Epidemiology and pathogenesis
Neonatal meningitis is an extremely serious problem in pediatrics due to the enormous risks to an infant's life. The disease features an exceptionally high mortality rate of around 50%. The prognosis for surviving children also remains poor: approximately one-third of patients develop permanent neurological sequelae later in life.
From the standpoint of pathogenesis, meningeal inflammation may develop as an isolated pathology, but it frequently acts as one of the purulent foci in full-blown neonatal sepsis. A significant predisposing factor that worsens the course of the disease is prior perinatal nervous system injury (PNSI).
The etiology largely depends on the child's age at the onset of the disease. Group B streptococci and Escherichia coli (E. coli) are recognized as the most relevant pathogens for the first week of life. Subsequently, staphylococci, Klebsiella, and other microorganisms begin to play a significant role.
Clinical presentation
The insidious nature of neonatal meningitis lies in the predominance of non-specific symptoms at onset. Important diagnostic nuance: nuchal rigidity and other classic meningeal signs appear in newborns only in the late stages of the disease.
Clinical manifestations are grouped into the following syndromes:
- General infectious and intoxication syndrome: unstable condition alternating between lethargy and restlessness. The infant refuses enteral feeding and regurgitates. Temperature reaction (fever), pallor with acrocyanosis, and intestinal paresis (abdominal distension) are characteristic.
- Increased intracranial pressure syndrome: manifested by a specific "cerebral" cry, bulging and tense anterior fontanelle, as well as vomiting.
- Focal and neurological symptoms: hyperesthesia, pronounced seizure activity, oculomotor disturbances (dancing eyes/roving eye movements, Graefe's sign).
Diagnostics
Since early clinical signs are non-specific, lumbar puncture is the "gold standard" of diagnosis. It is indicated at the slightest suspicion of meningitis.
In a purulent process, the following changes are observed:
- Macroscopy: cerebrospinal fluid flows out under increased pressure (frequent drops or a stream), visually it is turbid or opalescent.
- Laboratory analysis (cytology and biochemistry): pronounced neutrophilic pleocytosis is detected. Hypoglycemia (decreased glucose level) and hyperproteinorrachia (increased protein concentration) are characteristic.
- Microbiology: bacterioscopy and bacteriological culture of the CSF sediment are mandatory.
To monitor treatment efficacy, diagnostics do not stop: repeat punctures are performed every 4–5 days until complete CSF clearance.
Principles of treatment
The cornerstone of patient survival is emergency etiotropic therapy. Antibiotics with high blood-brain barrier (BBB) penetration are prescribed.
- Drug selection: cephalosporins (ceftriaxone, cefotaxime, ceftazidime), carbapenems (meropenem), aminoglycosides (gentamicin), amoxicillin, and vancomycin are used.
- Dosing regimen: maximum age-approved dosages are used. The course of treatment is prolonged, with antibiotic rotation every 1–2 weeks.
- Routes of administration: drugs are administered systemically. Endolumbar and intraventricular administration is recognized as ineffective.
Pathogenetic and symptomatic therapy is carried out in parallel. It includes detoxification, dehydration (to manage cerebral edema and intracranial pressure), and anticonvulsant therapy.
To remember the purulent CSF profile: Protein High, Sugar Low, Neutrophils Abundant.
Class and exam questions
When do classic meningeal signs appear in a newborn?
Unlike older children, newborns exhibit nuchal rigidity and other classic symptoms only in the late stages of the disease.
Is endolumbar administration of antibiotics effective?
No, endolumbar and intraventricular administration of antibacterial drugs for this pathology is considered ineffective.
How often should the antibiotic be changed during treatment?
The course of therapy is prolonged, and mandatory drug rotation is performed every 1–2 weeks.
What else to study on this topic
- Diagnostic criteria for neonatal sepsis
- Perinatal CNS injury (PNSI): risk factors and classification
- Oculomotor disorders in neonatology (Graefe's sign)
- Technique of lumbar puncture in newborns
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