eMedicine Specialties > Neurology > Pediatric Neurology

Neonatal Meningitis

Author: David C Dredge, MD, Clinical Fellow in Child Neurology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School
Coauthor(s): Kalpathy S Krishnamoorthy, MD, Associate Professor of Pediatrics and Neurology, Harvard Medical School; Consulting Staff, Division of Pediatric Neurology, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Jan 15, 2010

Introduction

Background

Despite development of effective vaccines, tools for rapid identification of pathogens, and potent antimicrobial drugs, neonatal meningitis continues to contribute substantially to neurological disability worldwide. The persistence of neonatal meningitis results from increasing numbers of infants surviving premature delivery and from limited access to medical resources in developing countries. In addition, the absence of specific clinical findings makes diagnosis of meningitis more difficult in neonates than in older children and adults. Moreover, a wide variety of pathogens are seen in infants because of immaturity of their immune systems and intimate exposure to possible infection from their mothers.

This review focuses on common presentations of treatable bacterial and viral meningitis in the neonatal period, defined as birth to 44 weeks postconceptual age. Common CNS infections caused by bacteria and viruses (eg, herpes simplex) are emphasized.

Excluded from this discussion are the meningitides caused by HIV and fungi as well as other organisms implicated in congenital CNS damage (eg, cytomegalovirus, toxoplasmosis).

Pathophysiology

Neonates are at greater risk of sepsis and meningitis than other age groups because of deficiencies in humoral and cellular immunity and in phagocytic function. Infants younger than 32 weeks' gestation receive little of the maternal immunoglobulin received by full-term infants.1,2 Inefficiency in the neonates' alternative complement pathway compromises their defense against encapsulated bacteria.3 T-cell defense and mediation of B-cell activity also are compromised. Finally, deficient migration and phagocytosis by neutrophils contribute to neonatal vulnerability to pathogens of even low virulence.4

Frequency

United States

The incidence of bacterial meningitis is approximately 0.3 per 1000 live births in industrialized countries.4 The incidence of herpes simplex virus (HSV) meningitis is estimated to be 0.02-0.5 cases per 1000 live births.5

International

The incidence of neonatal meningitis is difficult to accurately determine because of testing limitations. However, a recent study of neonatal infections in Asia (collecting data from China, Hong Kong, India, Iran, Kuwait, and Thailand), reported estimated incidence of neonatal meningitis from 0.48 per 1000 live births in Hong Kong to 2.4 per 1000 live births in Kuwait.6 Another recent publication that looked at neonatal infections in Africa and South Asia found an incidence of neonatal meningitis ranging from 0.8 to 6.1 per 1000 live births.7 These numbers are felt to underestimate the true incidence, given the lack of access to health care facilities in underdeveloped countries.

Mortality/Morbidity

  • Bacterial meningitis: In developed countries, the rate of mortality from bacterial meningitis among neonates has declined from almost 50% in the 1970s to less than 10% in the late 1990s. However, a corresponding decrease in the morbidity rate has not occurred.8 Morbidities related to neonatal bacterial meningitis continue to be a significant source of disability. In a prospective sample of more than 1500 neonates surviving until age 5 years, the prevalence of neuromotor disabilities including cerebral palsy was 8.1%, learning disability 7.5%, seizures 7.3%, and hearing problems 25.8%.9 No problems were reported in 65% of babies who survived group B streptococcal (GBS) meningitis and in 41.5% of those who survived Escherichia coli meningitis. 
  • HSV meningitis: Mortality among neonates with HSV infection of the central nervous system is 15%. Of these cases, 25-40% will have culture-proven cerebrospinal fluid (CSF) infection. Interestingly, both HSV serotypes (HSV-1 and HSV-2) carry the same risk of mortality, but HSV-2 is more commonly associated with morbidities, including cerebral palsy, mental retardation, seizures, microcephaly, and ophthalmic defects.5

Clinical

History

Regardless of the specific pathogen involved, neonatal meningitis is most often caused by vertical transmission during labor and delivery. It occurs most frequently in the days following birth and is more common in premature infants than term infants.4 Neonatal meningitis occurs in roughly 0.3 per 1000 live births; it is closely associated with sepsis, which is 5 times as common.

Risk factors for the development of meningitis include low birth weight (<2500 g), preterm birth (<37 weeks' gestation), premature rupture of membranes, traumatic delivery, fetal hypoxia, and maternal peripartum infection (including chorioamnionitis).

When evaluating a neonate for meningitis, consider these 3 key points: (1) be vigilant for maternal infection "set-ups," including prolonged rupture of membranes, fever, and chorioamnionitis, remembering that asymptomatic maternal infection is always a possibility even with screening; (2) early-onset and late-onset bacterial infections have distinctive clinical courses, as detailed below; and (3) in HSV infections, the presence of skin lesions in a meningitic neonate are the exception rather than the rule.

Physical

  • Bacterial meningitis, early onset
    • Symptoms appearing in the first 48 hours of life are referable primarily to systemic illness rather than meningitis. These include temperature instability, episodes of apnea or bradycardia, hypotension, feeding difficulty, hepatic dysfunction, and irritability alternating with lethargy.1
    • Respiratory symptoms can become prominent within hours of birth in GBS infection; however, the symptom complex also is seen with infection by Escherichia coli or Listeria species.
  • Bacterial meningitis, late onset
    • Late-onset bacterial meningitis (symptom onset beyond 48 hours of life) is more likely to be associated with neurologic symptoms. Most commonly seen are stupor and irritability, which Volpe describes in more than 75% of affected neonates.
    • Between 25% and 50% of neonates will exhibit the following neurological signs: seizures; bulging anterior fontanel; extensor posturing/ opisthotonus; focal cerebral signs including gaze deviation and hemiparesis; cranial nerve palsies. Nuchal rigidity per se is the least common neurologic sign in neonatal bacterial meningitis, occurring in fewer than 25% of affected neonates.1
  • HSV meningitis: Early features may mimic those associated with bacterial meningitis, including pallor, irritability, high-pitched cry, respiratory distress, fever, or jaundice, progressing to pneumonitis, seizures, hepatic dysfunction, and disseminated intravascular coagulopathy (DIC).5

Causes

  • Bacterial meningitis
    • Among US neonates, group B streptococci are the most commonly identified organisms, implicated in roughly 50% of all cases of bacterial meningitis, and E coli accounts for another 20%; identification and treatment of maternal genitourinary infections is thus an important prevention strategy.10 Listeria monocytogenes is the third most common pathogen, with 5-10% of cases; it is unique because it exhibits transplacental transmission.11
    • Studies from underdeveloped countries suggest that gram-negative bacilli, specifically Klebsiella organisms and E coli, may be more common than group B streptococci. In their series from Africa and South Asia, Tiskumara et al noted that 75% of cases of late-onset meningitis were due to gram-negative bacilli.6 In a review of studies from Asia, Africa, and Latin America, Zaidi et al reported that the most common organisms were Klebsiella species, E coli, and Staphylococcus aureus.12
    • With the widespread use of intrapartum antibiotic prophylaxis since 1996 in developed countries, the incidence of early-onset group B streptococcal infection has decreased, while the incidence of late-onset disease had remained fairly constant.13 However, from 2003-2006, the CDC reported a slight increase in early-onset disease, particularly in the African American population in the United States. The reasons for this are unclear.14
  • HSV meningitis: As many as 95% of viral infections caused by HSV result from intrapartum transmission, with occasional postnatal exposure by oropharyngeal shedding or cutaneous shedding of virus by parents or hospital contacts. Late presentation in the second postnatal week is more commonly seen than early presentation of disseminated disease.
  • Emerging pathogens
    • As cases of neonatal enteroviral sepsis and aseptic meningitis are increasingly recognized, reporting and identification of more virulent serotypes as they affect infants will likely have a role.15 As many as 12% of neonates may be infected with this family of viruses. While many of these babies can be asymptomatic, enterovirus may be responsible for as many as 3% of neonates presenting with a sepsislike picture.16
    • Enterobacter sakazakii has been identified as an emerging pathogen in neonates. This bacterium is most typically associated with the ingestion of contaminated reconstituted formula. This pathogen has been reported with increasing frequency in the last decade, prompting the FDA to publish warnings of possible contamination of dried formula.17

More on Neonatal Meningitis

Overview: Neonatal Meningitis
Differential Diagnoses & Workup: Neonatal Meningitis
Treatment & Medication: Neonatal Meningitis
Follow-up: Neonatal Meningitis
References
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Further Reading

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Keywords

neonatal meningitis, meningitis in the newborn, meningitis in neonates, bacterial meningitis in the neonatal period, viral meningitis in the neonatal period

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Contributor Information and Disclosures

Author

David C Dredge, MD, Clinical Fellow in Child Neurology, Department of Neurology, Massachusetts General Hospital and Harvard Medical School
David C Dredge, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, Child Neurology Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Kalpathy S Krishnamoorthy, MD, Associate Professor of Pediatrics and Neurology, Harvard Medical School; Consulting Staff, Division of Pediatric Neurology, Massachusetts General Hospital
Disclosure: Nothing to disclose.

Medical Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Neurology, Department of Neurology, Oregon Health and Science University; Consulting Staff, Shriners Hospital for Children
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

 
 
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