Bacterial Cerebro-Spinal Meningitis

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Bacterial epidemics for Cerebro-Spinal Meningitis are commonly caused by Neisseria meningitidis.  Other  common  bacteria  are  Haemophilus  influenza,  Staphylococcus  aures  and  Streptococcus  pneumoniae. Human-to-human disease transmission is via large respiratory droplets from the nose  and throats of infected people. Incubation period is 2 to 10 days. Attack rates are highest among  children aged less than 15 years. Case fatality rates are usually 8-15% among treated patients, and  >70%  among  untreated  cases.  Many  survivors  suffer  long-term  sequelae  including  mental  retardation, hearing loss and loss of limb use. Further information on Meningitis for Nervous system related management.  

Case Definition 

Suspected meningitis case: Any person with a sudden onset of fever (>38.5°C rectal or 38.0°C  axillary), and neck stiffness or other meningeal signs and in case of infants, a bulging fontanelle. 

Probable  meningitis  case: Any suspected case with macroscopic aspects of cerebrospinal fluid  (CSF) (turbid, cloudy or purulent); or with a CSF leukocyte count >10 cells/mm3 or with bacteria  identified by Gram stain in CSF; or positive antigen detection (for example, by latex agglutination  testing) in CSF 

In infants: CSF leucocyte count >100 cells/mm3; or CSF leucocyte count 10–100  cells/mm3 and either an elevated protein (>100 mg/dl) or decreased glucose (<40  mg/dl) level. 

Confirmed  meningitis  case:  Any  suspected  or  probable  case  that  is  laboratory  confirmed  by  culturing or identifying (i.e. polymerase chain reaction) a bacterial pathogen (Neisseria meningitidis,  Streptococcus pneumoniae, Haemophilus influenzae type b) in the CSF or blood 

Clinical Diagnostic Criteria 

  • Sudden fever 
  • Neck stiffness
  • Intense headache, nausea and vomiting
  • Altered consciousness and convulsions, Bulged anterior fontanelle (in infants)  

Laboratory Investigation  

  • Lumbar puncture for Cerebrospinal Fluid Analysis with a median opening pressure   
  • CSF leukocyte count in episodes with CSF leak–associated meningitis   
  • CSF Culture and Sensitivity   
  • Elevated white blood cell count (WBC) in CSF of over 1000 cells/mm3  
  • Glucose concentration <1.9 mmol/L 
  • Ratio of CSF glucose concentration to blood glucose concentration <0.23  
  • Protein concentration 
  • WBC count >2000 cells/mL; CSF neutrophil count >1180 cells/mL 

Table 4.1: Cerebrospinal Fluid Analysis Findings 

CSF Characteristic Normal Range Suggestive of Bacterial Meningitis

Suggestive of Viral Meningitis

Colour

Clear

Cloudy

Cloudy

RBC Count

None

None

None

Gram stain

Negative

Usually Positive

Usually Negative 

(60%-90%)

Pressure* 

20–30 cmH2O (16–24 mmHg or 2.1–3.2 kPa) with the patient sitting up 

 Above > 42 cm H2O  Normal
 Protein 15 to 20.2 milligrams per deciliter (mg/dL) or 0.15 to 0.6 milligrams per milliliter (mg/mL)

Above 20.2
milligrams per deciliter (mg/dL) , >2.20 g/L 

Above 20.2 milligrams per deciliter (mg/dL), >2.20 g/L 
 Glucose

50-75 mg/dL (around 1.9 mmol/L) 

50 to 75 mg/dL (or greater than 2/3 of the blood sugar level). 

Below normal (<1.9 mmol/L) 

Usually normal or below normal
Lymphocytic Pleocytosis  None Positive with neutrophilic pleocytosis

Positive with lymphocytic pleocytosis 

*Measured by recording the height of CSF in the manometer tube with the patient's leg  gently and return the neck to a neutral position with the head supported with a pillow. Use intravenous tubing sets and a ruler to measure cm of pressure if manometer is not  available 

Prevention  

  • Vaccines targeted against N. meningitidis serogroups A or C, or a tetravalent A, C, Y, and W135 vaccine are useful for immunocompromised children.  
  • Hib conjugate vaccine is useful for immunocompromised children  

Pharmacological Treatment 

A: benzathine penicillin(IV/IM) 300,000U/kg/day with a maximum dose of 24MU/day for 10-14 days, give 4 million units 4 hourly IV in adults and pediatric patients older than 1 month for 10-14 days

AND 

A:  chloramphenicol  (IV)  50  to  100mg/kg/day with  a  maximum  dose  of  4  g/day  give  in divided doses at 8 hourly intervals for 10-14 days

  • Serum concentrations requires monitoring due to chloramphenicol toxicity 
  • Recommended therapeutic levels include a trough of 5 to 10 mcg/mL and a peak of 10 to 20 mcg/mL 

If no improvement in 3 days give 

C: ceftriaxone (IV) 2g (50 mg/kg in pediatric patients older than 1 month) 12 hourly for 10-14 days OR cefotaxime (IV) 2 g (50 mg/kg in pediatric patients older than 1 month) 6 hourly  for 10-14 days

C:  ceftriaxone (IV or IM) 2g for Adults daily for 10-14 days is preferred for patients with central nervous system involvement 

AND  

B: dexamethasone (IV/IM) 0.15mg/kg with a maximum dose of 10mg 8hourly for 3 days 

Public Health Control Measures 

  • Mass vaccination within 4 weeks of crossing the epidemic threshold*** 
  • Mobilize  community  to  permit  early  case  detection,  treatment,  and  improve  vaccine coverage during mass vaccination campaigns for outbreak control. 
  • Conduct community education on the disease symptoms and signs, early reporting/seeking of medical care, disease transmission and prevention. 
  • Maintain  regular  collection  of  5-10  CSF  specimens  per  week  throughout  the  epidemic season in all affected districts to detect possible serogroup shift. Distribute treatment to health centres
  • Treat all cases with appropriate antibiotics as recommended by National protocol.

***If a neighbouring area to a population targeted for vaccination is considered to be at risk (cases early in the dry season, no recent relevant vaccination campaign, high population density), it should be included in a vaccination programme.