Table of Contents
Meningitis is the spinal cord and brain covering membrane inflammation. Different microorganisms, including fungi, bacteria, and viruses can provoke this disease. Viral meningitis is a self-determining disorder without serious consequences. The fungal meningitis is a rare disorder, which is still dangerous. It can be provoked by the different fungi and appear mostly among immunocompromised patients. However, the most challenging and life-threating type is bacterial meningitis. Despite the representation of efficient vaccinations in the world, bacterial meningitis among children remains one of the most significant healthcare challenges. According to the estimation, this disorder provokes the death of 125000 patients annually and neurological consequences occur in 18-47% of survivors globally (Baines, Reilly, & Gill, 2009, p.307). Therefore, bacterial meningitis is the dangerous and life-threatening disorder and, despite vaccination, leads to the deaths of many people in the world, especially among children and inhabitants of sub-Sahara region.
Meningitis is the leptomeninges inflammation and cerebrospinal fluid underlying subarachnoid. Such inflammation results from infection with bacteria, viruses, and other non-infective causes or microorganisms. The meningococcal disorder is the main reason of the death in early childhood and it can be represented as the septicemia, bacterial meningitis or both diseases simultaneously (WHO, n.d). Early meningitis symptoms can be similar to the flu and they can appear within several hours or days. The signs in people aged above two years old can be skin rash, absence of appetite, light sensitivity, sleepiness, seizures, confusion, concentration difficulties, headache, vomiting, stiff neck and sudden high fever (WHO, n.d). Among newborns, the symptoms can be stiffness in the body, poor feeding, inactivity, irritability, constant crying and high fever. Bacterial meningitis is a serious disorder that can be fatal within the several days without the appropriate antibiotic treatment (WHO, n.d). The delays in treatment can raise the risk of permanent damage or death.
From the historical perspective, meningitis was found in ancient texts, and Hippocrates mentioned this disorder. In addition, Robert Whytt was the first who described the tuberculosis meningitis in 1768. In general, meningitis was primary recovered in 1805 in Geneva. The first outbreak happened in 1840 in Africa and this epidemic became more common issue in the 20th century (WHO, n.d). The first big epidemics appeared in Chana and Nigeria in 1905-1908 and, at that time, many people died due to this disorder. Anton Vaykselbaum was the first person who provided evidence that related the bacterial infection to the meningitis cause. Further, the scientist provided the new lumbar puncture technique to organize the early cerebrospinal fluid analysis. In the 19th century, it was found that organisms provoking meningitis are Haemophilus influenza, Neisseria meningitides and streptococcus pneumonia (WHO, n.d). In the 20th century, one introduced the Haemophilus vaccine that assisted in meningitis’ reduction. Further, an opinion appeared stating that penicillin could be an effective treatment (WHO, n.d.). The first effective treatment became the serum therapy, while antibiotic therapy started with the penicillin and sulfonamides use. Hence, the history of this disorder is considerably long.
Despite the modern treatment nowadays, meningitis can be a serious challenge. In particular, bacterial meningitis provokes the death and substantial disorders similarly to the persistent neurological defects, especially among children and young people. Bacterial meningitis can be the most critical cause of the acquired deafness (WHO, n.d). At the same time, viruses provoke the acute aseptic meningitis syndrome that is explained as acute meningitis with the CSG lymphocytic pleocytosis, for which there is no case after the initial evaluation, routine staining and culture of the CSF. Such disorder in rare cases is serious and fast in recovery (WHO, n.d). Hence, bacterial meningitis is the most challenging issue from the global health perspective.
One of meningitis leading cases is the Neisseria meningitidis. The meningococcal disorder incidences for the high-income states amount from 0.9 to 1.5 cases per one hundred thousand people. However, the incidence for low-income states is higher, whereas sub-Sahara Africa faces the most difficult situation where the rates are up to thousand cases per one hundred thousand inhabitants (Brouwer & van de Beek, 2009). Several studies suggest that genetics has a critical role in the meningococcal disorder outcomes. Multicolor sequence typing analysts found genetic variation in seven meningococcus housekeeping genes and represented that most disorder cases are provoked by the several clonal complexes of related sequence types, namely the hypervirulent lineages (Brouwer & van de Beek, 2009) The modern techniques also showed the host genetic polymorphosis that impact meningococcal disorder’s outcome and severity. The strong relation between the meningococcal disorder and mortality was notices for polymorphisms in the IL-1, Il-1 receptor antagonist, and plasminogen activator inhibitor 1 genes as well as for the eight different polymorphisms were explained in six studies that involved 2534 patients in total. In four out of six types specified in the research diagnose was microbiologically confirmed. The authors analyzed “the available researchers and stated that polymorphisms AI 4G/5G, IL1-RA +2018C/T, and IL-1B -511C/T were related to death, with ORs of 2.3 (95% CI, 1.5-3.5), 1.9 (95% CI, 1.3-2.9), and 1.8 (95% CI, 1.1-3.1), respectively” (Brouwer & van de Beek, 2009). Therefore, there is a great relation of meningitis with the genetics; however, there is a necessity for further research.
In order to provoke disorder, the pathogen was in the neurological procedure absence or CSF leak colonized the nasopharynx, traversed the nasopharynx in the bloodstream, survived the host defense mechanisms in the intravascular space, invaded the blood-brain barriers, survived and replicated in the subarachnoid space that finally led to the disorder (Hoffman & Weber, 2009). In recent years, the researchers have described multiple interactions between the organism and the host. In addition, the main meningeal pathogens have some similarities, such as particular physiologic features as autolysis, DNA transformation, phase variation and IgA process, polysaccharide capsules, phosphorylcholine moieties, devastating disorder, and asymptomatic carriage in the nasopharynx (Hoffman & Weber, 2009). The high-grade bacteremia presides meningitis invading from the bloodstream to the central nervous system. Moreover, it can reach the central nervous system through local infections or dural defect as the potential routes. Endothelial cells inflammatory activation is the prerequisite for bacterial invasion and lead to the adhesion molecules regulation. The researches defined that around half of the bacterial meningitis survivors suffer from disabling neuropsychological deficits, whereas the most vulnerable part seems to be the hippocampus in the brain (Hoffman & Weber, 2009). Therefore, the pathogenesis consists of three parts, such as bacterial invasion, inflammatory response, and neuronal damage.
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A person with the invasive meningococcal disorder can have the chronic benign meningococcemia, only meningitis, meningitis and shock, bacteremia with shock, but without meningitis, and bacteremia without shock. Factors impacting the patient's disorder type will develop depending on the disorder duration before hospitalization, prognosis, mediator activation pattern, severity, and the site (Manchanda, Gupta, & Bhalla, 2006). These patients’ classification in one of the clinically recognizable group can be a great assistance for clinical decision making, especially for the maximal and immediate intensive care support application. Due to the hematogenous spread, meningeal infection appeared in 50%-55% and it is similar to other acute purulent meningitis forms (Manchanda, Gupta, & Bhalla, 2006). The early symptoms are identified by the rapid meningococcal entry in the bloodstream and can resemble fulminant meningococcemia. The characteristic hemorrhagic skin lesion occurs in 80% of patients and become apparent only twelve to eighteen hours after the first disorder symptoms. Less than one percent of people, mostly adults, can experience one or more cases of recurrent rash, arthritis, arthralgia, spiking a fever, whereas this syndrome is designated as chronic benign meningococcemia (Manchanda, Gupta, & Bhalla, 2006). Patients experience fevers from days to weeks, and about 20% experience meningitis later. Hence, bacterial meningitis demands a strong attention from the medical perspective.
It is possible to confirm the bacterial meningitis diagnosis by the patients’ medical history and laboratory tests in addition to the physical examination of the investigational local meningeal irritation symptoms. Nonetheless, the most critical issue is the CSF examination. In case of meningitis suspicions, the doctor should examine CSF of the patients after the lumbar puncture collection despite the uncorrected coagulopathy or cases, which provoke elevated intracranial pressure (Al Bekairy at al., 2014). The high intracranial cases involve head trauma, focal neurological deficit, and seizure. The cardiopulmonary instability presence is another contradiction. For LP and in this situation, brain imaging is recommended. There if a necessity to do gram stain and culture in order to confirm the presence and to identify the bacterial infection type. CFS results involve the high white blood cell values with neutrophils predominance, low CSF glucose and high CSF protein (Al Bekairy at al., 2014). The causative microorganism determination assists in the efficient treatment selection. One shall recommend CSG gram staining as an accurate, inexpensive and fast tool for the bacterial etiology determination because CSF culture can take 48 hours. In addition, “polymerase chain reaction and latex agglutination test can be used for the bacterial meningitis diagnosis confirmation when negative culture results are gained in patients with prior antibiotics treatment because it has no dependence in the viable bacteria presence” (Al Bekairy at al., 2014, p. 471). Hence, the diagnosis has to be immediate and appropriate in order to avoid time lost for treatment.
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Disease Management and Treatment
Antimicrobial therapy is one of possible intervention alternatives. The antimicrobial agents’ selection depends on the different issues, such as CSF sensitivity and culture, blood isolate, gram stain, ability to gain concentration in the CSF above the minimum inhibitory concentration, CSF count, presumed immune status, clinical setting, and patients age (Al Bekairy at al., 2014). It is critical not to delay the intervention while waiting for the first test results. When the microorganism has been determined, one can apply the therapy modification. Another issue is the adjunctive treatment. Physiological support is crucial while one is waiting for the definitive therapy effect. Oxygenation and fluid are the basis of the supportive therapy and have to be augmented by ventilation and pressors as needed. It is important to treat convulsions in the appropriate way as well as carefully address the fluid management. The hydration status monitoring is crucial as over-hydration can provoke the associated cerebral edema and raised intracranial pressure. One can allow fluid intake liberalization, but appropriately monitor the output and intake as the serum electrolytes. It is advised on the individual basis for children aged above two months with the possible risks and benefits realization to apply antimicrobial therapy. The dexamethasone adjunctive is recommended by the antibiotic treatment beginning among the patients with pneumococcal meningitis (Al Bekairy at al., 2014). The administration mode is from ten to twenty minutes before or with the first antibiotic dose.
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Another issue is the chemoprophylaxis. There is a risk of contracting the disease in case of N. meningitidis or H. influenza. Other bacterial meningitis types involve cases provoked by S. pneumonia and believed to be less transmissible. The two-day rifampin course therapy is recommended as the first-line regimen for chemoprophylaxis (Manchanda, Gupta, & Bhalla, 2006). The right dose of 10 mg/kg every twelve hours for children aged above one month or 600 mg every twelve hours for adults (Manchanda, Gupta, & Bhalla, 2006). Another alternative is vaccines. Nowadays, there are three vaccines that target the most widespread meningitis bacterial causes. The quadrivalent polysaccharide vaccine provides the protection and it is available globally. The primary vaccination for children aged above two years and adults are provided by single 0.5 ml dose (Manchanda, Gupta, & Bhalla, 2006). The doctors recommend vaccinating children aged from three months to two years under specific circumstances. Such children have to receive two doses, three months apart. Moreover, the immunogenicity and effectiveness of the serogroup A and C meningococcal vaccines was provided (Manchanda, Gupta, & Bhalla, 2006). These vaccines have good immunogenicity with clinical effectiveness of 85% or higher among children whose age is five years old or older and adults.
Public Health Concerns
Bacterial meningitis is a serious disorder that can have an extremely negative influence on the public health. Excluding epidemics, at least 1.2 million bacterial meningitis cases happen annually and 135000 of patients die. Around 500000 of the cases and 50000 deaths happen due to the meningococcus (WHO, n.d., p.16). In most states in the world, endemic attack rates of meningococcal disorder range from 1 to 5 per 100000 people (WHO, n.d., p.16). The most challenging situations exist in the sub-Saharan region considering the fact that the incidence rate is extremely high. Seasonal factors are critical in contributing bacterial meningitis. In the northern hemisphere, involving subtropical states, the seasonal upsurge occurs in spring and winter. Mostly, the disorder is common among children aged from three months to five years old. States within the meningitis belt, the maximum incidents can be registered among children aged from five to ten years old (WHO, n.d., p.16). Hence, the global prevalence is considerable.
Despite all medical care advances with the introduction and active antibiotic use, meningitis provokes high morbidity and mortality rates. In Saudi Arabia, bacterial meningitis usually appears after Omhar and Al Haji seasons (Al Bekairy at al., 2014, p.470). In the US, the meningitis incidence was reduced to 1.38 cases in 2007 (Al Bekairy at al., 2014, p.470). Nonetheless, the attack rates are age-specific with high extend among elderly and infants. The infant attack rates range from 400 cases per 100000 in exchange to 20 per 100000 among children whose age is two and above, while among adults its only 1 to 2 per 100000 (Al Bekairy at al., 2014, p.470). Additionally, males are more affected as compared to females. The death incidence and proportion of bacterial meningitis diagnosed care depends on the state and age. The main morbidity related to meningitis is involved neurological consequences, such as limb weaknesses, mental disorder and hearing loss (Al Bekairy at al., 2014, p.470). Therefore, the bacterial meningitis is a challenging disorder that one should seriously and appropriately address.
Overall, bacterial meningitis is a serious disorder that provokes high levels of mortality and morbidity. The realization of the efficient directed and empiric antimicrobial therapy regimes can help to reduce the mortality and morbidity rates. It is necessary to apply chemoprophylaxis, dexamethasone, and vaccinations to the appropriate patient population in order to represent the effective patient care. In case of bacterial meningitis, the survival depends on the immediate diagnosis and early treatment, whereas and both issues are extremely challenging. Hence, meningitis is a serious disorder with challenging consequences and it is critical to consider all the aspects in order to provide effective healthcare management.