Neonatal meningitis - symptoms, signs, treatment
Neonatal meningitis - symptoms, signs, treatment
Neonatal meningitis is the inflammation of the meninges due to bacterial invasion during the first 90 days of life. Clinical manifestations are the same as in sepsis, irritation of the central nervous system - lethargy, convulsions, vomiting, anxiety, stiff neck, bulging and tension of a large fontanel - and focal symptoms on the part of the cranial nerves. The diagnosis is made on the basis of the results of spinal puncture. Treatment is carried out with antibiotics.
The incidence of neonatal meningitis is 2 in 10,000 full-term newborns and 2 in 1,000 newborns with low birth weight, more often in boys. Meningitis develops in approximately 25% of cases of neonatal sepsis, occasionally as an isolated lesion.
Streptococcus group B, Escherichia coli and Lysteria monocytogenes cause 75% of neonatal meningitis.
Enterococci, non-enterococcal group D streptococci, alpha-hemolytic streptococci and other gram-negative intestinal microorganisms are also important pathogens. There are also reports of the causative significance of Haemophilus influenzae type b, Neisseria meningitidis Streptococcus pneumoniae.
Neonatal meningitis most often develops with bacteremia due to neonatal sepsis; the more massive the bacteremia, the higher the risk of developing meningitis. Meningitis can also develop with damage to the scalp, especially if, due to developmental defects, there is a communication between the skin surface and the subarachnoid space, which predisposes to the development of thrombophlebitis of diploid veins. Rarely, there is direct infection of the central nervous system from an adjacent focus.
Symptoms and signs of neonatal meningitis
Often the disease is manifested only by symptoms characteristic of neonatal sepsis. Symptoms of CNS damage [lethargy, convulsions, vomiting, anxiety] more accurately indicate meningitis. A thumping or tight spring is observed in about 25% and stiff neck in 15% of patients. Focal neurological symptoms of the cranial nerves can also be noted.
Meningitis caused by HBV can develop in the first week of life, accompanying early neonatal sepsis, and often manifests as a lung disease. At the same time, usually meningitis caused by HBV develops after this period as an isolated lesion, characterized by the absence of previous obstetric or perinatal complications and the presence of more typical manifestations of meningitis.
Ventriculitis often accompanies neonatal meningitis, especially caused by gram-negative intestinal bacteria. Meningitis caused by microorganisms that lead to the development of concomitant vasculitis, in particular Citrobacter diversus and Enterobacter sakazakii, often forms cysts and abscesses. Pseudomonas aeruginosa E. coliKI Serratia sp can also lead to the formation of brain abscesses. An early sign of brain abscess formation is an increase in intracranial pressure, which is often manifested by vomiting, protrusion of fontanelle, and sometimes an increase in head size. The deterioration of the condition in a child with meningitis, previously stable, indicates a progressive increase in ICP due to an abscess or hydrocephalus, or an abscess rushing into the ventricular cavity.
The final diagnosis is made in case of lumbar puncture and examination of the cerebrospinal fluid, which should be carried out in any newborn with suspected sepsis or meningitis. At the same time, it is difficult for a newborn to perform an LP, and there is also a risk of hypoxia. The difficult condition of the child increases the risk during the drug. If the holding of the LP is delayed, the child should be treated as if he had meningitis. Even with the improvement of the child’s condition, the presence of inflammatory cells and biochemical changes in the cerebrospinal fluid a few days after the onset of the disease indicates meningitis. For LP, a needle with a trocar should be used to avoid the introduction of epithelial cells and the subsequent development of the epithelioma. Spinal fluid should be sown, even if it contains blood or there are no cells in it. About 15% of newborns with negative blood culture results have positive cerebrospinal fluid cultures. LP should be repeated 24–48 hours if the clinical response is uncertain, and after 72 hours if meningitis is caused by gram-negative flora.Some experts believe that holding an LP after 24 hours in newborns with GWH meningitis has prognostic significance. If the child’s condition is good, the drug should not be repeated at the end of therapy.
Normal indicators of cerebrospinal fluid are contradictory and depend on age. In general, for babies with low birth weight before 4 weeks of age, 40 leukocytes / µl, a protein level of 220 mg / dl and a glucose level of 50 mg / dl are considered the upper limit of normal. For full-term newborns, the upper limit of normal is 20 leukocytes / µL, the protein level is 170 mg / dL and the glucose level is 50 mg / dL. The concentration of glucose in the cerebrospinal fluid largely depends on the concentration of glucose in the serum and, as a rule, it can normally be only 20-30 mg / dl, therefore, the glucose level in the blood serum should be determined before the drug so that the glucose ratio can be determined in the cerebrospinal fluid and in the serum.
Ventriculitis is suspected in a newborn who does not respond to antimicrobial therapy. The diagnosis is made if during the puncture of the ventricle the leukocytosis is greater than with the LP, the Gram stain or the cerebrospinal fluid cultures are positive, the pressure in the ventricles is increased and the ventricles are dilated.If you suspect ventriculitis or abscess of the brain, MRI or CT with contrast can help establish the diagnosis.
Without treatment, mortality from neonatal meningitis reaches 100%. In treatment, the prognosis is determined by weight at birth, the causative agent and the severity of the course. Mortality from neonatal meningitis caused by gram-negative microorganisms is from 20 to 30%, with gram-positive flora - 10-20%. In meningitis caused by microorganisms, leading to the development of concomitant vasculitis and brain abscesses, mortality can reach 75%. Neurological complications develop in 20-50% of infants who have had meningitis, with a more unfavorable prognosis for Gram-negative intestinal pathogens.
The prognosis also depends in part on the number of organisms in the cerebrospinal fluid at the time of diagnosis. The duration of the period during which positive cultures of cerebrospinal fluid are observed directly correlates with the frequency of complications. In general, cereal cultures in newborns with hypertension usually become sterile during the first 24 hours of antibiotic therapy.For meningitis caused by gram-negative bacteria, cerebrospinal fluid cultures remain positive for an average of 3 and a half days.
With GWH meningitis, mortality is significantly lower than with early GHB-sep-system.
Treatment of neonatal meningitis
Empirical treatments begin with ampicillin and cefotaxime. Hospitalized infants who have previously received antibiotics may have resistant flora; fungal diseases can also be considered as a cause in newborns with sepsis after prolonged hospitalization. Until the diagnosis of meningitis is confirmed, all sick newborns with nosocomial infection should receive vancomycin with an aminoglycoside or third-generation cephalosporin.
Antibacterial therapy is adjusted when the results of the drug are obtained and the results of seeding of the cerebrospinal fluid and sensitivity to antibiotics are known.
Penicillin G 100–150 thousand U / kg intravenously after 8 hours or ampicillin 100 mg / kg intravenously after 8 hours, plus gentamicin 2.5 mg / kg intravenously after 8, is recommended for the initial treatment of SGB meningitis of infants less than 1 week of life. hoursIf clinical improvement occurs, or sterilization of the CSF is documented, gentamicin can be canceled.
For meningitis caused by enterococci or L monocytogenes, ampicillin is usually treated with gene-tamycin.
With bacterial meningitis caused by gram-negative flora, treatment is difficult. The traditional scheme, including ampicillin with aminoglycosides, leads to a mortality of 20-30%, with a high level of complications in the survivors. The third generation of cephalosporins should be primarily thought of in newborns with proven gram-negative meningitis or with convincing evidence for sepsis. If there is a suspicion of antibiotic resistance, both aminoglycosides and the third generation of cephalosporins can be used until sensitivity results are obtained. However, these drugs are routinely not used routinely, since in some gram-negative microorganisms, third-generation cepha-losporins induce beta-lactamase synthesis, which leads to the rapid development of resistance.
Parenteral therapy for meningitis caused by gram-positive flora, is held at least 14 days, and complicated meningitis caused by gram-positive or gram-negative flora, at least 21 days.
Since meningitis can be a syndrome of neonatal sepsis, additional measures used in the treatment of neonatal sepsis should also be used in the treatment of neonatal meningitis. Patients should be screened regularly for neurological complications during the first two years of life.
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