History

Fact Explanation
Introduction Meninges are the lining that covers the brain and spinal cord. Meningitis is inflammation of the meninges around the brain and spinal cord. It is usually caused by an infectious pathogens such as bacteria, virus, fungi and parasites. Depending on he duration of the symptoms, it can be subdivided into acute and chronic form. Bacterial meningitis is a medical emergency requiring immediate treatment. Haemophilus influenzae is one of the major causative organisms for the meningitis. H. influenzae is a nonmotile, facultatively anaerobic, gram-negative coccobacillus. [5] Haemophilus influenzae has six serotypes from a- f and Haemophilus influenzae type b is the main type involved in the pathogenesis of many of the invasive disease conditions. [5] Acute epiglottitis, is the second most common Hib disease following meningitis. Septic arthritis and pneumonia are some of the other clinical manifestations of the Haemophilus influenzae. [4] Meningitis is caused by mainly Haemophilus influenzae type b and less commonly by non type b organisms. [5] Nontypeable strains causes upper respiratory tract infections in children and adults. [5]
Headache Encapsulated strains (including type b and other serotypes) invade the bloodstream and hematogenous dissemination occurs. Capsular polysaccharide is one of the important virulence factor involved in the pathogenesis. [5] Once the organism entered through the blood brain barrier, immune system of the body gets activated to release various cytokines and chemokines. Bacteria in cerebrospinal fluid (CSF) causes production of nitrite, which is a potent vasodilator causing generalized vasodilatation in meninges. [9] This will lead severe headache experienced by the patient. severe headache. [9]
Fever [1] Inflammation of the meninges and endothelium releases pyrogens causing fever. [1,6]
Vomiting Vomiting is a common finding in the meningitis. [4]
Sensitivity to light (photophobia) Inability to tolerate light is due to the meningism that indicates inflammatory activation of the trigeminal sensory nerve fibers in the meninges. [1]
Pain during retraction of the neck [1] Due to the meningeal irritation. [1]
Seizures [1] Altered cerebral perfusion pressure can cause reduction of the cerebral blood flow and ischaemia. [1]
Decreased alertness and drowsiness [1] There can be increased intracranial pressure which may be due to the increased blood brain barrier permeability, swelling of the cellular elements of the brain, interstitial edema results from obstruction of flow in normal CSF pathways etc. Neuronal cell death and cerebral edema may also contribute to the drowsiness. [1]
Excessive crying, refusing the feeds Infants and young children present with nonspecific features. [2]
Hearing loss Inflammation can extends to the cranial nerves, when the 8th nerve is involved that causes sensorineural type hearing loss. [7]
Visual problems Involvement of the optic and other cranial nerves related to the vision can be the cause. [7]
Difficulty in breathing Acute epiglottitis, is the second most common Haemophilus influenzae type b disease following meningitis. [4]
Rhinorrhoea and nasal congestion Nontypeable H. influenzae infections are occurreed due to the contiguous spread, and spread of bacteria occur from nasopharynx to adjacent structures, including sinuses, trachea, and lower airways. [5]
Ear pain Middle ear infections can occur due to H. influenzae infection. Otitis media is commonly due to non typeable serotypes. [5]
History of immunodeficiency People with immune deficiency like malignancy, chemotherapy, long term steroid use, organ transplant and HIV AIDS are particularly vulnerable for the disease. [3,5]
Age Invasive H. influenzae disease is common in persons >65 years of age and is associated with a high mortality rate. [8]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  3. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  4. PELTOLA H. Worldwide Haemophilus influenzae Type b Disease at the Beginning of the 21st Century: Global Analysis of the Disease Burden 25 Years after the Use of the Polysaccharide Vaccine and a Decade after the Advent of Conjugates Clin Microbiol Rev [online] 2000 Apr, 13(2):302-317 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100154
  5. ENG RH, CORRADO ML, CLERI D, SIERRA MF. Non-Type b Haemophilus influenzae Infections in Adults with Reference to Biotype J Clin Microbiol [online] 1980 Jun, 11(6):669-671 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC273483
  6. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107
  7. LO S, PHILLIPS DI, PETERS JR, HALL M, HALL R. Papilloedema and cranial nerve palsies complicating apparent benign aseptic meningitis. J R Soc Med [online] 1991 Apr, 84(4):201-202 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293181
  8. RUBACH MP, BENDER JM, MOTTICE S, HANSON K, WENG HY, KORGENSKI K, DALY JA, PAVIA AT. Increasing Incidence of Invasive Haemophilus influenzae Disease in Adults, Utah, USA Emerg Infect Dis [online] 2011 Sep, 17(9):1645-1650 [viewed 13 October 2014] Available from: doi:10.3201/eid1709.101991
  9. WIWANITKIT V. Nitrite, vasodilation, and headache in bacterial meningitis: Theoretical approach J Neurosci Rural Pract [online] 2013, 4(3):374-375 [viewed 15 October 2014] Available from: doi:10.4103/0976-3147.118775

Examination

Fact Explanation
Febrile Fever is one of the most common presenting features. This is due to the infection. [1]
Stiff neck Nuchal rigidity is present due to the meningeal irritation. [1]
Kernig sign This is a bedside diagnostic sign used to evaluate suspected cases of meningitis. Patient is kept in supine position, hip and knee are flexed, the knee is slowly extended by the examiner. It is positive if there is a resistance or pain during extension. [2]
Brudzinki sign Another sign of meningeal irritation. First one hand is kept behind the patient's head and the other on chest in order to prevent the patient from rising, passive flexion of the neck produces reflex flexion of the patient's hips and knees in a positive Brudzinski's sign. [2]
Tachycardia and hypotension Fast heart rate is observed in hypotensive, confused patients. [1] Septicaemia may occur in patients with Hib disease. [5]
Mental status changes Alteration in mental status is a poor prognostic indicator. [3]
Focal neurological signs Subdural effusion or cerebral-space-occupying lesions such as abscess formation can cause these symptoms. [4]
Buldging of fontanelle Due to the increased intracranial pressure. [1]
Growth retardation and cognitive impairment Ischaemia can cause neuronal cell death and tissue damage, if the developing brain is affected child may ends up with poor growth. Cognitive impairment is most prominent after pneumococcal meningitis. [4]
Sensorineural hearing loss Cranial nerve palsies specially VIII the nerve palsy is the cause for this hearing loss. [7]
Papilloedema This is due to the increased intracranial pressure. [7] Increased blood brain barrier permeability, swelling of the cellular elements of the brain, interstitial edema results from obstruction of flow in normal CSF pathways as in hydrocephalus are the possible causes for the raised intracranial pressure.
Hydrocephalus There can be involvement of the ventricles causing ventriculitis. [2] Inflamed areas are gradually fibrosed with creating an obstruction to the cerebrospinal fluid outflow, leading to hydrocephalus.
Sinus tenderness, red eye Non typeble strains of Haemophilus influenzae causes sinusitis, conjunctivitis etc. [6]
Ear discharge Otitis media is commonly due to non typeable serotypes of H. influenzae. [8]
Stridor Acute epiglotitis is the second commonest infection due to H. influenzae. [5]
Features of lung consolidation: reduced chest expansion, increased vocal fremitus, dull percussion note and reduced breath sounds on affected side Pneumonia is a known complication of H. influenzae infection. [6]
References
  1. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107
  2. MEHNDIRATTA M, NAYAK R, GARG H, KUMAR M, PANDEY S. Appraisal of Kernig's and Brudzinski's sign in meningitis Ann Indian Acad Neurol [online] 2012, 15(4):287-288 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.104337
  3. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  4. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  5. PELTOLA H. Worldwide Haemophilus influenzae Type b Disease at the Beginning of the 21st Century: Global Analysis of the Disease Burden 25 Years after the Use of the Polysaccharide Vaccine and a Decade after the Advent of Conjugates Clin Microbiol Rev [online] 2000 Apr, 13(2):302-317 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100154
  6. AGRAWAL A, MURPHY TF. Haemophilus influenzae Infections in the H. influenzae Type b Conjugate Vaccine Era J Clin Microbiol [online] 2011 Nov, 49(11):3728-3732 [viewed 13 October 2014] Available from: doi:10.1128/JCM.05476-11
  7. LO S, PHILLIPS DI, PETERS JR, HALL M, HALL R. Papilloedema and cranial nerve palsies complicating apparent benign aseptic meningitis. J R Soc Med [online] 1991 Apr, 84(4):201-202 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293181
  8. ENG RH, CORRADO ML, CLERI D, SIERRA MF. Non-Type b Haemophilus influenzae Infections in Adults with Reference to Biotype J Clin Microbiol [online] 1980 Jun, 11(6):669-671 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC273483

Differential Diagnoses

Fact Explanation
Meningitis due to other infectious causes Neisseria meningitidis and Streptococcus pneumoniae are the most common causative pathogens for bacterial meningitis. [4] Organisms may differ according to the age of the patient. Eg:- During neonatal period-E.coli, gram negative bacilli, Listeria monocytogens and Group B streptococci, children older than 3 months-Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae, children between 1-3 months with the organisms from both above mentioned groups. [5]
Chronic meningitis Chronic meningitis is different from acute meningitis as it is an uncommon disease with a gradual onset over 2 weeks or more. Fungal infections are the common cause for chronic meningitis. Cryptococcal meningitis is one of the commonest fungal form of the disease.Cryptococcus neoformans is an encapsulated yeast causingopportunistic life-threatening infections, particularly in immuno-compromised patients. [6]
Encephalitis Encephalitis [1] is an acute, usually diffuse, inflammatory process of the brain. About 90% of cases are associated with herpes simplex virus (HSV-1). [3] They also present with the fever, headache, and clouding of consciousness which may be associated with seizures and focal neurology in some patients. Encephalitis associated with meningitis. Meningoencephalitis may give the same picture as in meningitis making diagnosis difficult. [2]
Encephalopathy due to non infectious causes Same clinical features of encephalitis presents with a history of anoxic/ischaemic damage, nutritional deficiency, alcoholism, critical illness, malignant hypertension, traumatic brain injury or epileptic (non-convulsive status). [2] Fever, headache like features are uncommon in encephalopathy than in encephalitis/ meningitis. Depressed mental status is steadily deteriorating in encephalopathy rather than that may be fluctuating in encephalitis/ meningitis. Focal neurologic signs are uncommon in encephalopathy. Types of seizures are usually generalised.
References
  1. JAKKA S, VEENA S, ATMAKURI R, EISENHUT M. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis Cerebrospinal Fluid Res [online] :8 [viewed 16 August 2014] Available from: doi:10.1186/1743-8454-3-8
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. BANATVALA JANGU E. Herpes simplex encephalitis. The Lancet Infectious Diseases [online] 2011 February, 11(2):80-81 [viewed 16 August 2014] Available from: doi:10.1016/S1473-3099(11)70012-3 Investigations - for Diagn
  4. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  5. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  6. LEE CH, CHANG TY, LIU JW, CHEN FJ, CHIEN CC, TANG YF, LU CH. Correlation of anti-fungal susceptibility with clinical outcomes in patients with cryptococcal meningitis BMC Infect Dis [online] :361 [viewed 11 August 2014] Available from: doi:10.1186/1471-2334-12-361

Investigations - for Diagnosis

Fact Explanation
Full blood count There can be elevated lymphocytes/leucocytes in the blood. [2]
Erythrocye sedimentation rate/ C reactive protein Inflammation will increase the ESR /CRP levels. [1]
Blood culture [1] Is done if the patient seems to be septic or lumbar puncture can not be done safely due to the possibility of increased intracranial pressure before the antibiotics. [1] Blood culture will isolate the Haemophilus influenzae [2] which will be appearing as gram-negative coccobacillus.
Computer tomography(CT) scan of the head and Magnetic Resonance Imaging(MRI) CT scan will be even better as the first investigation specially to rule out the possibility of increased intracranial pressure before doing lumbar puncture. [3] MRI will demonstrate the inflammatory dural meningeal process with enhanced uptake over the affected areas. This also show the intracranial complications such as brain edema, hydrocephalus and infarcts. [1]
Lumbar puncture Opening pressure will be elevated in meningitis. Regarding the protein content in the CSF, in bacterial meningitis there is markedly elevated protein (< 1 g/l), where as in other types that may be less prominent. CSF glucose level is decreased. [2] Markedly elevated white blood cell count with predominant neutrophils is seen in haemophilus meningitis. [2] Bacterial antigen detection using latex agglutination-based antigen detection can visualize the Haemophilus influenzae type b in the CSF. [2]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107
  3. NAGRA I, WEE B, SHORT J, BANERJEE AK. The role of cranial CT in the investigation of meningitis JRSM Short Rep [online] , 2(3):20 [viewed 15 October 2014] Available from: doi:10.1258/shorts.2011.010113

Investigations - Fitness for Management

Fact Explanation
Erythrocyte sedimentation rate(ESR) and C Reactive protein(CRP) Is elevated due to the inflammation. [1,3]
Renal functions and serum electrolytes Syndrome of inappropriate Antidiuretic Hormone secretion is a complication of meningitis. This can cause hyponatraemia. [5] Reduced intake of fluids can cause electrolyte imbalances. Baseline value for the renal functions is needed before the treatment. [6]
Liver function tests Medications may alter the liver functions and therefore baseline value is needed before the treatment. [2]
Random blood sugar Should be done immediately especially if the patient is drowsy, to rule out the hypoglycaemia. [4]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. ELWIR SM, SHAFFER CC, ARVAN SW, KUPERMAN EF. Disseminated Varicella Zoster Virus Infection with Encephalitis in a UC Patient Receiving Infliximab Gastroenterol Hepatol (N Y) [online] 2013 Jan, 9(1):54-56 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3975981
  3. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107
  4. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252
  5. PILLAI BP, UNNIKRISHNAN AG, PAVITHRAN PV. Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S208-S215 [viewed 23 September 2014] Available from: doi:10.4103/2230-8210.84870
  6. MISRA UK, KALITA J, PRABHAKAR S, CHAKRAVARTY A, KOCHAR D, NAIR PP. Cerebral malaria and bacterial meningitis Ann Indian Acad Neurol [online] 2011 Jul, 14(Suppl1):S35-S39 [viewed 15 October 2014] Available from: doi:10.4103/0972-2327.83101

Investigations - Followup

Fact Explanation
CT imaging CT imaging is performed if there is poor response within 48 hours of antibiotic treatment. [2] This may be due to the potential complications of the disease such as subdural empyema with severe brain edema. [3]
Full blood count Serial blood count may be showing reduction in the elevated white cell count with the treatment. [1]
References
  1. LIN TY, CHEN WJ, HSIEH MK, LU ML, TSAI TT, LAI PL, FU TS, NIU CC, CHEN LH. Postoperative meningitis after spinal surgery: a review of 21 cases from 20,178 patients BMC Infect Dis [online] :220 [viewed 14 October 2014] Available from: doi:10.1186/1471-2334-14-220
  2. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  3. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107

Investigations - Screening/Staging

Fact Explanation
MRI/CT brain Increased intracranial pressure is evident on MRI by severe sulcal effacement and midline shift on brain imaging. [1] Therefore cranial CT should be done before the lumbar puncture, specially in those present with focal neurological deficits or seizures and those who have a disturbed consciousness due to the possible risk of cerebral herniation due to raised intracranial pressure. [1] Subdural empyema and brain edema maynbe veident on MRI imaging. [2]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. GREENBERG-KUSHNIR N, HASKIN O, YARDEN-BILAVSKY H, AMIR J, BILAVSKY E. Haemophilus influenzae Type b Meningitis in the Short Period after Vaccination: A Reminder of the Phenomenon of Apparent Vaccine Failure Case Rep Infect Dis [online] 2012:950107 [viewed 13 October 2014] Available from: doi:10.1155/2012/950107

Management - General Measures

Fact Explanation
Immediate management This is particularly important if the patient presents with confusion and drowsiness. Airway, breathing, circulation, disability and environment need to be attended. Random blood sugar is done to exclude hypoglycaemia. [4] Lumbar puncture needs to be done before the antibiotics [5] are started ( only if the possibility of increased intracranial pressure can be rule out preferably by a CT scan of the head) [9] If it is not safe to do the LP blood culture is done and antibiotics are started as soon as possible without delay.
Supportive management Antipyretics (i.e acetaminophen) and antiemetics (i.e. promethazine), may be given. Hydration should be checked and due to the possibility of syndrome of inappropriate Antidiuretic hormone, 2/3 of maintenance is preferable. Usual recommended fluid intake is less than 800 mg/day. [1] Monitoring of the vital parameters should be done during the initial period.
Management of the complications Ventriculoperitoneal (VP) shunt is placed for the symptomatic improvement in hydrocephalus. If there are seizures, anticonvulsants should be continued and close follow-up should be done. If there is of rapidly increasing intracranial pressure with clinical deterioration where medical treatment failed, surgical decompression has to be considered as a life saving measure. [2] Extracranial complications such as sepsis, disseminated coagulopathy, multiorgan failure, arthritis and electrolyte imbalance, can occur due to the usually syndrome of inappropriate antidiuretic hormone (SIADH) secretion. [1]
Management of associated Haemophilus influenzae infections Otitis media, acute sinusitis, pneumonia like associated infections need specific management. [5]
Patient education Parents of the affected child need a full explanation of the nature of the disease, its complications. Regular follow up as advised should be made as there can be complications like hearing loss, visual problems, hydrocephalus and development abnormalities. [8]
Follow up As they are vulnerable for complications such as hearing loss, vision problems, growth retardation, learning disability they need to be followed up with hearing, vision and growth assessment. [4]
Prevention Administration of conjugated Hib vaccines in infancy as a mass childhood vaccination programme will prevent one-third to two-thirds of cases of H. influenzae meningitis. [6] Nasopharyngeal carriage of H.influenzae is higher in household and other contacts of infected children which is highest in contacts less than 2 years of age. [7] Chemoprophylaxis with rifampicin 20mg/kg in single daily dose for 4 days will eliminate this carriage in most of the contacts. [7] All household contacts with an index case of H.influenzae invasive disease irrespective of the age and another child under 3 years of age, all classroom contacts where there is 2 or more cases have occurred within 120 days and all the index cases before getting discharged from the hospital will need this chemoprophylaxis treatment. [7]
References
  1. PILLAI BP, UNNIKRISHNAN AG, PAVITHRAN PV. Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S208-S215 [viewed 23 September 2014] Available from: doi:10.4103/2230-8210.84870
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. FLORET D. [Suppurative meningitis in infants and in children: adjuvant treatments and treatments of neurological forms]. Pediatrie [online] 1993, 48(1):21-7 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8392687 Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  4. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  5. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  6. HAMMOND GW, RUTHERFORD BE, MALAZDREWICZ R, MACFARLANE N, PILLAY N, TATE RB, NICOLLE LE, POSTL BD, STIVER HG. Haemophilus influenzae meningitis in Manitoba and the Keewatin District, NWT: potential for mass vaccination. CMAJ [online] 1988 Oct 15, 139(8):743-747 [viewed 14 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1268293
  7. CARTWRIGHT KA, BEGG NT, HULL D. Chemoprophylaxis for Haemophilus influenzae type b. BMJ [online] 1991 Mar 9, 302(6776):546-547 [viewed 14 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669378
  8. LO S, PHILLIPS DI, PETERS JR, HALL M, HALL R. Papilloedema and cranial nerve palsies complicating apparent benign aseptic meningitis. J R Soc Med [online] 1991 Apr, 84(4):201-202 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293181
  9. NAGRA I, WEE B, SHORT J, BANERJEE AK. The role of cranial CT in the investigation of meningitis JRSM Short Rep [online] , 2(3):20 [viewed 15 October 2014] Available from: doi:10.1258/shorts.2011.010113

Management - Specific Treatments

Fact Explanation
Antibiotic therapy Aims of the therapy would be to treat the infection and prevention of long-term central nervous system sequelae. Diagnostic delays should not be a cause fro delaying the immediate antibiotic therapy. [5] Empiric treatment with vancomycin plus an expanded-spectrum cephalosporin such as cefotaxime or ceftriaxone is usually started without a delay. [6] Alternate therapies for H. influenzae include chloramphenicol, cefepime and meropenem. β-lactamase negative, ampicillin susceptible H. influenzae, can be treated with ampicillin with an expanded-spectrum cephalosporin, cefepime, or chloramphenicol as alternate regimens. Many cases of Ampicillin resistance been has reported and therefore it is not a choice. [9] β-Lactamase positive H. influenzae can be be treated with an expanded-spectrum cephalosporin, with cefepime or chloramphenicol as alternatives. Parenteral antibiotics such as ceftriaxone, ceftazidime, cefotaxime, ampicillin-sulbactam, fluoroquinolones, azithromycin for 7-14 days can be used in patients with uncomplicated meningitis. Chloramphenicol is effective against Haemophilus influenzae, [7] but is not commonly used as it needs monitoring of drug levels and due to the resistance reported against Haemophilus influenzae. [8]
Steroids Dexamethasone (4 mg every six hours) is given to reduce the inflammatory response occur during the anti microbial treatment. Dexamethasone may reduce the incidence of hearing loss in some patients. [4]
Vaccination There is a conjugate pentavalent vaccine available for Haemophilus influenzae. [2] Introduction of vaccine has lead to dramatic reduction of the diseases caused by Haemophilus influenzae including meningitis, epiglottitis and septic arthritis etc. [1] Hib conjugate vaccines develop a protective humoral immune response and also reduce the circulating strains of Hib by reducing nasopharyngeal carriage of Hib. [3] Organism's capsular polysaccharide, polyribosylribitol phosphate is the target of the vaccine. [6] Hib conjugate vaccine is not fully effective among HIV-positive patients. [2]
References
  1. PELTOLA H. Worldwide Haemophilus influenzae Type b Disease at the Beginning of the 21st Century: Global Analysis of the Disease Burden 25 Years after the Use of the Polysaccharide Vaccine and a Decade after the Advent of Conjugates Clin Microbiol Rev [online] 2000 Apr, 13(2):302-317 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100154
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