Clinical Analysis On 129 Hospitalized Children With Purulent Bacterial Meningitis

Objectives;i.To identify bacterial bacteria responsible in causing purulent bacterial meningitis(PBM)in children.ii.To explore common clinical features and laboratory findings of PBMiii.To identify antibiotics used in treatment of PBMiv.To determine early complications of PBMMethodology;Hospital based cross sectional study,we retrospectively reviewed children aged lmonth-15 years with diagnosis of PBM admitted at Pediatric Medical Center-Qilu hospital of Shandong University from January 2011 through September 2016.Data collected and analyzed were clinical features,laboratory findings,treatment and early complications.Inclusion criteria were(1)Children with a history of fever>38.5 ?,headache,neck stiffness,limb weakness,vomiting,convulsions,bulging anterior fontanelle,alteration of mental status(lethargy,irritability,coma).(2)CSF examination showing at least one of the following;turbid CSF appearance,leukocytosis>100/mm3.Leukocytosis of 10-100/mm3 with elevated protein level(>41 mg/dl or 0.41 g/1)and decreased glucose level(<2.5 mmol/1).(3)The identification of a bacterial in the cerebrospinal fluid(CSF)culture.(4)Blood culture positive with clinical symptoms consistent with bacterial meningitis.Exclusion criteria were all cases not fulfilling any of the above criteria and/or those with evidence suggesting other central nervous system CNS disorders.Descriptive analysis was analyzed as mean ±SD,one way ANOVA(Analysis of variance)used to compare two means in more than two groups,Chi-square test(?2)or Fisher's exact test was used to analyze association between categorical variables as appropriate.Data collected were analyzed by using statistical software,Statistical Package for Social Science(SPSS)version 18.P value less than 0.05 was regarded as statistically significant.Results:129 children met criteria and were analyzed,male to female ratio was 1.8:1,82(63.6%)males and 47(36.4%)female.Cases were classified into five age groups:the highest prevalence was seen on children of lmonth-1 year 76%,1-2 years 4.7%,2-5 years 8.5%,5-12 years 8.5%and 12-15 years 2.3%(mean age is 2.93months).Summer was the season of the highest incidence of PBM(44%)followed with winter(27%),spring(16%)and autumn had the lowest incidence(13%).Most of cases came from rural 78(60.5%)whereas 51 cases(39.5%)were from urban areas.The mean length of hospital stay was 3 weeks and 2 days.About 103(79%)of patients were on antibiotics before admission to our hospital.Clinical features seen were fever of more than 38.50Centigrade in 129 cases(100%),alteration of mental status was present in 85 cases(65.5%),convulsions 53 cases(43.4%),vomiting 48 cases(37.2%),neck stiffness 38 cases(29.5%),limb weakness 36 cases(28%),bulging anterior fontanelle 23 cases(17.8%)and the least symptom was headache in 20 cases(15.5%).In the CSF analysis we observed substantial increase in CSF WBC count>500 mm3 in 48.1%cases,CSF neutrophils>50%in 62(48.9%)cases,lower glucose level<2.2mmol/l on 81(63%)cases,103(79.8%)cases with high protein levels>0.41 g/1.66(59%)cases had CSF lactate of more than 2.1 mmol/1.We found 24(36.4%)cases with raised levels of CSF lactate have positive CSF culture,the association between lactate and positive CSF culture(P =0.02).CRP levels more than 70mg/l seen in 60 cases(50%)and between 8-69 mg/l in 40 cases(34%).We found 37(63.7%)of patients with subdural effusion had CRP>70mg/l.Lactate dehydrogenase(LDH)levels of more than 230 U/L was seen in 87 cases(85.5%).Pathogen positive cases of PBM were 48(37%),the main bacteria cultured in CSF and blood were Staphylococcal species 21%,Streptococcus pneumoniae 19%,group B Streptococcus(GBS)15%and Escherichia coli 13%and less detected bacteria were Enterococcus fecalis,Enterococcus fecium,Klebsiella pneumoniae,Salmonella species and Hemophilus influenza.Staphylococcal species(n=8)showed resistance to penicillin G by 100%,Oxacillin 62%,Amoxicillin 50%,Ampicillin sulbactam 38%and Ceftriaxone 38%.Gram positive bacterial were sensitive to vancomycin,chloramphenicol,Meropenem and linezolid.Gram negative bacteria were sensitive to carbapenems and amikacin.Brain MRI was performed in 129 cases,about 90 cases(70%)found to have abnormal Brain MRI results which are subdural effusion in 62 cases(48%),hydrocephalus 15 cases 12%,abnormal brain signal 11 cases 8.5%and brain abscess in 2 case 1.5%.Early complications developed in 98 cases(76%),complications seen were subdural effusion,seizures,regressed developmental milestone,limb weakness,anemia and hydrocephalus with 48%,43.4%,35%,28%,24%and 12%respectively.Conclusion;Staphylococcal species,Streptococcal pneumoniae,Group B streptococcal and E.coli were the predominant pathogens responsible for purulent bacterial meningitis over the past 53/4 years.Children with age<1 year,male sex and living in rural areas were factors associating to purulent bacterial meningitis.CSF culture examination remains an essential test for diagnosis of purulent meningitis;it is necessary to confirm diagnosis,identify the causative microorganism,and allow testing for antibiotic sensitivities to rationalize and individualize treatments.Low detection of etiologies has been contributed with higher rate of antibiotics use before lumbar puncture,about 79%children were on antibiotics prior admission and we had pathogen positive cases 48%only.CSF Gram staining,CSF analysis for(glucose,protein,lactate),PCR for antigen detection,serum C reactive protein(CRP)and serum procalcitonin,are important supportive investigations in reaching diagnosis of purulent bacterial meningitis.Worldwide,PBM remains a disease with devastating attack rates and the presence of drug resistance among causative bacteria,prompting to treatment failures.Therefore empirical antibiotic therapy should be adjusted basing on the local drug resistance patterns.