Especial examination of CSFSpecific bacteri
33、al antigen testCountercurrent immuno-electrophoresisLatex agglutinationImmunofluorescent test Neisseria meningitidis (meningococcus)Haemophilus influenzae Streptococcus pneumoniae ( pneumococcus)Group B streptococcus,Laboratory FindingsEspecial ex,Laboratory Findings,Especial examination of CSFOther
34、 test of CSFLDHLactic acidCRPTNF and IgNeuron specific enolase (NSE),Laboratory FindingsEspecial ex,Laboratory Findings,Other bacterial testBlood cultivationFilm preparation of skin petechiae and purpuraSecretion culture of local lesion Imageology examination,Laboratory FindingsOther bacte,Diagnosis
35、,Diagnostic methodsA careful evaluation of history A careful evaluation of infants signs and symptomsA careful evaluation of information on longitudinal changes in vital signs and laboratory indicatorsRout examination of cerebrospinal fluid (CSF),DiagnosisDiagnostic methods,Differential diagnosis,Cl
36、inical manifestation of bacterial meningitis is similar to clinical manifestation of viral, tuberculous , fungal and aseptic meningitis. Differentiation of these disorders depends upon careful examination of cerebrospinal fluid obtained by lumbar puncture and additional immunologic, roentgenographic
37、, and isotope studies.,Differential diagnosisClinical,Characteristics of CSF on common disease in CNS,Characteristics of CSF on comm,Treatment Antibiotic Therapy,Therapeutic principleGood permeability for Blood-brain barrier Drug combination Intravenous drip Full dosage Full course of treatment,Trea
38、tment Antibiotic TherapyT,Antibiotic Therapy,Selection of antibioticNo Certainly BacteriumCommunity-acquired bacterial infectionNosocomial infection acquired in a hospitalBroad-spectrum antibiotic coverage as noted belowChildren under age 3 monthsCefotaxime and ampicillinCeftriaxone and ampicillin (
39、children over age 1months)Children over 3 monthsCefotaxime or Ceftriaxone or ampicillin and chloramphenicol,Antibiotic TherapySelection of,Antibiotic Therapy,Certainly BacteriumOnce the pathogen has been identified and the antibiotic sensitivities determined, the most appropriate drugs should select
40、ed.N meningitidis : penicillin, tert- cephalosporin S pneumoniae: penicillin, tert- cephalosporin, vancomycin H influenzae: ampicillin, tert- cephalosporin S aureus: penicillin, nefcillin, vancomycin E coli: ampicillin, chloramphenicol, tert- cephalosporin,Antibiotic TherapyCertainly Ba,Antibiotic T
41、herapy,Course of treatment7 days for meningococcal infection1014 days for H influenzae or S pneumoniae infectionMore than 21 days for S aureus or E coli infection1421 days for other organisms,Antibiotic TherapyCourse of tr,Treatment General and Supportive Measures,Monitor of vital sign Correcting me
42、tabolic imbalancesSupplying sufficient heat quantity Correcting hypoglycemia Correcting metabolic acidemiaCorrecting fluids and electrolytes disorderApplication of cortical hormoneLessening inflammatory reaction Lessening toxic symptom lessening cerebral edema,Treatment General and Support,General a
43、nd Supportive Measures,Treatment of hyperpyrexia and seizures Pyretolysis by physiotherapy and/or drugConvulsive management Diazepam Phenobarbital Subhibernation therapy Treatment of increased intracranial pressureDehydration therapy 20%Mannitol 5ml/kg vi q6hLasix 1-2mg/kg vi,General and Supportive
44、Measure,General and Supportive Measures,Treatment of septic shock and DICVolume expansionDopamine Corticosteroids Heparin Fresh frozen plasmaPlatelet transfusions,General and Supportive Measure,Treatment Complication Measures,Subdural effusions Subduaral prickingDraw-off effusions on one side is 20-
45、30ml/time.Once daily or every other day is requested. Time cell of pricking may be prolonged after 2 weeks. Ependymitis Ventricular puncture drainage Pressure in ventricle be depressed. Ventricular puncture may give ventricle an injection of antibiotic.,Treatment Complication Measur,Complication Mea
46、sures,HydrocephalusOperative treatmentAdhesiolysis By-pass operation of cerebrospinal fluid Dilatation of aqueductSIADH (Cerebral hyponatremia)Restriction of fluidsupplement of serum sodium diuretic,Complication MeasuresHydroceph,Prognosis,Appropriate antibiotic therapy reduces the mortality rate fo
47、r bacterial meningitis in children, but mortality remain high.Overall mortality in the developed countries ranges between 5% and 30%.50 percent of the survivors have some sequelae of the disease.,PrognosisAppropriate antibioti,Prognosis,Prognosis depends upon many factors:AgeCausative organismNumber of organisms and bacterial virulence Duration of illness prior to effective antibiotic therapyPresence of disorders that may compromise host response to infection,第一课件网站 ,PrognosisPrognosis depends upo,
