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Pediatrics
Bacterial Central
Nervous System
Infections
in ChildrenSheldon L. Kaplan, MD
Baylor College of Medicine
Texas Children’s Hospital
Houston, TX
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Disclosures
•Pfizer-Grant for Investigator initiated multicenter
pediatric surveillance study of invasive and local
pneumococcal infections.
•Allergan-Investigator initiated study of ceftaroline
for acute osteomyelitis in children
•MeMed-Site PI for Apollo study of MeMed device
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Learning Objectives
•Review key ABP 2021 ID Subboard
Infectious Diseases Content for Central
Nervous System Infections
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Pathogenesis of Bacterial Meningitis
•Usually is the result of hematogenous dissemination
of organisms
•Bacterial invasion from a contiguous focus of infection,
as in infection of the mastoid or paranasal sinuses, or
as a complication of otitis media.
•Fracture through the paranasal sinuses as a result of
head trauma may precede development of meningitis
caused by S. pneumoniae and H. influenzae
Kim KS Lancet Infect Dis 2010;10:32-42
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Pathogenesis of Bacterial Meningitis
•Direct invasion also may occur in individuals with
dermoid sinus tracks or meningomyeloceles, where a
direct communication between the skin and the
meninges is present
•Neurosurgical procedures
and devices
Chen T-M J Pediatr Infect Dis Soc 2021;28:635-640
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Clinical Manifestations of Bacterial Meningitis
•Fever generally is present
•Nausea, vomiting, irritability, anorexia, headache,
confusion, back pain, and nuchal rigidity
•Signs of meningeal inflammation (Kernig and
Brudzinski signs) may be minimal in the infant, but
irritability, restlessness, and poor feeding may be
noted
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Clinical Manifestations of
Bacterial Meningitis
•Increased intracranial pressure is the rule; it may be reflected by complaints of headache in older children and by a bulging fontanelle and diastasis of sutures in the infant.
•Papilledema is an uncommon finding in acute meningitis, presumably because of the relatively brief duration of increased pressure at the time of diagnosis.
•When papilledema is observed, venous sinus occlusion, subdural empyema, or brain abscess should be sought
•Transient or permanent paralysis of cranial nerves may be noted
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Bacterial Meningitis
Normal Child Greater than Two Months Old
Expected Organisms
Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenzae type b
(type a, f, or non-typeable)
Soeters et al. Clin Infect Dis 2020 June 26
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Bacterial Meningitis
Infants less than Two Months Old
Expected Organisms
Group B streptococcus
Gram-negative Enterics (E. coli)
Streptococcus pneumoniae
Listeria monocytogenes
Haemophilus influenzae non-typeable
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Bacterial Meningitis
Unusual Organisms
• Dermal sinus- S. aureus, CONS, Gram-negative enterics
• Post neurosurgical procedures- S. aureus, Gram-negative
enterics, CONS
• Renal transplantation- Listeria monocytogenes
• Group A streptococcus*
• In infants-Enterococcus spp, Salmonella spp, Cronobacter
sakazakii, Citrobacter koseri (brain abscess), Pasteurella
multocida (cat or dog)
*Van Veen et al. Transplant Infect Dis 2016;18:674-680
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Seizures in Bacterial Meningitis
•20% of patients have seizures prior to admission
•A third of patients have seizures prior to or during 1st 48
hours of hospitalization
•Early, generalized or multifocal seizures of short duration
and minimal frequency are related to “toxic
encephalopathy” associated with bacterial toxins,
hypoperfusion and metabolic derangements; EEG usually
not helpful. Usually controlled easily and have no
prognostic implications
Pomeroy SL et al. N Engl J Med 1990;323:1651-7
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Seizures in Bacterial Meningitis
•Persistent focal seizures or recurrent seizures of varying focality imply an underlying complication such as venous or arterial thrombosis with infarction or symptomatic subdural effusion
•Seizures which are difficult to control, which persist beyond the 3rd hospital day or which develop initially after the 3rd hospital day may be associated with permanent sequelae
Pomeroy SL et al. N Engl J Med 1990;323:1651-7
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CSF Diagnostic Tests
•Gram stain-60 to 90% positive
•PCR-particularly helpful for N. meningitidis in culture negative patient.
•Role of multiplex nucleic acid amplification CSF panels that include bacterial, viral and fungal pathogens is not certain. Most helpful in patients with negative CSF cultures and/or PCR for more common viral etiologies although false positive results are not uncommon.*
Olarte L et al. Clin Infect Dis 2015;61:767-775
*Ekambaram et al. 2020 IDWeek
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Bacterial Meningitis
Normal Child Greater than Two Months Old
Expected Organisms
Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenzae type b (a, f, NT)*
Empiric therapy+
Ceftriaxone +
Vancomycin
+Rifampin may be considered if adjunctive
dexamethasone administered
*Ampicillin-resistance can be due to ß-lactamase production or alterations in PBP3
Tsang et al. J Antimicrob Chemother 2017;72:1314
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Failure of Broad-Spectrum Cephalosporins
for Pneumococcal Meningitis- USA
MIC
Location Age Therapy mg/kg/day Penicillin Cefotaxime Ceftriaxone
San Diego 2.5 y ceftriaxone (100)* 0.5 2 2Memphis 13 mo
13 mo4 mo11 mo
cefotaxime (200)*cefuroxime (150)cefotaxime (200)cefotaxime
0.254
0.52
3288
16
16
848
Dallas 9 mo ceftriaxone (80) 2 4 4Indianapolis 28 mo ceftriaxone (90)* 4 2 2Ann Arbor 6 mo cefotaxime (200)* 2 >2 >2Providence 33 y ceftriaxone (4 gm)* 1.4 1.4 1.0
*dexamethasone also administered
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2021 CLSI Pneumococcal Breakpoints
Antimicrobial
Agent
MIC (µg/mL)
Interpretive Standard
S I R
Penicillin parenteral
(meningitis)
0.06 0.12-1 2
Penicillin parenteral
(nonmeningitis)
2 4 8
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2021 CLSI Pneumococcal Breakpoints
Antimicrobial
Agent
MIC (µg/mL)
Interpretive Standard
S I R
ceftriaxone or
cefotaxime
(meningitis)
0.5 1 2
ceftriaxone or
cefotaxime
(nonmeningitis)
1 2 4
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Current Antibiotic Susceptibilities of
Streptococcus pneumoniae
•In 2018 and 2019, 31% and 6% of IPD
isolates in the Pediatric Multicenter
Pneumococcal Surveillance Study were
non-susceptible to penicillin (MIC > 0.06
µg/mL) and ceftriaxone (MIC > 0.5
µg/mL), respectively, for treating
bacterial meningitis.
Kaplan et al. Abstract #176
IDWeek 2020
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Treatment of Pneumococcal Meningitis
Penicillin MIC Ceftriaxone MIC Therapy
(1) < 0.06 µg/ml < 0.5 µg/ml Penicillin
(2 ) > 0.12 /µg/ml < 0.5 µg/ml Ceftriaxone
1 µg/ml Ceftriaxone
+Vancomycin
> 2 µg/ml Ceftriaxone +
Vancomycin+
? Rifampin
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Meningococcal Meningitis
Treatment Options•Penicillin
•Ampicillin
•Ceftriaxone/cefotaxime
•Meropenem for patients with anaphylactic reactions
to ß-lactam antibiotics (Chloramphenicol)
•Duration-5-7 days for most cases
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•During 2019–2020, 11 meningococcal isolates from U.S. patients had
isolates containing a blaROB-1 β-lactamase gene associated with
penicillin resistance and mutations associated with ciprofloxacin
resistance. An additional 22 cases reported during 2013–2020
contained blaROB-1 but did not have mutations associated with
ciprofloxacin resistance.
What are the implications for public health practice?
•Ceftriaxone and cefotaxime can continue to be used for empiric
bacterial meningitis treatment; meningococcal isolate susceptibility
to penicillin should be determined before switching to penicillin or
ampicillin.* Prophylaxis failures and antimicrobial resistance among
meningococcal isolates should be monitored to inform meningococcal
prophylaxis recommendations.
MMWR June 19, 2020
*2021 Red Book also has this recommendation
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Gram-Negative Meningitis
•Combination therapy with cefotaxime (cefepime,
ceftazidime) and an aminoglycoside is used for
empirical therapy and until CSF is sterile.
•For ampicillin-susceptible CSF isolates of E coli,
meningitis can be treated with ampicillin or cefotaxime
(cefepime, ceftazidime)
•Meningitis caused by an ampicillin-resistant,
cefotaxime-susceptible isolate can be treated with
cefotaxime (cefepime, ceftazidime).
2021 Red Book
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Gram-Negative Meningitis
A carbapenem is the drug of choice for treatment of
infections caused by ESBL-producing organisms, especially
some Klebsiella pneumoniae isolates. Of the
aminoglycosides, amikacin retains the most activity against
ESBL-producing strains.
2021 Red Book
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Causes of Prolonged or Recurrent Fever
in Children with Bacterial Meningitis
•Inadequate Treatment
•Nosocomial Infection
•Dexamethasone D/CD
•Phlebitis
•Immune mediated arthritis
•Drug Fever
•Suppurative complication
-Pericarditis
-Pneumonia
-Pyogenic arthritis
-Subdural empyema
•Unknown
Lin Ty et al. Pediatr Infect Dis J 1984;3:319-22
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Indications for Repeat Lumbar
Puncture
•Patient not responding clinically after
48 h of appropriate therapy.
•Pneumococcal isolate resistant to
ceftriaxone (MIC > 2 µg/ml)
•Patient with Gram-negative meningitis
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Indications for Neuroimaging
in Bacterial meningitis
•Neonatal bacterial meningitis
•Persistent focal neurologic findings
•Persistently positive CSF cultures despite appropriate therapy
•Recurrent meningitis
* In general neuroimaging does not elucidate the cause of prolonged fever
Klein JO et al. Pediatrics 78:959-82
Kralik et al. AJNR Am J Neuroradiol 2019;40:1413-1417
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•H. influenzae 43%
•S. pneumoniae 30%
•N. meningitidis 22%
•No difference in duration of fever or outcome
between children with or without an effusion.
Snedeker et al. Pediatrics 1990;86:163-170
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Neurologic Sequelae of Bacterial Meningitis
•intellectual disabilities
-language delay
-learning disorders
•behavior disorders
•delayed or abnormal motor
development
•hemiparesis
•hearing handicap
•ataxia
•seizure disorder
•blindness
•hydrocephalus
•hypothalamic dysfunction
Olarte L et al. Clin Infect Dis 2015;61:767-775
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Sensorineural Hearing Loss in
Bacterial Meningitis
•Unilateral or bilateral loss
S. pneumoniae 30%
H. influenzae type b 6-15%
N. meningitidis 5-10%
•Ataxia commonly associated with deafness#
•Hearing loss appears to occur early-present at or near
time of admission*Dodge PR et al. N Engl J Med 1984;311:869-874
#Kaplan SL et al. Pediatrics 1981;68:8-13
*Wald ER et al. Pediatrics 1995;95:21-28
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Pathogenesis of Deafness in
Bacterial Meningitis•labyrinthitis develops following bacterial invasion of the cochlea presumably via the cochlear aqueduct from CSF
•bacteria may also reach the cochlea hematogenously via the stria vascularis, a highly vascularized wall of the scalamedia
•direct damage to auditory nerve by inflammatory response or bacteria reaching the nerve through the internal auditory canal
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Brain Abscess-Location and Origin
•Ear and mastoid sources are associated with abscess formation at the temporal or cerebellar locations
• Sinus and dental infections give rise to purulent collections in the frontal lobe
• Metastatic spread from distant foci in children with congenital cardiac or pulmonary right-to-left shunts commonly results in involvement of any parenchyma area, including parietal or occipital regions
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Usual Location of Lesion, and Associated Neurologic
Findings in Children with Brain Abscess
•Headache in older children and adolescents,
irritability in infants and younger children
•Behavioral changes if abscess in the frontal or
temporal lobes
•CN palsy, gait disturbance, headache or altered
mental status if abscess in the cerebellum
•Seizures occur in up to 25% of patients
Textbook of Pediatric Infectious Diseases 2019
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Brain Abscess-Neuroimaging
•MRI scanning is superior to CT for soft-tissue resolution and imaging detail. It is more sensitive for detecting cerebritis and edema formation than CT.
•MRI scanning is also more accurate than CT for diagnosis of cerebellar and brainstem purulent collections.
•Serial CT or MRI scanning, performed weekly or biweekly, provides evaluation on the response to therapy and on the need for a repeat surgical procedure.
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Primary Source Usual Etiologic MicroorganismsUpper Respiratory Infection
Sinusitis/dental infection Viridans and anaerobic streptococci, Haemophilus spp., Fusobacterium spp., Bacteroides spp. (non-fragilis)
Chronic otitis/mastoiditis Aerobic and anaerobic streptococci, gram-negative enteric bacilli, Bacteroides spp. (including B. fragilis), Pseudomonas aeruginosa
Head trauma Staphylococcus aureus, aerobic streptococci, gram-negative enteric bacilli
Postoperative Staphylococcus epidermidis, S. aureus, gram-negative rods, P. aeruginosa
Endocarditis S. aureus, viridans streptococci
Pulmonary infection Aerobic streptococci, Actinomyces, Fusobacterium
Congenital heart disease Viridans streptococci, Haemophilus spp., Haemophilus aphrophilus
Bacterial meningitis S. pneumoniae, Haemophilus influenzae, Salmonella spp., Citrobacter (neonates)
Cryptogenic source and immunosuppression Any type of microorganisms
Nocardia, fungi, Mycobacterium tuberculosis
Primary Source, Usual Etiologic Pathogens in Children with Brain Abscess
Textbook of Pediatric Infectious Diseases 2019
Dou Z-Z et al. Pediatr Infect Dis J 2021;40:109-115
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Brain Abscess-Empiric Antibiotics
•Sinusitis/Otitis media/Mastoiditis/Dental infection
Vancomycin + Ceftriaxone/Cefotaxime +
Metronidazole
•Head trauma
Vancomycin/nafcillin + Ceftriaxone/cefotaxime
•Post-operative
Vancomycin + Ceftazidime or cefepime
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Brain Abscess-Operative Treatment•Prompt surgical intervention is critical in most
cases
•By removing purulent material, reduction of
intracranial pressure and relief of the mass effect
caused by the abscess are rapidly achieved.
•By providing a specimen for bacteriologic analysis
and antibiotic susceptibility testing, specific
antimicrobial therapy can be promptly
administered.
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Brain Abscess
Non-Operative Treatment•May be appropriate for clinically stable patients who are poor candidates for surgery or have inaccessible lesions.
•Small collections (<2 cm) located in well-vascularized cortical areas are more likely to respond to antibiotics alone.
•Cases treated in this manner may require a more prolonged duration of treatment and close clinical and radiographic follow-up.
•Repeat CT and MRI (some experts discourage MRI for follow up) imaging will eventually show a decrease in size of the abscess, disappearing of surrounding edema, and lessening of the enhancement ring. These improvements are usually observed within 1 to 4 weeks but complete radiographic resolution often extends to several months of follow-up.
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Brain Abscess
•The appropriate duration of antimicrobial therapy
for brain abscess is unclear.
•A 4- to 8-week course of parenteral antibiotics has
been recommended traditionally, provided that the
etiologic organisms are susceptible and adequate
surgical drainage is achieved. Also resolution or
substantial improvement of neuroimaging findings
help determine duration.
Textbook of Pediatric Infectious Diseases 2019
UpToDate
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Cranial Epidural Abscess
•Localized collection of pus between the dura mater and the overlying skull or vertebral column
•Pathogenesis of cranial epidural abscess is usually spread from a focus in the paranasal sinuses, middle ear, or mastoid cells via phlebitic bridging veins, hematogenous spread, or direct extension from adjacent structures.
•Etiology-streptococci (Streptococcus anginosusgroup) including S. pneumoniae and GAS, anaerobes and microaerophilic streptococci, S. aureus, polymicrobial; gram-negative bacilli (chronic sinusitis)
Otto et al. JPIDS 2021;10:309-316
McNeil et al. PIDJ 2020;39:108-113
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Cranial Epidural Abscess Treatment
•The management of cranial epidural abscess requires a combined medical and surgical approach. Empirical antimicrobial therapy for cranial epidural abscess usually vancomycin, ceftriaxone/cefotaxime plus metronidazole if secondary to sinusitis or mastoiditis pending cultures.
•Surgical drainage typically required; craniotomy or craniectomy is generally preferred over burr hole placement or aspiration of purulent material through the scalp. Endoscopic sinus surgery (EES) generally also performed if complication of sinusitis.
• If abscess associated with minimal mass effect, EES plus antibiotics may suffice.
•Therapy is usually continued for 3 to 6 weeks after surgical drainage, or longer (6 to 8 weeks) if osteomyelitis is present. Transition to oral levofloxacin successful in completing therapy for purulent S. anginosisintracranial infections in a preliminary pediatric report. (Dodson et al. 2020 IDWeek)
Bonfield et al. J Infect 2015;71:S42-S46
Pediatrics
Thank You
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Supplemental Material
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2004 IDSA Bacterial Meningitis Guidelines
Suspected Bacterial Meningitis in a Child
•If patient is immunocompromised, has a history of
selected CNS diseases (ie mass lesion,
hydrocephalus), has papilledema, or selected focal
neurologic deficits (facial palsy)
Delay LP
Obtain blood cultures
Administer empiric antibiotics
Head CT scan, if negative proceed with LP
IDSA Bacterial Meningitis Practice Guidelines
Clin Infect Dis 2004;39:1267-84
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Bacterial meningitis
Differential Diagnosis
•Tuberculous meningitis
•Fungal meningitis
•Aseptic meningitis
•Brain abscess
•Intracranial or spinal epidural abscesses
•Bacterial endocarditis with embolism
•Subdural empyema with
or without
thrombophlebitis
•Ruptured dermoid cysts
•Ruptured spinal
ependymomas
• Brain tumors
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https://www.cdc.gov/pneumococcal/surveillance.html
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https://www.cdc.gov/meningococcal/images/meningococcal-disease-incidence.jpg
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https://www.cdc.gov/meningococcal/images/meningococcal-incidence-serogroup.jpg?noicon
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https://www.cdc.gov/meningococcal/images/meningococcal-
graph.jpg?noicon
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Neisseria meningitidis
Antimicrobial Susceptibility•Susceptible
penicillin MIC < 0.06 μg/ml
ceftriaxone MIC < 0.12 μg/ml
• Intermediate
penicillin MIC 0.12-0.25 μg/ml
ceftriaxone MIC not defined
• Resistant
penicillin MIC > 0.5 μg/ml
ceftriaxone MIC not defined
CLSI
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Meningococcal Disease
Clinical Manifestations•Fever
•Muscle Aches
•Headache (stiff neck with meningitis)
•Nausea and vomiting
•Hypotension
•Rash
-macular papular rash initially in 25%‐petechiae-50-60%; primarily on trunk and extremities) -purpura-15-25%
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United States Pediatric
Meningococcal Surveillance StudySelected Clinical and Laboratory Features in Children with
Meningococcal Infections by Age at Admission to Hospital
Features < 5 yo
N=105
6-10 yo
N=21
>10 yo
N=33
Petechiae 57 13 17
Purpura 36 11 13
Hypotension 13 0 3
Platelet Ct <
100,000/mm3
5 1 3
ANC < 1500/mm3 8
P=0.007
0 0
Kaplan et al Pediatrics
2006;118:e979-984.
Kaplan et al Pediatrics 2006;118:e979-984
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United States Pediatric Meningococcal
Surveillance Study: Outcome
• The mortality rate for all patients with invasive infections was 8% (13/159).
• The mortality rate was greater for children > 11 years old [7/33 (21.2%)] than for children < 11 years old [6/126 (4.8%)] (RR-3.0, 95% CI 1.6-5.6; P<0.001).
• Mortality in the three age groups < 5 years, 6-10 years and > 10 years old was 4/105 (3.8%), 2/21 (9.5%) and 7/33 (21.2%), respectively (P= 0.01).
Kaplan et al Pediatrics 2006;118:e979-984.
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United States Pediatric Meningococcal
Surveillance Study: Outcome
• Of the 13 patients who died, 9 had meningitis
including one associated with fulminant bacteremia
and 4 had fulminant bacteremia alone. There was no
significant difference in mortality rates for children
with meningitis (9/112) versus those with bacteremia
alone (4/43).
Kaplan et al Pediatrics 2006;118:e979-984.
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United States Pediatric Meningococcal
Surveillance Study: Outcome
•Hearing loss occurred in 14 children (all < 10 years old; 8 < 2 years old) or 12.5% of those with meningitis.
•Skin necrosis (n = 13; 9 < 4 years old) with some requirements for grafting was the second most common sequela.
•2 children suffered amputations.
•3 children had vasculitis and one had pericarditis
Kaplan et al Pediatrics 2006;118:e979-984.
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Dexamethasone for Bacterial Meningitis
•For infants and children 6 weeks and older, adjunctive
therapy with dexamethasone may be considered after
weighing the potential benefits and risks. Some experts
recommend use of corticosteroids in pneumococcal
meningitis, but this issue is controversial and data are
not sufficient to make a routine recommendation for
children. The Infectious Diseases Society of America
recommends use of dexamethasone in adults with
suspected or proven pneumococcal meningitis. If used,
dexamethasone should be administered before or
concurrently with the first dose of antimicrobial agents.
2021 Red Book
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Dexamethasone for Bacterial Meningitis
• Dexamethasone is beneficial for treatment of infants
and children with Hib meningitis to diminish the risk of
hearing loss, if administered before or concurrently
with the first dose of antimicrobial agent(s)
2021 Red Book
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Eosinophilic Meningitis•Angiostrongylus
•Gnathostoma
•Baylisacscaris
•Coccidiodes
•Schistosoma spp.
•M. tuberculosis
•T. pallidum
•Toxocariasis
•Toxoplasmosis
•Neurocysticercosis
•Chemical
•Drug hypersensitivity
•Neoplastic
Textbook of Pediatric Infectious Diseases 2019
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Chronic Meningitis-Selected Causes
•M. tuberculosis
•Spirochetal: B. burgdorferi,
T. pallidum
•Bacterial: Brucella spp, Whipple’s
Disease, F. tularensis
•Viral: EBV, CMV, HIV, Enterovirus,
Herpes, Varicella
•Fungal: Cryptococcus,
Histoplasma, Coccidioides,
Blastomyces
•Parasitic: T. solium,
Angiostrongylus, Toxoplasma,
Acanthamoeba
•Non-infectious: neoplastic,
sarcoidosis, SLE, Vasculitis
•Drugs: TMP-SMX, IVIG, NSAIDS,
intrathecal chemotherapy
UpToDate
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Symptoms Percent Signs Percent
Headache 60-70% Focal Neurologic Deficits 35-50%
Fever 50-80% Papilledema 30-40%
Vomiting 35-55% Meningeal Signs 25-35%
Seizures 30-45% Hemiparesis 20-30%
Mental changes 30-40% Cranial nerve palsy 10-20%
Coma 15-20% Ataxia 5-15%
Frequency of Presenting Signs and Symptoms in
Children with Brain Abscess
Textbook of Pediatric Infectious Diseases 2019
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Primary Source Location of Abscess Associated Neurologic Findings
Sinusitis Frontal lobe Headache, behavioral changes, motor speech disorders, depressed consciousness, forced grasping and sucking, hemiparesis
Chronic otitis/mastoiditis Temporal lobe Dyspraxia and aphasia (dominant hemisphere), ipsilateral third cranial nerve palsy, ipsilateral headache, upper homonymous hemianopsia, motor dysfunction of face and arm
Cerebellum Dizziness, vomiting, ipsilateral ataxia and tremor, sixth cranial nerve palsy, nystagmus (toward lesion)
Dental infection Frontal lobe
Head trauma Related to injured site Variable by region involved
Postoperative At operative site Variable by region involved
Metastatic spread Multiple lesions Variable by region involved
If parietal lobe involved Visual field defects in inferior quadrant, homonymous hemianopsia, dysphasia (dominant hemisphere), dyspraxia and contralateral spatial neglect
Primary Source, Usual Location of Lesion, and Associated
Neurologic Findings in Children with Brain Abscess
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Brain Abscess
•Steroid treatment of brain abscess is controversial. These agents are usually indicated to control life-threatening intracranial hypertension that is associated with risk of herniation or when significant symptoms and signs are presumed to be the result of cerebral edema.
•Severe brain edema may necessitate the additional administration of intravenous mannitol.
•Anticonvulsants are recommended in children who have developed seizures to potentially prevent further episodes
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Brain Abscess
•Mortality associated with brain abscess in infantsand children is < 20%, reflecting earlier, moreaccurate diagnosis, appropriate antimicrobialtherapy, and novel surgical modalities.
• Focal residual deficits may persist, depending onthe location of the abscess and the underlyingpathologic process of affected patients.
•The mortality is higher among pediatric patientswith severe mental status changes onpresentation, multiple collections, and rapidlyprogressing neurological impairment
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Cranial Epidural Abscess
Clinical Manifestations
•Most common in adolescent males
•Facial or eye swelling (associated with sinusitis); Pott’s puffy tumor or frontal bone osteomyelitis
•Headache, nausea, vomiting
•Altered mental status
•Papilledema, focal neurologic signs
•New onset seizures
Otto et al. JPIDS 2021;10:309-316
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Cranial or Spinal Epidural Abscess
Diagnosis
•Head CT usually obtained initially
•MRI with gadolinium enhancement is
the diagnostic procedure of choice
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Subdural Empyema
•A collection of purulent material in the space
between the dura and arachnoid membranes.
•Most common predisposing conditions to cranial
subdural empyema are ENT infections, especially
of the paranasal sinuses, which are affected in
50% to 80% of cases.
•Complication of bacterial meningitis
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Subdural Empyema-Pathogenesis
•Spread of the infection from sinuses to the subdural space via valveless emissary veins in association with thrombophlebitis, or via extension of an osteomyelitis of the skull with accompanying epidural abscess.
•Once infection reaches the subdural space, it can spread without interruption over the convexities of the brain.
•The mastoid and middle ear are the source in 10% to 20% of patients.
•Other predisposing conditions in patients with subdural empyema include skull trauma, neurosurgical procedures, and infection of a preexisting subdural hematoma.
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Subdural Empyema-Etiology
•Aerobic streptococci most common
•Staphylococci (10% to 15% of cases)
•Aerobic gram-negative bacilli (3% to 10% of cases),
anaerobic streptococci and other anaerobes
•Polymicrobial infections are common
•Postoperative and post-traumatic infections are more
commonly caused by staphylococci and aerobic gram-
negative bacilli.
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Subdural Empyema
Clinical Manifestations
•High Fever
•Increasingly severe headache; signs of increased intracranial pressure or meningeal irritation
•Progressive neurologic deficits depending on the site of infection
•Altered mental status (i.e., drowsiness and disorientation), which can progress to obtundationor coma.
•Focal or generalized seizures
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Subdural Empyema Diagnosis
• MRI is imaging modality of choice
• CT scan maybe preferred for patients who are critically ill and require immediate neurosurgical intervention
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Subdural Empyema Treatment
•Treatment optimally requires a combined medical and surgical approach
•If S. aureus is a suspected pathogen, vancomycin should be used empirically but changed to nafcillin if the organism is found to be methicillin susceptible and the patient is not allergic to penicillin.
•Metronidazole is recommended if anaerobes are suspected.
•For infection likely caused by aerobic gram-negative bacilli, empirical therapy with cefepime, ceftazidime or meropenem is appropriate, pending microorganism identification and in vitro susceptibility testing.
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Subdural Empyema Treatment Duration
•Depending on the clinical response, parenteral antimicrobial therapy should be continued for 3 to 4 weeks after drainage; longer periods of intravenous, and perhaps oral, therapy may be required if the patient has accompanying osteomyelitis.
•Antimicrobial therapy alone may be appropriate in patients with minimal or no impairment of consciousness, no major neurologic deficit, limited extension of the empyema without midline shift, and early improvement with antimicrobial therapy alone. These selected patients need careful clinical and radiographic monitoring, and probably longer courses of antimicrobial therapy.
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Subdural Empyema Outcome
•Mortality rates among patients with cranial subdural
empyema range from 7 to 12%
•Permanent neurologic deficits can occur
•Cranial subdural empyemas may also be complicated
by septic venous thrombosis, localized cerebritis, and
cerebral abscesses
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Spinal Epidural Abscess-Etiology
•Spinal epidural abscess is less common than cranial epidural abscess in children
•Spinal epidural abscess usually occurs secondary to hematogenous dissemination from foci elsewhere in the body to the epidural space, or by extension from vertebral osteomyelitis or congenital dermoid cyst.
•In otherwise normal children without prior surgery, S. aureus is most common followed by GAS.
• Other isolates include aerobic and anaerobic streptococci and aerobic gram-negative bacilli.
Houston et al. World Neurosurg 2019;126:453-460
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Spinal Epidural Abscess
Clinical Manifestations•Fever
•Back pain
•The specific neurologic signs depend on the level of
spinal cord involvement; the most common locations
are the thoracic and lumbar epidural spaces.
•Neurologic manifestations are usually reversible
before complete paralysis occurs, thus emergency
imaging studies and intervention are necessary if the
diagnosis is being considered
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Spinal Epidural Abscess
Treatment•Prompt surgical decompression and drainage of the abscess based on neurologic signs present and extent of the abscess; non-surgical management possible in selected cases determined by neurosurgery and interventional radiology with close monitoring
•Empirical antimicrobial therapy includes vancomycin and nafcillin plus ceftriaxone or ceftazidime/cefepime if there was preceding neurosurgery.
•Antimicrobial therapy can be modified based on in vitro susceptibility testing.
•Duration of antibiotics usually 4 to 6 weeks
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Spinal Epidural Abscess
Treatment•Patients with spinal epidural abscess and neurologic dysfunction require laminectomy with decompression and drainage performed as a surgical emergency to minimize the likelihood of permanent neurologic sequelae.
• CT-guided aspiration may be used in place of laminectomy in selected patients.
• In collaboration with neurosurgical colleagues, antimicrobial therapy alone can be considered in patients who have localized pain or radicular symptoms without long-tract findings. However, these patients require frequent neurologic examinations and serial MRI studies to demonstrate resolution of the abscess. Emergency surgical decompression should be performed for any patient with increasing neurologic deficit and/or persistent severe pain.
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Ventriculo-Peritoneal Shunt
Infections
•Majority occur within one month of placement
•Incidence is higher in the first 6 months of life
compared to older children
•Prematurity and IVH important patient risk factors
•VP shunt infections are most commonly associated
with inoculation of the organism during surgery or
bacteria colonization during early wound healing
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Ventriculo-Peritoneal Shunt
Infections-Pathogens
•Coagulase negative Staphylococci
(normal skin flora and biofilm production)
•Staphylococcus aureus
•Streptococci and Enterococcus spp.
•Corynebacterium and Cutibacterium
•Gram-negative enterics (bowel perforation)
•Candida spp and Mycobacteria-less common
•Streptococcus pneumoniae-hematogenous
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Ventriculo-Peritoneal Shunt
Infections-Management
•Most successful approach includes removing the infected
VP shunt and placing an EVD
•Empiric antibiotics include vancomycin +
ceftazidime/cefepime depending on gram stain of
ventricular fluid and severity of illness
•Duration of antibiotics prior to replacement of VP shunt in
patient with abnormal ventricular fluid parameters and after
repeat ventricular fluid cultures are negative
CONS-7d
S. aureus and Gram negative enterics-10 d
Textbook of Pediatric Infectious Diseases 2019
Tunkel et al. Clin Infect Dis 2017;64:e34-e65