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Philippine Clinical Practice Guidelines on the Diagnosis And Pediatric Infectious Diseases Society of the Philippines Journal Vol 16 No.2 pp 2-42 Jul-Dec 2015 PIDSP and CNSP Bacterial Meningitis TWG, Acute Bacterial Meningitis CPG 2015 PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS AND MANAGEMENT OF ACUTE BACTERIAL MENINGITIS IN INFANTS AND CHILDREN Copyright 2015 A joint project of the Pediatric Infectious Disease Society of the Philippines (PIDSP) and Child Neurology Society of the Philippines (CNSP) 2 Pediatric Infectious Diseases Society of the Philippines Journal Vol 16 No.2 pp.2-42 Jul-Dec 2015 PIDSP and CNSP Bacterial Meningitis TWG, Acute Bacterial Meningitis CPG 2015 TABLE OF CONTENTS Page I. Introduction A. History of the guideline 5 B. Target users of the guideline 5 C. Forming the guideline 5 D. PIDSP/CNSP Steering Committee 6 E. Criteria for Assessment of Strength of Evidence and Recommendation 6 II. Recommendations A. Diagnosis of Acute Bacterial Meningitis 1. What are the signs and symptoms to suspect acute bacterial meningitis? 7 2. What is the definitive test for bacterial meningitis? 8 3. How do we differentiate acute bacterial meningitis from other CNS infections? 9 4. What are the contraindications to lumbar puncture? 9 5. What are the ancillary tests in the diagnosis of bacterial m eningitis? What is the value of each diagnostic test? a. Complete blo od count (CBC) 10 b. Blood culture 11 c. C-reactive protein (CRP) 11 d. Polymerase chain reaction (PCR) 13 e. Latex Agglutination Test (LAT) 13 f. Procalcitonin 14 6. What is the role of imaging tests in the diagnosis of bacterial meningitis? 15 B. Treatment of acute bacterial meningitis 7. What are the most common pathogens of acute bacterial meningitis in the different age groups? 17 8. Are there signs and symptoms suggestive of a specific etiology? 21 9. What are the empiric antibiotics for acute bacterial meningitis? a. Neonate (0-28 days old) 22 b. One month to 18 years old 23 10. What is the drug of choice for a specific et iologic agent? a. Haemophilus influenzae 24 b. Streptococcus pneumoniae 24 c. Neisseria meningitidis 25 d. E. coli 25 3 Downloaded from pidsphil.org Pediatric Infectious Diseases Society of the Philippines Journal Vol 16 No.2 pp.2-42 Jul-Dec 2015 PIDSP and CNSP Bacterial Meningitis TWG, Acute Bacterial Meningitis CPG 2015 e. Group B Streptococcus (GBS) 26 11. What is the recommended duration of treatment wherein the organism was not isolated ? 27 12. What are the indications to shift to another antibiotic agent? 28 13. Is it appropriate to step down to oral therapy? 28 C. Adjuvant Therapy 14. What is the value of using steroids for acute bacterial meningitis? 29 15. What are the supportive management for acute bacterial meningitis? 30 B. Prevention 16. Is there a need for follow up antimicrobial to eradicate the carrier state? 31 17. What are the indications for prophylaxis among close contacts? 31 What is the drug of choice? a. Haemophilus influenzae 31 b. Neisseria meningitidis 32 18. What is the role of vaccines? a. Haemophilus influenzae type B 33 b. Streptococcus pneumoniae 33 c. Neisseria meningitidis 33 19. What are the infection control measures necessary to prevent disease transmission? 34 II. Appendix A: Dosages for Antimicrobials (Treatment and Chemoprophylaxis ) 35 Appendix B: Definition of Terms for Chemoprophylaxis 36 III. References 37 4 Downloaded from pidsphil.org Pediatric Infectious Diseases Society of the Philippines Journal Vol 16 No.2 pp 2-42 Jul-Dec 2015 PIDSP and CNSP Bacterial Meningitis TWG, Acute Bacterial Meningitis CPG 2015 INTRODUCTION Th ese recommendations are intended for Acute bacterial meningitis is defined as use by pediatricians, general practi tioners and the inflammation of the meninges which is emergency medicine physicians t o serve as a caused by bacteria such as Streptococcus guide in the management of bacterial pneumoniae , Haemophilus influenza e and meningitis. This guideline serves only as Neisseria meningitidis. In developed countries, suggestions based on evidences collected that the advent of vaccines for these organisms has would help lead each clinician to his/her rightful significantly decreased the prevalence of decisions in the management of the patient. bacterial meningitis 1. For developing c ountries Key questions were formulated for the like the Philippines however, uptake of the diagnosis (involving both clinical paramet ers vaccines on a nationwide scale has yet to and laboratory procedures) and treatment occur, thus a change in the epidemiology has protocols which include empiric and targeted not been seen. From 2001 till 2010, meningitis therapy, as well as preventive measures by the has always been in the top 10 leading causes PIDSP/CNSP Steering Committee . The of mortality in children 2. Based on the committee searched for both local and Philippine Pediatric Society disease registry, international researches pertaining to the out of the 934,633 cases reported from diagnosis, treatment and prevention of acute January 1, 2006 to August 31, 2010, there bacterial meningitis. Workshops were also were 5,611 cases of unspecified meningitis . organized for the critical appraisal of the Resistance rates of pathogens to evidence and were graded using the WHO antimicrobials have not decline d. The criteria for strength of ev idence. emergence of new resistance for antibiotics Recommendations were made based on the have been reported. In 2012, all S. literature obtained, local data, and expert pneumoniae isolated were sensitive to opinion of committee members. The guideline levofloxacin. H owever, in the 2013 has been presented to the CNSP and PIDSP. Antimicrobial Resistance Surveillance Program It also has been presented at the Philippine (ARSP), 2% resistance to levofloxacin (95% Pediatric Society Annual C onvention as well as CI: 0.5-5.8) was reported. 4 With varying clinical the PIDSP annual convention. The therapeutic presentations and rising rates of bacterial guidelines has also b een discussed with the resistance, the appropriate management of this with the National Antibiotic Guideline disease from its recognition to therapy remains Committee of the Department of Health, of paramount concern. Thus to address these Philippines. The feedback generated were chan ges, this guideline was developed. taken into consideration and incorp orated in The first guideline for acute bacterial the guideline where appropriate . meningitis was completed in 1998 as commissioned by the Philippine Society for Microbiology and Infectious Diseases (PSMID), however, the guideline was not published. The Disclaimer: Brand names of certain products Pedi atric Infectious Disease Society of the may appear within the text, however, we are Philippines (PIDSP), in line with its 20 th not in any way promoting or encouraging its anniversary celebration in 2013, saw the need use. They appear in this guideline for for an update and publication of this guidelin e, information purposes only . thus, it formed a committee in partnership with Child Neurology Society of the Philippines (CNSP) to develop these current recommendations. 5 Pediatric Infectious Diseases Society of the Philippines Journal Vol 16 No.2 pp.2-42 Jul-Dec 2015 PIDSP and CNSP Bacterial Meningitis TWG, Acute Bacterial Meningitis CPG 2015 The PIDSP/CNSP Steering Committee for the Clinical Practice Guideline of Acute Bacterial Meningitis CRITERIA FOR ASSESSMENT OF Chair: Cecilia C. Maramba-Lazarte, MD STRENGTH OF EVIDENCE AND Members: Janet A. Adajar, MD RECOMMENDATION Imelda Asetre-Luna , MD Evidences obtained and the strength for Eva Luna-Dizon, MD each recommendation were graded according Fatima I. Gimenez, MD to the World Health Organization’s assessment Grace Devota Gomez-Go, MD criteria as shown in the following tables ( lifted Martha Lu-Bolanos,Bolanos, MD from the WHO recommendations for Edna S. Mallorca, MD management of common childhood conditions: Anna Lisa Ong-Lim, MD evidence for technical update of pocket book Marimel R. Pagcatipunan, MD recommendations: newborn conditions, Suzanne Ponio-Degollado, MD dysentery, pneumonia, oxygen use and Pauline Reyes-Solis, MD delivery, common causes of fever, severe Mayan Uy-Lumandas , MD acute malnutrition and supportive care, 2012) 5 Advisers: Estrella Paje-Villar, MD Madeleine M. Sosa, MD Consultant: Charissa Salud-Gnilo , MD Medical Writer: Mari Anne M. Yorobe, MD Table 1. Grading scheme for level of evidence in assessing articles Level of Evidence Rationale Further research is very unlikely to change confidence in the estimate of High effect. Further research is likely to have an important impact on confidence in the Moderate effect. Further research is very likely to have an estimate of effect and is likely to Low change the estimate. Very Low Any estimate of effect is very uncertain. Table 2. Grading scheme for strength of recommendation in assessing articles. Strength of Recommendation Rationale The panel is confident that the desirable effects of adherence Strong to the recommendation outweigh the undesirable effects. The panel concludes that the desirable effects of adherence to Conditional/Weak a recommendation probably outweigh the undesirable effects. However, the recommendation is only applicable to a specific group, population or setting OR where the new evidence may result in changing the balance of risk to benefit OR where the benefits may no t warrant the cost or resource requirements in all settings. Further research is required before any recommendation can No Recommendation be made. 6 Downloaded from pidsphil.org Pediatric
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