meningitis

Question 1

how might neonates and infants present

Answer 1

poor feding
irritability
lethargy
vomiting
fever

Question 2

symptoms by age

Answer 2

Question 3

presentation by age

Answer 3

Question 4

kernig and brudzinski sign

Answer 4

Question 5

pathogens by age

Answer 5

Question 6

investigations

Answer 6

lumbar puncture: allows identification of the oragnism with antibiotic susceptibility testiing, thus ensuring appropriate use of antibiotics
LP should be performed in all children with suspected meningitiss

Question 7

contraindications of LP

Answer 7

coma/decreased level of consciousness
signs of raised ICP
seizures (wait until stable)
focal neurological sgns
purpuric rash
shock, cardiovascular compromise

Question 8

things that are not contraindications for LP

Answer 8

breif tonic-clonic
drowsiness
irritability
vomiting

Question 9

if LP is contraindicated

Answer 9

start antibiotics and consider CT instead

Question 10

what tests to conduct on CSF

Answer 10

microscopy, culture and suscpetbilty
glucose aand protein
PCR to identfy viral and bacterial pathogens

Question 11

other nvestigations

Answer 11

blood culture
PCR on blood
throat and rectal swabs (enterovirus testing)
FBC
C reactive protien
electrolytes
capillary/venous blood gas
coagulation studies
group and hold

Question 12

role of cranial CT

Answer 12

when diagnosis is in doubt or when complications of meningitis are suspected

Question 13

manaagement of suspected maningitis

Answer 13

empirical antibiotics

Question 14

antimicrobial choice <1 month

Answer 14

<1 months: IV cefotaxime AND IV benzylpenicillin AND IV aciclovir

Question 15

antimicrobial choice >1 month

Answer 15

IV ceftriaxone
ADD IV vancomycin maybe
In all children and especially neonates, consider adding IV aciclovir for suspected herpes simplex or varicella encephalitis.

Question 16

when to add vanc

Answer 16

if gram positive cocci are seen on gram stain (pneumococcal)
patient has known or susppected otitis meda or sinusitis
patient has been recently treated with penicillin, cephalosporin orr carbepenem
patient is too unwell to undergo LP

Question 17

when to add acicilovir

Answer 17

when suspected herpes ssimplex
or varicella encephalitis

Question 18

role of steroids

Answer 18

dexamethasone
controversial but may reduce neurological sequelae
give early if at all
Current management at PCH is to give IV Dexamethasone: 3 months – 18 years, 0.15 mg/kg (maximum 10 mg) every 6 hours for 4 days.6
Where possible, give the first dose just prior to or at least concurrently with antibiotics.6

Question 19

fluids

Answer 19

patients with meningitis are at risk of hyponatraemia due to SIADH
any fluid replacement should be isotonic with or without glucose
30-70% maintenance rate
boluses of IV fluid should be avoided unless patient is hypotensiveto avoid precipitating/exacerbating cerebral oedema

Question 20

obsservations

Answer 20

use the observation and response tool
hourly full neurological examinations
admit

Question 21

complications of bacterial meningitis

Answer 21

death
intellectual disability, spasticity, seizures, hydrocephalus, deafness
learning and behavioural disorders

Question 22

decorticate/decerebrate posturing

Answer 22

Question 23

signs of raised ICP

Answer 23

altered pupillary responses, absent doll’s eyes reflexes, papilloedema, decorticate/decerebrate posturing, cushings triad (abnormal respiratoyr pattern, hypertension, bradycardia)