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01-12-2021 | Neck Stiffness | Research article

Clinical features of bacterial meningitis among hospitalised children in Kenya

Authors: Christina W. Obiero, Neema Mturi, Salim Mwarumba, Moses Ngari, Charles R. Newton, Michaël Boele van Hensbroek, James A. Berkley

Published in: BMC Medicine | Issue 1/2021

Abstract

Background

Diagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae. In sub-Saharan Africa, many public hospitals lack laboratory capacity, relying on clinical features to empirically treat or not treat meningitis. We investigated whether clinical features of bacterial meningitis identified prior to the introduction of conjugate vaccines still discriminate meningitis in children aged ≥60 days.

Methods

We conducted a retrospective cohort study to validate seven clinical features identified in 2002 (KCH-2002): bulging fontanel, neck stiffness, cyanosis, seizures outside the febrile convulsion age range, focal seizures, impaired consciousness, or fever without malaria parasitaemia and Integrated Management of Childhood Illness (IMCI) signs: neck stiffness, lethargy, impaired consciousness or seizures, and assessed at admission in discriminating bacterial meningitis after the introduction of conjugate vaccines. Children aged ≥60 days hospitalised between 2012 and 2016 at Kilifi County Hospital were included in this analysis. Meningitis was defined as positive cerebrospinal fluid (CSF) culture, organism observed on CSF microscopy, positive CSF antigen test, leukocytes ≥50/μL, or CSF to blood glucose ratio <0.1.

Results

Among 12,837 admissions, 98 (0.8%) had meningitis. The presence of KCH-2002 signs had a sensitivity of 86% (95% CI 77–92) and specificity of 38% (95% CI 37–38). Exclusion of ‘fever without malaria parasitaemia’ reduced sensitivity to 58% (95% CI 48–68) and increased specificity to 80% (95% CI 79–80). IMCI signs had a sensitivity of 80% (95% CI 70–87) and specificity of 62% (95% CI 61–63).

Conclusions

A lower prevalence of bacterial meningitis and less typical signs than in 2002 meant the lower performance of KCH-2002 signs. Clinicians and policymakers should be aware of the number of lumbar punctures (LPs) or empirical treatments needed for each case of meningitis. Establishing basic capacity for CSF analysis is essential to exclude bacterial meningitis in children with potential signs.

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Mann K, Jackson MA. Meningitis. Pediatrics Review. 2008;29(12):417–30. https://doi.org/10.1542/pir.29-12-417.CrossRef

Edmond K, Clark A, Korczak VS, Sanderson C, Griffiths UK, Rudan I. Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10(5):317–28. https://doi.org/10.1016/S1473-3099(10)70048-7.CrossRefPubMed

Ramakrishnan M, Ulland AJ, Steinhardt LC, Moisi JC, Were F, Levine OS. Sequelae due to bacterial meningitis among African children: a systematic literature review. BMC Med. 2009;7(1):47. https://doi.org/10.1186/1741-7015-7-47.CrossRefPubMedPubMedCentral

Manning L, Laman M, Mare T, Hwaiwhanje I, Siba P, Davis TM. Accuracy of cerebrospinal leucocyte count, protein and culture for the diagnosis of acute bacterial meningitis: a comparative study using Bayesian latent class analysis. Trop Med Int Health. 2014;19(12):1520–4.CrossRef

Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. 2001;108(5):1169–74.PubMed

Ayieko P, Ogero M, Makone B, Julius T, Mbevi G, Nyachiro W, et al. Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network. Arch Dis Childhood. 2016;101(3):223–9. https://doi.org/10.1136/archdischild-2015-309269.CrossRef

Herbert G, Ndiritu M, Idro R, Makani JB, Kitundu J. Analysis of the indications for routine lumbar puncture and results of cerebrospinal fluid examination in children admitted to the paediatric wards of two hospitals in East Africa. Tanzania J Health Res. 2006;8(1):7–10.CrossRef

WHO. Pocket book of hospital care for children: WHO Press; 2013. Available from: http://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/.

WHO IMCI. Integrated Management of Childhood Illness (IMCI) Chart Booklet. Distance Learn Course. 2014;(March):1–76.

10.

Weber MW, Herman J, Jaffar S, Usen S, Oparaugo A, Omosigho C, et al. Clinical predictors of bacterial meningitis in infants and young children in The Gambia. Trop Med Int Health. 2002;7(9):722–31. https://doi.org/10.1046/j.1365-3156.2002.00926.x.CrossRefPubMed

11.

Berkley JA, Versteeg AC, Mwangi I, Lowe BS, Newton CRJC. Indicators of acute bacterial meningitis in children at a rural Kenyan District Hospital. Pediatrics. 2004;114(6):e713–e9. https://doi.org/10.1542/peds.2004-0007.CrossRefPubMed

12.

MOH. Basic Paediatric Protocols for ages up to 5 years February 2016. Available from: https://www.tropicalmedicine.ox.ac.uk/_asset/file/basic-paediatric-protocols-2016.pdf.

13.

Mwenda JM, Soda E, Weldegebriel G, Katsande R, Biey JN-M, Traore T, et al. Pediatric bacterial meningitis surveillance in the World Health Organization African Region using the invasive bacterial vaccine-preventable disease surveillance network, 2011–2016. Clin Infect Dis. 2019;69(Supplement_2):S49–57.CrossRef

14.

Cowgill KD, Ndiritu M, Nyiro J, Slack MPE, Chiphatsi S, Ismail A, et al. Effectiveness of haemophilus influenzae type b conjugate vaccine introduction into routine childhood immunization in Kenya. Jama. 2006;296(6):671–8. https://doi.org/10.1001/jama.296.6.671.CrossRefPubMedPubMedCentral

15.

Gessner BD, Adegbola RA. The impact of vaccines on pneumonia: key lessons from Haemophilus influenzae type b conjugate vaccines. Vaccine. 2008;26:B3–8. https://doi.org/10.1016/j.vaccine.2008.04.013.CrossRefPubMed

16.

Wahl B, O'Brien KL, Greenbaum A, Majumder A, Liu L, Chu Y, et al. Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000-15. Lancet Global Health. 2018;6(7):e744–e57. https://doi.org/10.1016/S2214-109X(18)30247-X.CrossRefPubMed

17.

Zunt JR, Kassebaum NJ, Blake N, Glennie L, Wright C, Nichols E, et al. Global, regional, and national burden of meningitis, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(12):1061–82. https://doi.org/10.1016/S1474-4422(18)30387-9.CrossRef

18.

Berkley JA, Mwangi I, Mellington F, Mwarumba S, Marsh K. Cerebral malaria versus bacterial meningitis in children with impaired consciousness. QJM : monthly journal of the Association of Physicians. 1999;92(3):151–7. https://doi.org/10.1093/qjmed/92.3.151.CrossRefPubMed

19.

Mogeni P, Williams TN, Fegan G, Nyundo C, Bauni E, Mwai K, et al. Age, spatial, and temporal variations in hospital admissions with malaria in Kilifi County, Kenya: a 25-year longitudinal observational study. PLoS Med. 2016;13(6):e1002047. https://doi.org/10.1371/journal.pmed.1002047.CrossRefPubMedPubMedCentral

20.

Nkumama IN, O'Meara WP, Osier FHA. Changes in malaria epidemiology in Africa and new challenges for elimination. Trends Parasitol. 2017;33(2):128–40. https://doi.org/10.1016/j.pt.2016.11.006.CrossRefPubMed

21.

Njuguna P, Maitland K, Nyaguara A, Mwanga D, Mogeni P, Mturi N, et al. Observational study: 27 years of severe malaria surveillance in Kilifi, Kenya. BMC Med. 2019;17(1):124. https://doi.org/10.1186/s12916-019-1359-9.CrossRefPubMedPubMedCentral

22.

Schulga P, Grattan R, Napier C, Babiker MO. How to use lumbar puncture in children. Arch Dis Child Educ Pract Ed. 2015;100(5):264–71. https://doi.org/10.1136/archdischild-2014-307600.CrossRefPubMed

23.

Chun S, Kang C-I, Kim Y-J, Lee NY. Clinical Significance of Isolates Known to Be Blood Culture Contaminants in Pediatric Patients. Medicina. 2019;55(10):696. https://doi.org/10.3390/medicina55100696.

24.

Aipit J, Laman M, Hwaiwhanje I, Bona C, Pomat N, Siba P, et al. Accuracy of initial clinical diagnosis of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea. Trans R Soc Trop Med Hyg. 2014;108(7):444–8. https://doi.org/10.1093/trstmh/tru067.CrossRefPubMed

25.

Mwangi I, Berkley J, Lowe B, Peshu N, Marsh K, Newton CR. Acute bacterial meningitis in children admitted to a rural Kenyan hospital: increasing antibiotic resistance and outcome. Pediatric Infect Dis J. 2002;21(11):1042–8. https://doi.org/10.1097/00006454-200211000-00013.CrossRef

26.

Obiero CW, Mturi N, Mwarumba S, Ngari M, Newton C, Boele van Hensbroek M, et al. Clinical features to distinguish meningitis among young infants at a rural Kenyan hospital. Archives of disease in childhood. 2021;106(2):130–6. http://dx.doi.org/10.1136/archdischild-2020-318913.

27.

Abdul-Mumin A, Cotache-Condor C, Owusu SA, Mahama H, Smith ER. Timing and causes of neonatal mortality in Tamale Teaching Hospital, Ghana: a retrospective study. PLoS One. 2021;16(1):e0245065. https://doi.org/10.1371/journal.pone.0245065.CrossRefPubMedPubMedCentral

28.

Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010;126(5):952–60. https://doi.org/10.1542/peds.2010-0277.CrossRefPubMed

29.

Laman M, Manning L, Greenhill AR, Mare T, Michael A, Shem S, et al. Predictors of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea. Am J Trop Med Hyg. 2012;86(2):240–5. https://doi.org/10.4269/ajtmh.2012.11-0312.CrossRefPubMedPubMedCentral

30.

Nhantumbo AA, Gudo ES, Caierao J, Munguambe AM, Come CE, Zimba TF, et al. Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae in children with acute bacterial meningitis in Mozambique: implications for a national immunization strategy. BMC Microbiol. 2016;16(1):134. https://doi.org/10.1186/s12866-016-0747-y.CrossRefPubMedPubMedCentral

31.

Sanneh B, Okoi C, Grey-Johnson M, Bah-Camara H, Kunta Fofana B, Baldeh I, et al. Declining trends of pneumococcal meningitis in gambian children after the introduction of pneumococcal conjugate vaccines. Clin Infect Dis. 2019;69(Suppl 2):S126–S32. https://doi.org/10.1093/cid/ciz505.CrossRefPubMedPubMedCentral

32.

Manning L, Laman M, Greenhill AR, Michael A, Siba P, Mueller I, et al. Increasing chloramphenicol resistance in Streptococcus pneumoniae isolates from Papua New Guinean children with acute bacterial meningitis. Antimicrob Agents Chemother. 2011;55(9):4454–6. https://doi.org/10.1128/AAC.00526-11.CrossRefPubMedPubMedCentral

33.

Duke T, Michael A, Mokela D, Wal T, Reeder J. Chloramphenicol or ceftriaxone, or both, as treatment for meningitis in developing countries? Arch Disease Childhood. 2003;88(6):536–9. https://doi.org/10.1136/adc.88.6.536.CrossRef

34.

Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics. 2000;105(2):316–9. https://doi.org/10.1542/peds.105.2.316.CrossRefPubMed

35.

Nigrovic LE, Malley R, Macias CG, Kanegaye JT, Moro-Sutherland DM, Schremmer RD, et al. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Pediatrics. 2008;122(4):726–30. https://doi.org/10.1542/peds.2007-3275.CrossRefPubMed

36.

Tadesse BT, Foster BA, Shibeshi MS, Dangiso HT. Empiric treatment of acute meningitis syndrome in a resource-limited setting: clinical outcomes and predictors of survival or death. Ethiop J Health Sci. 2017;27(6):581–8. https://doi.org/10.4314/ejhs.v27i6.3.CrossRefPubMedPubMedCentral

37.

Kaplan SL, OʼBrian Smith E, Wills C, Feigin RD. Association between preadmission oral antibiotic therapy and cerebrospinal fluid findings and sequelae caused by Haemophilus influenzae type b meningitis. Pediatric Infect Dis J. 1986;5(6):626–32. https://doi.org/10.1097/00006454-198611000-00005.CrossRef

38.

Khumalo J, Nicol M, Hardie D, Muloiwa R, Mteshana P, Bamford C. Diagnostic accuracy of two multiplex real-time polymerase chain reaction assays for the diagnosis of meningitis in children in a resource-limited setting. PLoS One. 2017;12(3):e0173948. https://doi.org/10.1371/journal.pone.0173948.CrossRefPubMedPubMedCentral

39.

Bonsu BK, Harper MB. Corrections for leukocytes and percent of neutrophils do not match observations in blood-contaminated cerebrospinal fluid and have no value over uncorrected cells for diagnosis. Pediatr Infect Dis J. 2006;25(1):8–11. https://doi.org/10.1097/01.inf.0000195624.34981.36.

Title: Clinical features of bacterial meningitis among hospitalised children in Kenya
Authors: Christina W. Obiero
Neema Mturi
Salim Mwarumba
Moses Ngari
Charles R. Newton
Michaël Boele van Hensbroek
James A. Berkley
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Neck Stiffness
Malaria
Cyanosis
Febrile Seizure
Meningitis
Cyanosis
Focal Seizure
Published in: BMC Medicine / Issue 1/2021
Electronic ISSN: 1741-7015
DOI: https://doi.org/10.1186/s12916-021-01998-3

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Springer Medicine

Clinical features of bacterial meningitis among hospitalised children in Kenya

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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