Soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) were found to be a biomarker in cerebrospinal fluid during the presence of bacterial meningitis; however, it is not yet recommended for clinical practice (Brouwer et al., 2010). Blood cultures and skin biopsy have been used to detect causative pathogens in patients when cerebrospinal fluid cultures are negative or unavailable, but these tests are not definitive enough to be used as the standard diagnostic method (Brouwer et al., 2010). Improvements to blood culture and skin biopsy testing could result in a quicker, more cost effective diagnostic technique that is also safer for the patient.
There are a variety of antibiotic regimens and therapies used for children with bacterial meningitis. Selecting the necessary antibiotic for treatment requires the assessment of its activity against the causative pathogen, its ability to penetrate the cerebrospinal fluid, and to determine the minimum antibiotic concentration for effective results (Chavez-Bueno et al., 2005). The compromised nature of the blood-brain barrier caused by meningitis also increases the permeability of most antibiotics, and must be considered when evaluating treatment dosage. Empirical therapy treatments are selected for children based on the most probable causative pathogen for the patient's age and the susceptibility patterns in the patient's geographical location (Yogev et al., 2005). Once the bacterial pathogen is known, or assumed, treatment providers will base the antibacterial regimen based on penicillin resistance and ?-Lactam allergy. The antibacterial treatments of choice for N. meningitidis are ceftriaxone or cefotaxime; Hib is cefotaxime or ceftriaxone; S. pneumoniae is cefotaxime or ceftriaxone plus vancomycin (Yogev et al., 2005). Peniciliin G. Or ampicillin is also considered standard therapies for susceptible (non-resistant) strains of N. meningitidis and S. pneumoniae (Chavez-Bueno et al., 2005). Antibiotic pretreatment of bacterial meningitis (treatment prior to lumbar puncture) is also employed in a significant number of childhood cases of bacterial meningitis, and is known to affect cerebrospinal fluid glucose and protein levels (Nigrovic et al., 2008).
One of the damaging effects of the inflammatory processes associated with bacterial meningitis causes permanent neurological sequelae, and most commonly, hearing loss (Yogev et al., 2005). Corticosteroid treatment, namely dexamethasone, is used (either before or with antibiotic treatment) to reduce hearing loss in children (Mongelluzzo et al., 2008). There are concerns with corticosteroid treatment due to the potential decrease in cerebrospinal fluid penetration of antibiotics; as well as side effects, such as gastrointestinal bleeding and prevention of secondary fever which indicates antimicrobial failure (Mongelluzzo et al., 2008). Anticonvulsant medications such as benzodiazepines and phenobarbital are recommended to prevent and control seizures (Chavez-Bueno et al., 2005).
Non-pharmacological strategies used to reduce the intracranial pressure caused by inflammation include the avoidances of vigorous procedures such as intubation, 30? head elevation, and short-term hyperventilation (Chavez-Bueno et al., 2005). Complications from treatment and bacterial meningitis include seizures, subdural effusions, brain abscesses, persistent fever, and fatality (Chavez-Bueno et al., 2005). The cost of treatment is relatively small due to lack of surgical intervention needed for bacterial meningitis. The majority of costs relevant to the patient concern the cost of vaccinations, antibiotics, and costs associated with hospital care. Costs of referral treatments must also be considered. From a research and development perspective, the greatest cost is vaccine development; the cost of which drives vaccination policies (Ceyhan et al., 2008).
Educating parents on the signs and risk factors for bacterial meningitis is critical in order for children to receive appropriate medical care as quickly as possible. Although symptoms such as fever and vomiting are not obvious signs of meningitis, educating parents on the risk of penetrating head injuries, and any immunosuppressive states (such as HIV infection), greatly increase the likelihood of acquiring bacterial meningitis (Chavez-Bueno et al., 2005). Children who undergo cochlear implants are also at a high risk of acquiring bacterial meningitis; the rate of which is 30 times greater than children in the general U.S. population (Biernath et al., 2006). Once a child is recovering from bacterial meningitis, parents and the patient must also be educated on potential lifestyle changes. Etiology, patient age, concentration of bacteria, and cerebrospinal fluid findings at the time of diagnosis can all impact the outcome of bacterial meningitis (Chavez-Bueno et al., 2005). The most common outcome in children is hearing loss, in which some measure of hearing loss occurs in 25% to 35% of patients; there is also risk of neuromotor, speech, and learning disabilities in children, in which approximately 10% of children will develop (Chavez-Bueno et al., 2005).
Follow-up and Referral
Hearing loss, learning disabilities, speech difficulties, behavioral problems, and neuromotor impairment are all known consequences of bacterial meningitis in childhood (Chavez-Bueno et al., 2005). To address these outcomes, patients may be referred to neurologists for further testing. A patient experiencing these outcomes may also be referred to speech therapists, psychologists, and utilize additional assisted learning programs to accommodate lasting effects of meningitis.
Underserved Populations and Ethical Considerations
The disparity in global access to the Hib vaccine indicates the overwhelmingly underserved and disadvantaged populations of children infected with bacterial meningitis. The bacteria, Hib, was once the most common causative pathogen of meningitis and is now near extinction in developed nations as a result of the successful application of the Hib vaccine (Yogev et al., 2005). In resource-poor countries, however, Hib is a major pathogen still affecting children. Bacterial meningitis is especially toxic in Africa, and remains an important source of mortality among African children (Roca et al., 2009). Resource-poor countries have limited, if any, access to vaccines and are also inhibited by limited awareness of the disease.
The degree in which developing and resource-poor countries are underserved are best exemplified by their mortality rates: bacterial meningitis claims 5% of cases in children in developed nations, and 30% of cases in the developing world (Best, & Hughes, 2008). This statistic indicates ethical concerns as the vaccines are available to reduce the mortality rate in children, yet resource-poor countries do not have the means to acquire them. Children in developing nations acquire bacterial meningitis through no fault of their own and often succumb to fatality due to lack of economic resources. The incidence of childhood bacterial meningitis in developing nations challenges the boundary between government control, pharmaceutical profit, and basic human rights. The lack of vaccine accessibility in developing nations fuels an ethical consideration and debate that questions if adequate medical care is a right, or a privilege afforded to a select economic population.
Bacterial meningitis is a significant cause of morbidity and mortality in children worldwide. Although the mortality rates are greatest in developing nations, bacterial meningitis poses a critical health threat to the global youth population. Signs and symptoms of bacterial meningitis depend on the age of the patient, and there is a range of variance between manifestations in infants vs. older children. Infants typically present with fever, poor feeding, irritability, lethargy, and vomiting, while older children may experience more common signs of meningeal irritability, neck stiffness, seizures, and different degrees of altered consciousness. The two most common causative pathogens in children are S. pneumoniae and N. meningitdis; the incidence of Haemophilus influenzae type b (Hib) infection has largely decreased due to the availability of the Hib conjugated vaccine.
The basic pathophysiology of bacterial meningitis involves the bacteria pathogen crossing the blood-brain barrier and causing an inflammatory response in the central nervous system, which leads to cell death and loss of brain function. Lumbar puncture and cerebrospinal fluid analysis are required for the definitive diagnosis of bacterial meningitis; developing a sTREM-1 screening procedure, blood cultures, and skin biopsy techniques have diagnostic potential for the future. Treating bacterial meningitis involves various antibiotic regimens, and corticosteroid and anticonvulsant medications are recommended to reduce adverse side effects. The outcomes of bacterial meningitis in children vary by age and other factors; parents must be educated on the risk factors and potential outcomes of meningitis, such as hearing loss and learning disability. Patients experiencing these outcomes may be referred to speech therapists and require learning assistance to combat the lasting effects of meningitis. The lack of vaccine availability in developing nations isolates underserved populations and also carries significant ethical implications. Bacterial meningitis is responsible for mortality in children worldwide. Prompt, accurate diagnosis of meningitis and the administering of the proper antibiotic are critical for the survival of the child.
Best, J., & Hughes, S. (2008). Evidence behind the WHO guidelines: hospital care for children-what are the useful clinical features of bacterial meningitis found in infants and children? Journal of Tropical Pediatrics, 54(2), 83-86.
Biernath, K., Reefhuis, J., Whitney, C., Mann, E., Costa, P., Eichwalk, J., & Boyle, C. (2006). Bacterial meningitis amoung children with cochlear implants beyond 24 months after implantation. Pediatrics, 117(2), 284-289.
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