Neonatal Meningitis

1
Neonatal Meningitis

• David Harvey
• Professor of Paediatrics and Neonatal Medicine
• Faculty of Medicine, Imperial College
• Hammersmith Hospital Campus
• London

2
Neonatal meningitis

• This lecture is based on the studies conducted
  and published by the team in the Karim Centre at
  Queen Charlotte's and Chelsea Hospital in London.
  
• We are grateful for financial support provided
  by the Al-Fayed Charitable Foundation.

3
Causative organisms

• The organisms causing meningitis in young
  infants are different from those seen in older
  patients.
• Escherichia coli was the leading cause but this
  has now been overtaken by the Group B
  beta-haemolytic streptococcus, particularly in
  industrialised countries.
• A small number of cases of viral meningitis are
  also reported.

4
Incidence of neonatal meningitis

• Meningitis is most common in infants under one
  year age.
• The incidence is even higher in the first month
  of postnatal life, in preterm babies, and in
  those of low birth weight.

5
Incidence (continued)

• In a two-year national study conducted in the UK
  in the middle 1980s, the incidence of meningitis
  from all causes was 0.32/1000 live births
  (bacterial meningitis 0.22/1000)1.
• Our other study in the middle 1990s showed a
  similar incidence of 0.39/1000 (bacterial
  meningitis 0.21/1000)2.

6
Clinical features

• The signs of meningitis in very young infants
  may be very difficult to detect.
• Characteristic features found in older patients,
  such as neck stiffness, do not occur.
• General signs of illness, including apnoeic
  attacks, vomiting and lethargy are common and
  significant.

7
Clinical features (continued)

• Some features will indicate that there is an
  illness affecting the brain.
• Thus convulsions, which may result from an
  illness of the brain, such as meningitis, or a
  metabolic disturbance, such as hypoglycaemia or
  hypocalcaemia, are an indication for lumbar
  puncture.

8
Studies

• The Karim Centre has studied two cohorts of
  babies with neonatal meningitis who were born in
  England and Wales in 1985 to 19871 and 1995 to
  19962.
• The first cohort was identified prospectively
  using a monthly reporting card sent by the Karim
  Centre to all consultant paediatricians.

9
Studies (continued)

• The second cohort (1995-96) was identified using
  the system set up by the British Paediatric
  Surveillance Unit (BPSU) at the Royal College of
  Paediatrics and Child Health.
• All members and fellows of the College are sent
  a card monthly on which they can report uncommon
  conditions.

10
Survey details (1985-87)

• 566 consultant paediatricians were sent a
  reporting card every month for two years.
• They were asked to notify the researchers if
  they had seen a case of neonatal or postnatal
  meningitis in the previous month. Clinical
  details were obtained from those who reported a
  case.

11
Survey details (1995-96)

• During an 18 month period from July 1995 to
  December 1996 monthly cards were sent by the BPSU
  to 1800 paediatricians, compliance rates for
  return of cards during the period were 94.

12
Survey details

• In both studies further cases were identified
  from the Communicable Diseases Surveillance
  Centre (CDSC) and the Meningococcal Reference
  Laboratory in Manchester.
• Death certificates were also obtained.

13
Cases of Neonatal Meningitis (1985-87)

• 423 cases were identified.
• Of these 118 (28) were caused by group B
  beta-haemolytic streptococci and 78 (18) by E
  coli. Listeria monocytogenes was identified as
  the cause in 23 cases (5).
• Viral meningitis was reported in 16 cases (4).

14
Cases of Neonatal Bacterial Meningitis (1996-97)

• 274 cases of neonatal meningitis were reported.
• This revealed that again the Group B
  beta-haemolytic streptococcus (42) and
  Escherichia coli (16) were the commonest
  organisms. 7 of cases were caused by
  enteroviruses.

15
Mortality in 1980s Survey

• The overall mortality from meningitis was 19.8,
  and it was 24 in bacterial meningitis.

16
Mortality in 1990s

• The mortality in the 1996-7 survey was lower
  than in 1985-87.
• It was 6.6 compared with 19.8 in the earlier
  survey.
• Eight of 69 babies with Group B streptococcal
  infection died (12) and 4 of 26 babies infected
  with Escherichia coli (15).

17
Antibiotic usage in 1980s

• To our surprise, in 1980s chloramphenicol was a
  commonly used antibiotic for neonatal meningitis.
  
• It was reported in 48 of cases. Cefotaxime was
  used in 26 and gentimicin in 40 of cases in
  combination with ampicillin or penicillin.

18
Antibiotics in 1990s

• The pattern of antibiotics used has changed
  dramatically.
• Chloramphenicol was used in only 1 of cases,
  whereas third-generation cephalosporins, notably
  cefotaxime, were used in 84.
• This may account for the improvement in
  mortality.

19
Additional Therapy

• Neonatal intensive care will be needed for these
  fragile infants.
• Ultrasound examination of the brain is needed to
  detect the beginning of hydrocephalus.
• The place of steroids needs further study.
• The length of antibiotic therapy is usually 2
  weeks, but 3 weeks for E coli.

20
Follow-up

• A five-year follow-up has been conducted by
  postal survey of the parents and family doctors
  of the 1985-87 cohort3.
• This study showed that there was a ten-fold
  increase in the risk of severe or moderate
  disability in the children who suffered
  meningitis.

21
Hearing Loss

• The overall relative risk of sensorineural
  hearing loss in meningitis under one year was
  22.8 (95 confidence intervals 7.22 to 72.1).
• Although children with neonatal meningitis had
  an overall increase in hearing problems,
  sensorineural hearing loss was not increased in
  the neonatal group compared with meningitis later
  in infancy.

22
Conclusions

• Neonatal meningitis in industrialised countries
  is now usually caused by Group B streptococci.
• It is difficult to detect early.
• The incidence has not changed, but the mortality
  has decreased recently.
• Developmental studies show that it is followed
  by an increase in disability.

23
Bibliography

• 1. de Louvois J, Blackbourn J, Hurley R, Harvey
  D. Infantile meningitis in England and Wales a
  two year study. Arch Dis Childhood 1991 66
  603-607.
• 2. Holt DE, Halket S, de Louvois J, Harvey D.
  Neonatal meningitis in England and Wales 10
  years on. Arch Dis Child Fetal Neonatal Ed 2001
  84 F85-F89.
• 3. Bedford H, de Louvois J, Halket S, Peckham
  C, Hurley R, Harvey D. Meningitis in infancy in
  England and Wales follow up at age 5 years. BMJ
  2001 323 533-6

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Acknowledgements

• Daphne Holt
• John de Louvois
• Sue Halket
• Helen Bedford
• Catherine Peckham
• Rosalinde Hurley