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Meningitis in Children

Meningitis in the newborn. By and large the most common organism is group B strep and most of the disease reflects maternal colonization with group B Streptococci meningitis. The risk of a child having sepsis in the newborn period increases with reports of a number of other factors, including maternal fever, prolonged rupture of membranes, premature rupture of membranes, being a low birth weight infant where they may not have received antibody from the mother which would be protective against these encapsulated bacteria. Epidemiological data continue to link lower socioeconomic status with a higher risk of sepsis, and a point not to forget.

The differential diagnosis of sepsis in the newborn period is extremely broad and always, I think, when we evaluate a child for neonatal sepsis, and child who presents with fever, shock or just almost anything that looks like significant disease, we always ask ourselves, "Could this be sepsis?" Sepsis just presents in many ways in children. But of course there are many dozens of alternative diagnoses. In the immediate newborn period, RDS, transient tachypnea.

On this list I would particularly like to make mention of is the fact that seizures, while ominous - seizures in the newborn period - tend to be something else other than sepsis, in early onset sepsis. When you see seizures in the first week of life, they generally are something else.

Here are the list of organisms that we have come to know and hate. Group B Streptococci, E. coli, a variety of gram negatives, always, always in large studies of neonatal sepsis you see Listeria monocytogenes appearing. It is not seen in all parts of the country. I know many pediatricians who are in ID who have never seen a case of Listeria. It isn't that common but it is a continuing problem in part because of contamination of food.

Another important point about the evaluation of a newborns is that you cannot accurately... you are going to miss cases of meningitis if you rely upon a positive blood culture to prompt you to look for meningitis. Whizwell, the same Whizwell that taught us about the length between urinary tract infections in the absence of circumcision - I've always enjoyed the irony of his name being Whizwell - he was able to do the study with a circumcision, whether or not you have foreskin and whether or not you have a urinary tract infection.

What antibiotics do we use? Nothing has changed lately. We continue to use ampicillin and aminoglycosides. But if no evidence of meningitis is found, some recommend using ampicillin and cefotaxime if meningitis is present, but in truth - because of the better CSF penetration of the third generation cephalosporins - but in fact there are no data to say that a third is better... using a third generation cephalosporin is better for meningitis. So in general, ampicillin and gentamycin, or ampicillin and cefotaxime are just fine for your average garden variety child being evaluated for neonatal sepsis.

Now transitioning a little bit to talk about sepsis in the older child. This is just to get focused on the reality that we as pediatricians spend most of our time taking care of younger children and immunological ontogeny is not completed when you are three months of age. In general, most cellular and humoral immune responses that you expect in an adult are not manifested until you are several years of age. This means that it's in younger children, like this two-year-old, where you tend to see a lot of invasive bacterial disease. You can see the petechial and purpuric lesions on the lower extremities, and this, as you would expect, is Neisseria meningitides disease. Nowadays with the 95% reduction of Hemophilus influenzae disease due to successful immunization in this country, we are just not seeing anything other than strep, pneumo.

The next two slides as short vignettes. LP; when should you not do an LP? Obviously, if there is local infection in the lumbar area. I have yet to see that as a contraindication. Severe respiratory distress. Obviously judgment and common sense have to prevail. Focal neurological abnormalities.