Niger J Paed 2013; 40 (1): 6 –14 REVIEW Ogunlesi TA Diagnosis and treatment of bacterial meningitis in the newborn DOI:http://dx.doi.org/10.4314/njp.v40i1.2 Accepted: 29th May 2012 Abstract Background: Bacterial riologic culture in the diagnosis of meningitis in the newborn is glob- meningitis can be improved with Ogunlesi, TA ( ) ally renowned for high mortality. serologic method like polymerase Department of Paediatrics, The associated morbidities also chain reaction. Widespread resis- Olabisi Onabanjo University Teaching include audiologic, motor, visual tance of pathogens may be threaten- Hospital, Sagamu P. O. Box 652, Sagamu-121001 and mental deficits. ing the use of penicillins and gen- Ogun State. Nigeria. Objective: To highlight the peculi- tamicin for empirical treatment of Email: [email protected] arities in the current diagnostic and newborn meningitis. No sufficient management strategies in newborn evidence presently supports the meningitis. current practices of fluid restriction, Methods: Relevant literature on the prolonged duration of antibiotic subject published only in English treatment and non-use of adjuvant language or translated to English steroid therapies in the newborn. language was searched manually Conclusion: Efforts to reduce the and electronically. The Medline, incidence of newborn meningitis PUBMED and HINARI were cannot be separated from the pre- searched for the period between vention of newborn sepsis gener- 1966 and 2012. The following key ally. In addition, more controlled words were used during the search: trials are required in the developing newborn/neonatal, bacterial/ world with respect to the various pyogenic meningitis, central nerv- aspects of management of newborn ous system infections, antibiotics, meningitis, particularly fluid man- dexamethasone and fluid agement and the use of adjuvant restriction. steroids. Results: The pattern of bacterial aetiology and mortality differ be- Keywords: Antibiotics, dexa- tween the developed and develop- methasone, meningitis, newborn, ing world. The usefulness of bacte- lumbar puncture. Introduction of neonatal meningitis in the middle belt was reported to be 1.9/1000 live births four and 6.5/ 1000 live births in Meningitis is an extensive inflammatory condition of the north-eastern Nigeria. 5 Similarly, the incidence rate leptomeninges. Although, it is generally described as reported in the Panama in the mid-nineties was 3.5 uncommon, meningitis occurs commonly in the neonatal cases/1000 live births. 6 period due to the increased susceptibility of newborn babies to severe infections.1 Neonatal meningitis is as- While the incidence has not changed remarkably, there sociated with significant mortality and severe morbid- has been a significant decrease in the mortality associ- ities. ated with meningitis over the last two decades due to improved antibiotic therapy and supportive care in most The overall incidence of meningitis in England and parts of the developed and industrialized world. On the Wales has not changed remarkably from the known 0.2 contrary, morbidity has not changed significantly over – 0.4 cases/1000 live births over the last three decades. this same period, even, in the developed world. The per- 2,3 These are similar to data obtained from other parts of sistently high morbidity rate among the survivors of the developed world. Although, consistent incidence neonatal meningitis remains a major clinical issue and rates are not available in most parts of the developing the need to minimize these morbidities is a challenge. 2,3 world, the few available ones are higher compared to the developed world. For instance, in Nigeria, the incidence Although, mortality rates in newborn meningitis vary by 7 region, the known rates in the various regions of the form the core of clinical diagnosis of meningitis in the world are not markedly different. For instance, mortality newborn. Due to the low sensitivity and specificity of rates included 0.7–1.9 ⁄ 1000 live births in sub-Saharan the clinical predictors of this severe infectious disease, Africa, 0.33–1.5 in the Middle East and North Africa laboratory diagnosis is indispensable. 12, 13 and 0.4-2.8 in the Americas and Caribbean. 7 Mortality in the developed world had dropped from close to 50% to Bacteriology of newborn meningitis about 10% over the last decade whereas morbidity Microbiology remains high at 15 to 60% among the survivors. 8 Although, under-reporting is a challenge in the develop- In consonance with sepsis, the bacterial aetiology of ing world, mortality associated with neonatal meningitis neonatal meningitis differs between the developing and also varies between 30% and 60% while morbidity fig- the developed world. In most developed countries, the ures vary greatly. Five to seven a high proportion of the leading pathogen in newborn meningitis is Group B survivors in neonatal meningitis develop chronic handi- Streptococcus (GBS). Others include Escherichia coli , capping conditions with serious medical and psycho- Listeria monocytogenes , other coliforms and lately, social implications such as cerebral palsy, mental retar- Streptococcus pneumoniae .1, 8, 14 Data obtained from dation, seizure disorder, hemiplegia, deafness and blind- England and Wales from 1985 to 1987 and from 1996 to ness. 5, 9 1997 showed very little change in the pattern of bacterial aetiology of neonatal meningitis over this period. GBS Although, bacterial meningitis is an important cause of accounted for 39% to 48% of all cases. Others included newborn death globally, the burden of neonatal sepsis Escherichia coli (18% to 26%), Streptococcus pneumo- and meningitis is most pronounced in the resource-poor niae (6%) and Listeria monocytogenes (5% to 7%). 2, 3 parts of the world where the disease constitutes a signifi- In a more recent French National survey, the leading cant proportion of neonatal admission and deaths. 10,11 pathogens in newborn meningitis included GBS (59%), In spite of the similarity in the pathology and patho- Escherichia coli (28%), Gram-negative bacilli apart genesis of meningitis in childhood, there are peculiari- from Escherichia coli (4%), other Streptococcus apart ties with regard to the diagnosis and management of from GBS (4%), Neisseria meningitidis (3%) and newborn bacterial meningitis. This review aims to high- Listeria monocytogenes (1.5%). 15 light the challenges in the diagnosis and management of bacterial meningitis in the newborn in comparison with The pattern of bacteriological aetiology in neonatal men- older children. Research issues which may possibly ingitis differs in terms of the spectrum of organisms as proffer solutions to the alarming high prevalence of neu- well as the relative prevalence of individual organisms rologic sequelae and poor quality of life among the sur- causing meningitis in most parts of the developing vivors of newborn bacterial meningitis will also be world. Escherichia coli was earlier reported as the lead- raised. ing aetiology in Nigeria 16 and more recently in Kenya. 17 Although E. coli was also commonly isolated in Nigeria, Diagnosis Staphylococcus aureus predominated in two other Nige- Symptoms and signs rian reports. 4, 5 In addition, some reports of GBS pre- dominance have also been made in parts of the develop- Bacterial meningitis can be extremely difficult to diag- ing world like Zimbabwe, Kenya and China. 17 - 19 Inter- nose in the newborn because the symptoms and signs estingly, none of the studies from Nigeria 4, 5, 16 reported are often subtle and non-specific at the early stage of the GBS as aetiology of neonatal meningitis. Even most disease. The clinical presentation of meningitis is indis- recent studies of newborn sepsis in Nigeria did not find tinguishable from that of sepsis without meningitis. The GBS or reported very few cases. 20 - 23 early symptoms of meningitis include pyrexia, poor feeding, vomiting, lethargy or irritability. These clinical Listeria monocytogenes is also uncommonly encoun- features may also characterize other newborn disorders tered in this part of the world. 17 On the other hand, such as hypoxic-ischaemic encephalopathy and meta- Gram negative bacilli (with the exception of E. coli ) bolic derangements such as hypoglycaemia. Therefore, have a global distribution but appear more common in distinguishing between early meningitis and other neo- the developing world, probably for reasons of poor hy- natal illnesses mentioned above may be challenging and giene. this is associated with the tendencies to frequently under -diagnose meningitis in the newborn. The emergence of unusual organisms like Haemophilus influenza in Nigerian babies with meningitis 5, 24 poses With the progression of the disease, bulging fontanelle, new challenges in the treatment of newborn meningitis shrill cry, apnoeas, seizures, opisthotonus and coma may in this population. This organism is not usually taken occur. 12 Although, these features are more specific fea- into consideration when planning empirical antibiotic tures of meningitis and thus, facilitate diagnosis on clini- treatment for newborn meningitis in Nigeria. This may cal grounds, they occur quite late in the disease. Instruc- constitute technical delay in the commencement of ap- tively, the classic signs of meningeal irritation in the propriate antibiotic therapy in possible cases of Haemo- older children, such as neck stiffness and positive Ker- philus influenzae infection among newborns. nig sign or Brudzinski sign are often absent and unreli- The highlighted