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Lectures

Bacterial Meningitis in Children

Nancy Henry
Mayo Clinic, Rochester, MN USA

he etiology of bacterial meningitis in the pediatric population is largely age-dependent. In the newborn period, Group B streptococcus, E. coli and other gram negative bacilli and Listeria are the organisms most often mentioned. In infancy and childhood, Streptococcus pneumoniae and Neisseria meningitidis are now the most common since introduction of the Haemophilus influenzae vaccine in 1989. But it is never as simple as it seems to be and other organisms, either antimicrobial resistant bacteria, serotypes of bacteria outside the coverage of a vaccine, or those less common bacteria, may cause disease. The presentation will review the common organisms and look at those less commonly seen.

Neonatal meningitis
Typically we would see Group B streptococcal disease in newborns born to mothers who are GBS positive who had not been screened at 35-37 weeks gestation or were positive on screening and did not receive intrapartum antimicrobial prophylaxis. This is not always the situation and infants born to GBS negative women may still develop GBS disease. E. coli meningitis in the newborn is the most common gram negative bacillus but Citrobacter and Enterobacter are being seen more frequently. Complications with Citrobacter include brain abscesses. Listeria meningitis is not commonly seen in the US but elsewhere cases are reported. Uncommon organisms include Pasteurella multocida which result from colonization of the newborn with oral flora of cats and dogs. Case 1: Group B streptococcus meningitis and bacteremia in one day old infant born to a mother who was GBS negative. Case 2: Pasteurella multocida meningitis and bacteremia in 3 week old infant.

Infancy and childhood meningitis

The introduction of vaccines for Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis has lessened the appearance of invasive disease due to these organisms, but unfortunately meningitis due to these organisms still occurs-most often in those children who are unimmunized or among those too young to have completed the primary immunization series or who have an unrecognized immunodeficiency. After the conjugate vaccine for H. influenzae type b was introduced in 1989, the incidence of invasive Hib disease in infants and young children decreased by 99% and was <1 case per 100,000 children < 5 years. In Minnesota, USA, there is concern with a recent rise in invasive Hib disease with five cases reported in 2008; two were partially immunized and three were unimmunized due to parental refusal-one of the latter children died.
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Lectures

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The conjugate vaccine for S. pneumoniae introduced in 1999 has had a marked and impressive impact on invasive pneumococcal disease due to the seven serotypes included in the conjugate vaccine. The concern now is that non-vaccine serotypes are developing more invasive characteristics and strains such as 19A, 1 and 3 are becoming more prevalent. Respiratory disease remains the most common presentation. In January 2005 a meningococcal polysaccharide-protein conjugate vaccine for serogroups A, C, Y, and W-135 (MCV4) was licensed for use in the United States for persons aged 11-58 years. This meningococcal vaccination is indicated for children as young as 2 years of age if they are considered high risk, i.e. with terminal complement component deficiency, anatomic or functional asplenia, and certain other high risk groups. Case 3: Meningococcal meningitis in an 8 month old boy complicated by communicating hydrocephalus.

Summary
Despite the advances in broad-spectrum antimicrobial drugs and vaccines, meningitis remains an ongoing infectious disease risk for newborns, infants and children.

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