ARBAMINCH UNIVERSITY

College Of Medicine and Health Science School of Nursing

Department Of Post graduate on neonatal nursing
Assignment on meningitis.(NN2).

Prepared by: - TSEHAYNESH DENEKE

Submitted to : - Mr.Agegnehu. B (M.SC, ASS,PROF ]

10/12/2023
april 3 ,2023
 Contents

• Introduction • Diagnosis
• Epidemiology • Differential diagnosis
• Pathophysiology • Management and
• Risk factors evaluation

• Etiology • Complication

• Clinical manifestation • Nursing intervention

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 Objectives

At the end of this session the learners will be able to:

• Discuss epidemiology, pathophysiology, etiology and

clinical manifestation of meningitis.

• List Risk factors, differential diagnosis and complication.

• Explain diagnosis and management of meningitis.

• Identify nursing intervention for neonates with meningitis.

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 INTRODUCTION

It’s an inflammation of the meninges and is more

common in the neonatal period than at any other time .
Is also one of the most potentially serious infections
occurring in infants and older children.
Symptoms seen with neonatal meningitis are often non
specific that may point to several conditions, such as
sepsis

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The incidence of bacterial meningitis is sufficiently high

in febrile infants that it should be included in the

differential diagnosis of those with altered mental status

and other evidence of neurologic dysfunction

This infection is associated with a high rate of acute

complications and risk of long-term morbidity.

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• NM is classified in 2 types, early and late .
• Early NM starts within the first 72 hours and is
related to contamination through the birth canal with
bacteria such as Escherichia coli, Streptococcus
group B and Listeria monocytogenes.

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•After 72 hours, late NM is associated with germs from
the hospital environment, such as coagulase-negative
Staphylococcus and gram-negative bacilli (Escherichia
coli, Klebsiella pneumoniae, Enterobacter spp.)

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 EPIDEMIOLOGY

• The incidence of bacterial meningitis in neonates

(infants <1 month) ranges from 0.25 and 0.32 per 1000
live births, depending upon the definition used (El-Naggar
W, Afifi J, et.al 2019)

• In developed countries, it is estimated to be around 0.3

cases per 1,000 live births, while in developing countries
this incidence can be as high as 6.1 cases per 1,000 live
births(Ku LC, Boggess KA, et al. 2015)

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 Risk factors
• Low birth weight,

• Preterm birth, premature

• Prolonged rupture of membranes,

• Maternal intra-amniotic infection, and others

• In addition, preterm neonates with intraventricular

hemorrhage are at increased risk of late-onset meningitis

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 ETIOLOGY

• Group B Streptococcus (GBS),

• Escherichia coli, and other gram-negative bacilli are the

most common causes of neonatal meningitis.(El-Naggar W,

Afifi J, et.al 2019)

• In prospective surveillance studies of neonates with sepsis

or meningitis within 72 hours of birth, approximately 65

to 75 percent had infection caused by GBS and E. coli .

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• Gram-positive organisms other than GBS (eg,

Enterococcus, coagulase-negative staphylococci,

Staphylococcus aureus, Listeria monocytogenes, group

A Streptococcus, and alpha-hemolytic streptococci)

contribute to the total disease burden,

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• Neisseria meningitidis, Streptococcus pneumoniae,
and nontypeable Haemophilus influenzae also rarely
cause meningitis in newborn infants.

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 CLINICAL FEATURES

 Temperature instability —fever (rectal temperature

>38°C) or hypothermia (rectal temperature <36°C).
 Term infants are more likely to have fever, whereas
preterm infants are more likely to have hypothermia .
Temperature instability is present in approximately 60
percent of neonates with bacterial meningitis.

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 Neurologic findings — include irritability, lethargy,
poor tone, tremors or twitching, and seizures.
• Poor feeding or vomiting
• Decreased activity
• Respiratory distress (tachypnea, grunting, flaring of
the nasal alae, retractions, decreased breath sounds) –
33 to 50 percent
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• Apnea – 10 to 30 percent
• Change in stool frequency or consistency
• Bulging fontanelle and nuchal rigidity are not
common findings at the time of initial presentation
but are found in approximately 25 and 15 percent of
affected neonates, .

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 DIAGNOSIS

• Clinical findings of sepsis or meningitis and in

neonates who have positive blood cultures.

• Risk factors

• Isolation of a bacterial pathogen from the cerebrospinal

fluid (CSF) culture confirms the diagnosis of bacterial

meningitis.
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 DIFFERENTIAL DIAGNOSIS
• Bacterial infections – bacterial infection with a
parameningeal focus (brain or epidural abscess),
congenital tuberculosis.
• Viral infections – Herpes simplex meningoencephalitis,
congenital cytomegalovirus, enteroviruses, rubella,
lymphocytic choriomeningitis, congenital varicella

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• Spirochetal infections – Syphilis
• Parasitic infections – Toxoplasmosis, Chagas disease
• Mycoplasma infections – Mycoplasma hominis
infection, Ureaplasma urealyticum infection
• Fungal infection – Candidiasis, coccidioidomycosis,
cryptococcal

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• Trauma – Subarachnoid hemorrhage, traumatic
lumbar puncture (LP)
• Malignancy – Teratoma, medulloblastoma, choroid
plexus papilloma and carcinoma
(Morven S Edwards, MD et.al Sep 19, 2022.)

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 EVALUATION

• Evaluation of neonates with suspected sepsis or

meningitis should include a review of the prenatal
history, delivery, and complete physical examination.

• Because the clinical presentation of bacterial

meningitis in the neonate is nonspecific,

• Neonates with suspected bacterial meningitis should

undergo a full laboratory evaluation for sepsis.
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 Complete blood count.

 Blood culture

 Urine culture (if >6 days of age)

 Lumbar puncture (LP) for cerebrospinal fluid (CSF)

cell count, protein, glucose, Gram stain, and culture

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• cele count>15 cells/microL is consistent with
meningeal inflammation, and bacterial meningitis
should be a consideration
• Protein — In the neonate, a CSF protein of >125 to
150 mg/dL in preterm and >100 mg/dL in term
infants is consistent with bacterial meningitis

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• Glucose — A CSF glucose concentration <30 mg/dL
(1.7 mmol/L) in a term infant or <20 mg/dL (1.1
mmol/L) in a preterm infant is consistent with bacterial
meningitis in the neonate
• Gram stain — The presence of an organism on CSF
Gram stain can suggest the diagnosis of bacterial
meningitis
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• Lumbar puncture — When signs of sepsis are present
in a neonate, an LP should be performed, ideally
before or soon after antibiotic therapy is initiated.

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 SUPPORTIVE CARE
• Management of cardiovascular instability or shock

• Provision of oxygen and additional respiratory support as

needed
• Careful fluid therapy, avoiding both hypo- and hypervolemia

• Prevention and management of hypoglycemia

• Control of seizures ("Treatment of neonatal seizures")

• Nutritional support

• Managing fever
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 ANTIMICROBIAL THERAPY

 For neonates whose clinical and initial cerebrospinal

fluid (CSF) findings are suggestive of bacterial
meningitis (eg, CSF pleocytosis, increased CSF protein
and/or decreased CSF glucose, organism present on
Gram stain), broad-spectrum antimicrobial therapy
should be initiated as soon as possible.

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 An appropriate regimen includes agents that have

adequate CSF penetration at appropriate doses to

achieve adequate levels in the CSF.

 cephalosporin eg, cefotaxime , ceftazidime, or cefepime);

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• Coagulase-negative staphylococci – Vancomycin is
the antimicrobial of choice for proven meningitis
caused by coagulase-negative staphylococci.
• ceftriaxone should not be used in neonates, because

it displaces bilirubin from albumin binding sites.

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 COMPLICATIONS

 ACUTE COMPLICATIONS • brain abscess,

• cerebral edema • cerebral infarction,
• increased intracranial • cerebral venous
pressure (ICP), thrombosis,
• ventriculitis, • arterial stroke, and
• cerebritis, subdural effusion or
• hydrocephalus, empyema

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 LONG-TERM COMPLICATIONS
• Hydrocephalus,
• Multicystic encephalomalacia and porencephaly (the
end of the continuum of multifocal parenchymal
injury)
• Cerebral cortical and white matter atrophy
• Developmental delay in approximately 25 to 50
percent(Ouchenir L,Renaud C,et al .2017)

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 • Late-onset seizures in approximately 10 to 20
percent
• Cerebral palsy in approximately 15 to 20 percent
• Hearing loss (which occurs acutely) in
approximately 5 to 10 percent
• Cortical blindness in <10 percent

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 FOLLOW-UP

• Long-term follow-up for survivors of neonatal

meningitis includes monitoring of hearing, vision,
and developmental status.

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 Factors predictive of death or serious adverse sequelae from bacterial meningitis
include.

• Low birth weight (<2500 g) or preterm birth (<37

weeks gestation)

• History of clinical signs for >24 hours before

hospitalization

• Leukopenia (white blood cell <5000/microL) and

neutropenia at presentation

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• Very high cerebrospinal fluid (CSF) protein (>300
mg/dL) and very low CSF glucose (<10 percent of
blood glucose value)

• Seizures continuing >72 hours after hospitalization

• Focal neurologic deficits noted during the acute illness

• Requirement for mechanical ventilation or inotropes

• Delayed sterilization of the CSF

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 summery

• Neonatal meningitis is a devastating disease and

Advances in infant intensive care have reduced
mortality, but morbidity remains high.
• The most common causes of neonatal meningitis is
bacterial infection of the blood, known as bacteremia.
• Delayed treatment of neonatal meningitis may cause
cerebral palsy, blindness, deafness.
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 Refeence

 Devi U, Bora R, Malik V, Deori R, Gogoi B, Das JK, et al.

Bacterial aetiology of neonatal meningitis:2017;145(1)
 Zhou Q, Ong M, Lan M, Ye XY, Ting JY, Shah PS, Lee SK,
Canadian Neonatal Network (CNN) Investigators Neonatology.
2022;119(1):60. Epub 2021 Dec 7.
 Morven S Edwards, MDCarol J Baker, MDet.al Sep 19, 2022.

 Ku LC, Boggess KA, Cohen-Wolkowiez M. Bacterial

Meningitis in the Infant. Clin Perinatol. 2015;42(1):29-45.)

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 El-Naggar W, Afifi J, McMillan D, Toye J, Ting J, Yoon EW, Shah
PS, Canadian Neonatal Network Investigator Pediatr Infect Dis J.
2019;38(5):476.
 Nizet V, Klein JO. Bacterial sepsis and meningitis. In: Infectious
Diseases of the Fetus and Newborn Infant, 8th ed, et al (Eds),
Elsevier Saunders, Philadelphia 2016. p.217.
 Thomson J, Sucharew H, Cruz AT, Nigrovic LE, Cerebrospinal
Fluid Reference Values for Young Infants Undergoing Lumbar
Puncture. Pediatrics. 2018 Mar;141(3):
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 THANK YOU

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