CONTENTS
Prevention and Treatment of Bacterial Meningitis
EDITORIAL BOARD
Co-Editors: Delane Shingadiaand Irja Lutsar
Board Members
David Burgner (Melbourne, Australia) Nicole Ritz (Basel, Switzerland) Tobias Tenenbaum (Mannhein, Germany)
Luisa Galli (Rome, Italy) Ira Shah (Mumbai, India) Marc Terbruegge (Southampton, UK)
Christiana Nascimento-Carvalho Matthew Snape (Oxford, UK) Marceline van Furth (Amsterdam,
(Bahia, Brazil) George Syrogiannopoulos The Netherlands)
Ville Peltola (Turku, Finland) (Larissa, Greece) Anne Vergison (Brussels, Belgium)
The ESPID Reports and Reviews of Pediatric Infectious Diseases series topics, authors and contents are chosen and approved
independently by the Editorial Board of ESPID.
The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015 www.pidj.com|441
Molyneux and Njirammadzi The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015
TABLE 1. Empirical Antibiotic Treatment for Bacterial Meningitis in Resource Poor Settings
isolates in 2009 in Nigeria, and a Ugandan ceftriaxone than by penicillin + gentamicin of antibiotic therapy had a similar outcome
report showed no full resistance, but 83% (99.1% vs. 91.8%; P = 0.006), especially for to those who received 10 days of treatment
intermediate penicillin resistance.8 Hib is Gram-negative isolates (95.1% vs. 86.0%; (60.4% vs. 60.8% survival without sequelae,
resistant to chloramphenicol and to ampicillin P = 0.012).9 Amikacin or parentral ciproflox- 26% vs. 27.2% with sequelae).
in most countries. Nontyphoidal salmonellae acin are effective for many Gram-negative
species have become resistant to chloram- bacterial infections (including ESBL), and ADJUVANT TREATMENT
phenicol, cotrimoxazole and ampicillin, leav- can be added for Gram-negative bacteria
ing the options of ciprofloxacin and/or ceftri- when a third generation cephalosporin fails. Dexamethasone
axone. Table1 shows the common causes of Corticosteroids as adjuvant treatment
bacterial meningitis in different age groups in BM remain controversial. In a large study,
and recommended treatment schedules. DURATION OF ANTIBIOTIC in African children dexamethasone conferred
In the non-neonatal group, S. pneumo- THERAPY no benefit.11 A Cochrane review of adjuvant
niae is the most common etiological agent, A large multicountry study (n = 1004) steroid therapy found no benefit to outcome
and if penicillin susceptibility is unknown in resource poor settings compared the out- in poorly resourced centers.12
a third generation cephalosporin should be come of 5 versus 10 days of ceftriaxone for
given. Empirical treatment can start with a BM caused by one of the 3 most common Glycerol
cephalosporin and change to an appropri- etiological agents, S. pneumoniae, Neisse- Glycerol has been used to reduce
ate narrow-spectrum antibiotic if and when ria meningitidis and Hib.10 Randomization intracranial pressure. A multicountry South
the cause is identified. In Malawi, more was on day 5 and only in stable patients with American study reported encouraging
neonatal cases were effectively treated by no complications. Children receiving 5 days results; when severe neurological sequelae
442 | www.pidj.com 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Pediatric Infectious Disease Journal Volume 34, Number 4, April 2015 Prevention and Treatment of Bacterial Meningitis
and death were combined, glycerol was bene- late or in coma. To these are added malnutri- 4. CDC. Updated recommendation from the
ficial compared with placebo (OR: 0.44; 95% tion and immunosuppression. Advisory Committee on Immunization Practices
(ACIP) for revaccination of persons at pro-
CI: 0.250.76; P = 0.003).13 In a Malawian longed increased risk for meningococcal disease.
study in which paracetamol and glycerol MMWR. 2009;58:10421043.
COMPLICATIONS
were the active adjuvant therapies, there was 5. Everett DB, Mukaka M, Denis B, et al. Ten years
no benefit or harm by adding glycerol or par- Acute complications other than those of surveillance for invasive Streptococcus pneu-
acetamol to standard antibiotic therapy.14 mentioned already include subdural empyema moniae during the era of antiretroviral scale-up
or intracranial abscess. If fever does not settle and cotrimoxazole prophylaxis in Malawi. PLoS
an ultrasound scan of the head should be done One. 2011;6:e17765.
SUPPORTIVE CARE in children with an open fontanelle. Large sub- 6. Pocket Book of Hospital Care for Children: guidelines
Supportive care is critical and the dural collections and intracranial abscesses can for the management of common childhood illnesses.
2nd edition. 2103. WHO: Geneva. http://apps.who.
importance of good nursing care and monitor- be drained trans-fontanelle by experienced per- int/iris/bitstream/10665/81170/1/9789241548373_
ing cannot be over-emphasized. Fluids should sonnel. Antibiotic therapy should be prolonged. eng.pdf. Accessed July 29, 2014.
be monitored, seizures controlled, adequate Fever may also be caused by infected injection 7. Falade AG, Lagunju IA, Bakare RA, et al. Invasive
calorie intake ensured and serum glucose and or cannula sites, joints or chest infections. pneumococcal disease in children aged <5 years
electrolytes kept within normal limits. Long-term neurological sequelae are admitted to 3 urban hospitals in Ibadan, Nigeria.
Clin Infect Dis. 2009;48(Suppl 2):S190S196.
A Cochrane review found no evidence frequent and often devastating. Some hearing
for fluid restriction and some evidence to loss occurs in up to 30% of survivors, espe- 8. Kisakye A, Makumbi I, Nansera D, et al.
Surveillance for Streptococcus pneumoniae men-
support maintenance intravenous fluids in the cially following pneumococcal or Salmonella ingitis in children aged <5 years: implications
first 48 hours in settings with high mortality spp. meningitis. Hydrocephalus may present for immunization in Uganda. Clin Infect Dis.
rates and late presentations.15 Where children after weeks or months. Therefore, all survi- 2009;48(Suppl 2):S153S161.
present early and mortality is lower, evidence vors should have their hearing tested and 9. Swann O, Everett DB, Furyk JS, et al. Bacterial
is insufficient to guide practice. head size monitored after discharge. Follow- meningitis in Malawian infants <2 months of
Seizures must be controlled promptly. age: etiology and susceptibility to World Health
up should include physical, neurological and Organization first-line antibiotics. Pediatr Infect
WHO recommends rectal diazepam and/or developmental assessments. Dis J. 2014;33:560565
paraldehyde followed by phenobarbitone if 10. Molyneux E, Nizami SQ, Saha S, et al; CSF 5
convulsions continue. Intractable seizures are Study Group. A double blind randomised study
difficult to manage without mechanical ven- FUTURE RESEARCH comparing 5 vs 10 days of ceftriaxone therapy
tilator support and loading doses of anticon- Monitoring of incidence and antibiotic for bacterial meningitis in children. The Lancet.
sensitivity must continue to be able to 2011; 377:18371845.
vulsant drugs such as phenobarbitone have
to be repeated despite the risk of respiratory inform empirical treatment. 11. Molyneux EM, Walsh AL, Forsyth H, et al.
Rapid diagnostic tests to identify the Dexamethasone treatment in childhood bacterial
failure. Neonatal seizures are usually man- meningitis in Malawi: a randomised controlled
aged with phenobarbitone. causative agent would reduce the overuse trial. Lancet. 2002;360:211218.
of broad-spectrum antibiotics. 12. Brouwer MC, McIntyre P, Prasad K, et al.
Research is needed into adjuvant therapy Corticosteroids for acute bacterial meningitis.
ANAEMIA AND MALNUTRITION and seizure control. Cochrane Database Syst Rev. 2013;6:CD004405.
Anemia and malnutrition are common Improved neonatal care to reduce infec- 13. Peltola H, Roine I, Fernndez J, et al. Adjuvant
comorbidities. Roine et al16 found that cor- tion rates. glycerol and/or dexamethasone to improve the
recting anemia (less than 8g/dL) with a blood outcomes of childhood bacterial meningitis: a
transfusion reduced mortality in BM to 23% prospective, randomized, double-blind, placebo-
controlled trial. Clin Infect Dis. 2007;45:
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