Guidelines With Gabi:
November 4, 2022
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. Meningitis remains one of the most potentially devastating diseases that a child can get. On this Guidelines with Gabi episode, Dr. Gabi Hester will talk with two of our kid experts at Children’s Minnesota about the diagnosis and management of pediatric meningitis.
Speaker 2: Welcome to Guidelines with Gabi.
Dr. Gabi Hester: Meningitis is a disease feared by clinicians and caregivers alike. My parents both completed medical training in the 1970s and they described performing lumbar punctures on children on most of their shifts, even in a smaller hospital. Thankfully, with the advent of vaccines such as Haemophilus influenza type B or Hib, this is much, much less common. Unfortunately, however, over a million cases of bacterial meningitis are still estimated to occur every year around the world. Today I’m going to be talking with two of our kid experts about different types of meningitis that we may encounter. I’ll be speaking with Dr. Emily Harrison, a pediatric infectious disease specialist, as well as Dr. Asitha Jayawardena, a pediatric otolaryngologist at Children’s Minnesota. So Emily and Asitha, thanks so much for joining me today. So Emily, tell me a little bit about what some of the common causes of meningitis are, particularly in our pediatric patients.
Dr. Emily Harrison: Usually I start thinking of bacterial causes first or that kind of bucket. And I usually think about it in different age groups. So for our babies, less than a month old, I’m usually thinking of group B Strep, E.coli, and so mostly things that babies are getting from their mom. And then in older infants, children or young adults, usually thinking of things like Neisseria meningitidis, Strep pneumo, Haemophilus influenzae, and especially type B. Unfortunately these are mostly vaccine preventable, that kind of bucket. And then of course there’s a bunch of viral causes too.
Dr. Gabi Hester: You mentioned vaccines, so I imagine the landscape of epidemiology has changed a little bit with vaccines. Are there any other new pathogens that we should be aware of that maybe aren’t things that we would historically thought about?
Dr. Emily Harrison: This summer there was a lot of attention on parechovirus and I think we saw more of it. And some of that may have been because of increased testing with the meningitis/encephalitis panel. But I’m not sure if it’s truly a new pathogen. We think it’s probably actually the most common cause of viral meningitis in infants after enterovirus. So not particularly new, but maybe just more identified and probably some kind of ebb and flow of how often we’re seeing it and may have been seen a bit more of it this summer.
Dr. Gabi Hester: And you talked a little bit about bacterial causes, viral causes. If we’re looking at a hundred kids with meningitis, what’s the likelihood that it’s going to be bacterial versus viral?
Dr. Emily Harrison: Probably in this time now of a lot of vaccination coverage, probably usually mostly viral causes.
Dr. Gabi Hester: So if you have a child with meningitis who comes to a clinic or to the emergency room, what are some of the key symptoms that they might be presenting with?
Dr. Emily Harrison: Certainly depends on the age of the kid that you’re looking at. Infants can be really tricky obviously because they may not have many signs of meningitis or serious infection. But typically for infants, you’re looking for things like fever, lethargy, poor feeding, irritability. And then that physical exam finding that everyone’s looking for that bulging fontanelle. And then older infants or kids, looking for things like fever, headaches, neck stiffness, if they’re old enough to complain about, may complain of photophobia, maybe acting a bit confused.
Dr. Gabi Hester: So most of these patients, if not all of these patients will have blood tests, spinal tap or lumbar puncture to help really understand the type of pathogen that we’re dealing with. Are there any other new tests or newer tests that are helpful in the diagnosis or the diagnostic workup of a patient with suspected meningitis.
Dr. Emily Harrison: So in all these kids we’re sending our standard tests, the ones that we’re used to looking at the CSS cell counts, so why blood cell count, red blood cell count, glucose, protein, and really helping us decide kind of which direction to go in. But the new test we’re getting used to using, figuring out when the right time to use it is the meningitis PCR panels, which can detect bacterial and viral pathogens.
Dr. Gabi Hester: Let’s talk a little bit about the clinical guideline that we’ve just developed recently here at Children’s Minnesota. I think it’s a really interesting quality improvement example because I think it stemmed from one specialty area noting a problem, and then we dug deeper and exposed other areas where I think improvement was needed. Asitha, can you tell me a little bit about the problem that you were seeing and how you got involved in this work?
Dr. Asitha Jayawardena: We were finding some inconsistencies in the timing of audiometric consultation for these kids that have diagnosed meningitis. And similarly, once we were consulted, there were inconsistencies amongst the practitioners about timing of intervention, subsequent imaging and follow up hearing testing. And so we thought, well, hey, this is a good opportunity to do a deep dive into the literature, create an evidence based guideline when it comes to timing of audiometric testing and subsequent intervention. And so we created basically a protocol solely thinking that we were going to be doing this from the ENT and audiology side. And then when we reached out to disseminate this to the emergency department to different practitioners involved, we found the opportunity that was there for basically expanding this to a much larger project beyond ENT and audiology and basically creating a standardized clinical practice guideline for meningitis care at Children’s.
Dr. Gabi Hester: It’s like everyone’s worst nightmare. We’ve got this project, we’re going to roll it out. And then someone like me comes along and says, “Hey, let me volunteer you to make this much larger and have a much broader scope”. But I think what we did was really ask some quality improvement style questions. Sometimes we think of them as the five why’s and when we really dug into the why are these kids missing the types of hearing or audiometric screening that they need, it was really that we lacked a standard process across the whole care spectrum for patients with suspected meningitis. So a good opportunity to bring all these different stakeholders together to develop one. But Emily, tell me a little bit more about the bacterial meningitis prediction score. I know this was developed by a team led by Dr. Lise Negrovic and published in JAMA in 2007. In our new clinical guideline for meningitis, how are we incorporating this tool in our assessment of patients presenting to our ED with suspected meningitis?
Dr. Emily Harrison: So this is a tool that we’re trying to use to help us differentiate kids who are higher likelihood to have bacterial meningitis and get them on the course of treatment and also to identify kids then that are lower risk than bacterial meningitis and more likely to viral meningitis. So this is a tool, kind of a scoring system that looked at features that made kids higher risk for having bacterial meningitis. And this looked at features of their CSF, so from their lumbar puncture, and then also looking at some blood studies.
So that initial study from JAMA in 2007, people have since looked at some other blood markers, things like the CRP and the Procalcitonin that we’ve added to the things we’re looking at here at Children’s. And then that scoring system also looks at seizures before presentation as well. But the details of that are found in our guidelines. What’s particularly helpful about this study is that it had an excellent negative predictive value of 99%. So lack of these features is really good at helping us say with some more confidence that children don’t have bacterial meningitis.
Dr. Gabi Hester: I’ve incorporated that tool quite a bit in making discharge decisions for my patients and really explaining to family, extremely helpful in thinking about the risk of meningitis.
Dr. Emily Harrison: If you don’t have those features, that’s pretty good about ruling out bacterial meningitis.
Dr. Gabi Hester: Right. Less helpful for us to say, okay, you have one of those features that pretty much just says we need to dig a little deeper, watch you longer in the hospital. So Emily, I know that the tool was really great, particularly for older age kids, but maybe not quite as sensitive for children who were less than 29 days of age. In that patient population, should we be approaching those kids differently? Are there other things that we should be worried about and having on our radar?
Dr. Emily Harrison: Yeah, like I mentioned before, that younger age group has different pathogens that we think about primarily if they get from exposure to their mothers. And I’d mentioned some of the bacterial causes. And of course I think I’d forgotten to mention HSV there too, which is also really important neonatal pathogen. But in particular for these bacterial meningitis scores, these studies have excluded that neonatal group. So we’re done in kids greater than 28 days of age, and so I wouldn’t trust them in that younger age group.
Dr. Gabi Hester: So Emily, focusing a little bit more on how we treat patients really targeting in on bacterial meningitis, what are some of the first line antibiotics that we would typically use?
Dr. Emily Harrison: Meningitis, I would rely primarily on Ceftriaxone and Vancomycin, especially in that age group that we’re focusing on here and that over 29 days of age, more than a month of age, and the Ceftriaxone is going to cover most of your pathogens. And then the Vancomycin is not really to cover MRSA, but is really to cover resistance strep pneumo. And then we also do think about adding Acyclovir when there’s any concern for HSV. Often we think about HSV in that younger age group, but certainly can occur in older kids with [inaudible 00:10:32].
Dr. Gabi Hester: Are there any indications for imaging of the brain?
Dr. Emily Harrison: So we do recommend any head imaging prior to a lumbar puncture in kids who have any focal neurologic deficits, anyone with new onset seizures or anyone with severely altered mental status. And then any of our kids who are severely immunocompromised, we’d also want brain imaging. And here we’re looking for any masses or any other contraindication to doing a lumbar puncture. And then this can also be helpful to get information if there’s any separative complications of Empra haemo or something where we might need to call our neurosurgical colleagues to get directly involved.
Dr. Gabi Hester: Asitha, we talked a little bit earlier about the role of audiometric screening in patients with meningitis, are there any exceptions to that or should all kids with all types of meningitis have that type of screening done?
Dr. Asitha Jayawardena: The reason we screen these kids is because there’s a subset of children that develop bacterial meningitis that get an infection within the cochlea. That infection within the cochlea can lead to fibrogenesis and ultimately osteogenesis that subsequently closes off the cochlear, creating a Sensorineural hearing loss and a permanent hearing loss that is not amendable to treatment by cochlear implantation because the cochlear itself is totally closed off. That’s called cochlear ossificans. And that’s the main reason, reason why we’re screening these children for hearing is to basically identify those kids early in the process because it is timing dependent.
If you identify them before that osteogenesis occurs, you can actually insert an electrode into the cochlear and preserve hearing via cochlear implantation. We actually divide kids into separate categories in our protocol based on if they have bacterial meningitis or a viral meningitis. Kids with a viral meningitis just need a single ABR as a screening test. If they pass that, they can move on and basically test out of the pathway because their risk of cochlear cancers is insignificant. So kids with bacterial meningitis, if they pass their initial ABR, we will subsequently test them three months after that and then again nine months after that. And that’s in order to pick up the delayed osteogenesis that can occur as part of cochlear ossificans.
Dr. Gabi Hester: As a hospitalist taking care of kids, particularly with bacterial meningitis usually, or in some settings viral meningitis, what would the process be for me to get these kids to have the appropriate audiometric testing that they need?
Dr. Asitha Jayawardena: So I would recommend that hospitalists do is basically you can place an audiometric consultation via Cerner and that’ll go electronically to our audiologists. Then they can use the protocol that we’ve designed to help determine the timing of audiometric testing, which basically will be as soon as the child is clinically stable enough to pursue that sort of testing and they can follow the algorithm that we’ve created in terms of if they fail the hearing test, what do we do next? So from a hospitalist perspective, all that you need to do is actually place the audiometric consultant in Cerner. If the initial audiometric testing is not normal, then the audiologist will consult ENT and subsequently repeat hearing testing and we’ll coordinate that testing with CT and MRI imaging in order to identify if there is any cochlear acidification that is started to develop.
Dr. Gabi Hester: So as Asitha, you mentioned that with viral meningitis, there’s sort of a one and done type testing as long as they pass, you don’t need any repeat. It sounds like maybe it’s a little bit more timing specific for kids with bacterial meningitis. If a child is hospitalized in a location where audiometric testing isn’t readily available, is there an indication for transfer of that patient or can you talk a little bit about the specifics of timing of that testing?
Dr. Asitha Jayawardena: I do think that is something that is quite timing dependent to at least have that initial audiometric test. And whether that occurs within the hospital or as an outpatient, I think is somewhat dependent on the resources of the area that you’re speaking of. But having that being done and having a good plan with good follow up to ensure that this child gets tested is incredibly important because what we have seen is when this gets transferred to the patient in terms of the responsibility to go to a hearing test, it is not necessarily apparent to the family that this child is developing a hearing loss, particularly if that’s unilateral because the child can hear the contra later side.
And so it is important to get that testing done because as I said, that is a hearing loss that if cochlear closes, we are not able to treat that. And even if we catch it late in the game, but we can partially insert an electrode, that hearing outcome for that cochlear implantation is going to be less than if we caught that earlier and could have a full cochlear insertion. So it is, particularly for bacterial meningitis, a very timing dependent thing that I would say is important. That’s part of the reason that we created this protocol.
Dr. Gabi Hester: Now you mentioned consultation of ENT if the audiometric testing is abnormal. Are there any other indications for ENT consultation in patients with bacterial meningitis?
Dr. Asitha Jayawardena: Very often children with bacterial meningitis have acute otitis media and in the setting of an acute otitis media that’s apparent on clinical examination through classic full bulging tympanic membrane, we would like to be consulted as an ENT group in order to place a tympanostomy tube. And the way that I think of this is that you often have otogenic meningitis, meaning that the bacteria is actually built up in the middle ear space, sub mastoid and has nowhere to go, and that reservoir of bacteria can subsequently influence meningitis.
And subsequently a tympanostomy tube can essentially relieve the dam or break the dam and all of that bacteria that has a place to go, we can suction that out and actually provide some sort of actual physical relief for that bacteria and apply topical antibiotics which are going to achieve a higher concentration of antibiotics within the middle ear space where that bacterial reservoir is as opposed to even the big gun antibiotics that Emily and her team is able to provide. So in the setting of an acute otitis media, a tympanostomy tube does have a role in these kids with meningitis.
Dr. Emily Harrison: Do they have better hearing outcomes?
Dr. Asitha Jayawardena: Immediately they’re going to because their fluid is going to be relieved. Now, does that influence Sensorineural hearing loss? There’s not been a study that I’m aware of that has evaluated that, but certainly one would think that by relieving that pressure, you would at least have less of a bacterial burden within the cochlear itself, and therefore you can maybe prevent cochlear acidification. But I don’t think there’s any data that actually says that other than the biologic plausibility that I just described.
Dr. Gabi Hester: So we just talked a little bit about hearing loss and some of the implications of meningitis in that realm. Emily, can you tell me a little bit about what other complications of meningitis we should be watching out for? I know families are often really obviously interested in hearing what outcomes are going to be down the road for kids with meningitis.
Dr. Emily Harrison: I usually think of the kind of shorter term and the longer term consequences. So the shorter term consequences I’m thinking of right up front in that initial hospital stay. So monitoring for things like cerebral edema, increased intracranial pressure, Hydrocephalus, looking for subdural effusions or empyemas. Again, things where we might need our neurosurgical colleagues help us with right away in the hospital. So then after the treatment of the bacterial meningitis, we’re looking at long-term consequences. So of course, thinking about that hearing loss. But we can also see things like seizures, developmental delay, and some other neurologic consequences. And those long-term outcomes really depends usually on the organism, the age of the kid, how much the infections progress before we’re able to start treatment, and then how quickly we’re able to treat the infection.
Speaker 2: Take home points.
Dr. Gabi Hester: Number one, patients with meningitis often present with symptoms such as fever, headache and stiff neck. However, these symptoms may be subtle, particularly in young infants.
Number two, bacterial meningitis prediction tools can help us to identify kids at very low risk of having bacterial meningitis who may be appropriate candidates for home supportive care if other discharge criteria are met.
Number three, audiometric testing is indicated in all patients with meningitis. In kids with bacterial meningitis, repeat testing is also indicated due to the risk of developing cochlear ossificans.
Number four, long-term complications of meningitis may include hearing loss, seizures, and developmental delay.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.