II.5.3.1) IMAGING TECHNIQUES
? COMPUTED TOPOGRAPHIC SCAN (CT SCAN): This
should normally be done before lumbar puncture in order to rule out any
presence of raised intracranial pressure in order to avoid brain herniation
during a lumbar puncture performance. Now it should be noted that, CT SCAN is
not sensitive at 100%, because a normal SCAN does not absolutely exclude
subsequent risk of herniation[21].
? MAGNETIC RESONANCE IMAGING (MRI): It is
also useful in the diagnosis meningitis and is more sensitive than the SCAN
with the fact that, it is able to show extensive inflammatory tissue
destruction of the meninges in their different spaces, also detects pus and
thus can be used when the others are not available or feasible[45].
II.6) CURRENT TREATMENT ON BACTERIAL MENINGITIS IN
CHILDREN
The three major aspects of treatment of bacterial meningitis
include (1) antibiotic therapy (2) fluid restriction (3) adjunctive therapy
[21].
II.6.1) ANTIBIOTIC TREATMENT
Most treatment guidelines recommend the use of a
third-generation cephalosporin (such as ceftriaxone or cefotaxime) in
conjunction with vancomycin as initial antibiotic therapy. Cefotaxime and
ceftriaxone have excellent activity against all Hib and N.
meningitidis strains [46].
Increasing resistance of S. pneumoniae to penicillins has been
reported, and although cefotaxime and ceftriaxone remain active against many
penicillin-resistant pneumococcal strains, treatment failure has been reported,
hence the addition of empirical vancomycin [46].
In resource limited settings the treatment of paediatric BM
generally has two protocols based on age (under 2 months and above 2 months of
age).Accordingly, for neonates and young infants (under 2 months of age) the
first-line antibiotics are Ampicillin and Gentamicin and alternatives, a
third-generation cephalosporin, such as Ceftriaxone or Cefotaxime plus
Gentamycin.For infants and children (above 2 months of age) the first line is
the combination of Penicillin G and Chloramphenicol and the alternative is
Ceftriaxone, or Cefotaxime [2].
22
II.6.2) ADJUVANT THERAPY AND SUPPORTIVE THERAPY
Recommended dexamethasone dosing regimens range from 0.6 to
0.8 mg/kg daily in two or three divided doses for 2 days to 1 mg/kg in four
divided doses for 2 to 4 days [47][48].
For optimal results, the first dose of dexamethasone could be
administered before, but due to its side effects in children like duodenal
perforation, it is better to administered it,concomitant with the first
parenteral antibiotic dose, since in either way the efficacy of the
corticosteroid still remains the same.
Control and prevention of seizures can be attained with
anticonvulsant medications; benzodiazepines, phenytoin, and phenobarbital are
commonly used for this purpose [21].
II.6.3) FLUID RESTRICTION
In general, it is a common practice to restrict fluids to two
thirds or three quarters of the daily maintenance during the management of
childhood meningitis. The basis for this practice is the need to reduce the
likelihood of the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH). SIADH is characterized by hyponatraemia, fluid retention and a
tendency to worsen cerebral oedema in meningitis. Therefore, practitioners
reduce fluid therapy in children with meningitis in the hope of preventing
SIADH [21].
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