The paediatric meningitis is, without a doubt, one of the diseases that cause the mostconcern for parents. However, we should emphasise that, despite the potential severity of the disease, it is rare in Spain, with the majority of cases occurring in children under five years of age, especially children under one year of age and adults over 65. This post aims to give parents a little insight into the symptoms of bacterial meningitis and how to treat them. First of all, let us find out a bit more about this disease.

What is Infectious Meningitis?

The meninges are membranes that cover and protect the Central Nervous System (brain, cerebellum and spinal cord), further to performing other functions. Between the meninges, there is the cerebrospinal fluid, which surrounds the Central Nervous System and also contributes to its functions.

When a germpenetrates these membranes and reaches the Central Nervous System,inflammation of the meninges (“meningitis”)occurs as a result of both the pathogenic activity of the germ and the body’s defensive response to the invasion. Some patients may also have certain risk factorsthat make them especially prone to some types of meningitis.

In addition to infectious meningitis, which is the most common type, other diseases can cause meningeal inflammation by abnormal activation of the immune system in the absence of infection (autoimmune meningitis).

Types of meningitis depending on the causing germ

Viral meningitis:Produced by a multitude of different viruses. It is the most frequent type of meningeal inflammation.

Bacterial meningitis:Caused by different bacteria. It is the most severe type of meningitis. The most common bacteria in our environment today are meningococcus and pneumococcus. In newborns, the most common are germs related to the birth canal.

Tuberculous meningitis: Caused by the bacteria that causes tuberculosis. It is also a severe type of inflammation, more frequent in immunocompromised patients. However, nowadaysit is very rear to see this type of meningitis in our environment.

Symptoms of Meningitis

Symptoms, as in almost any infection in Paediatrics, depend on the age of the patient. In general,the younger the child, the more non-specific are the symptoms, although fever is present in virtually all cases.

Innewborns and small children, irritability or drowsiness may also occur.

In older children, headache, vomiting, stiff neck, or sleep tendency are more common.

In all cases,seizures or other signs of neurological involvement may occur. The range of possibilities is very wide.

In any case, it is essential to bear in mind that these symptoms can be non-specific and could be a part any other banal infectious process,so when in doubt, it is crucial to assess the patient by a paediatrician.

How we diagnose Meningitis

First, thecomplete medical historyis analysed, and a detailed physical examinationis performed to establish the diagnosis of suspected acute meningitis.

If there is any suspicion, a blood testis usually requested, which in many cases can help the diagnosis and differentiate one type of meningitis from another.

However, the only test that can confirm or rule out the diagnosis of meningitis and identify the germ causing the infection is the lumbar puncture.

Besides,imaging tests, such as cranial ultrasound or computed tomography (CT), are sometimes performed at the discretion of the paediatrician.

Lumbar puncture as a definitive test

It is the only test that can confirm or rule out the diagnosis of meningitis and identify the germ causing the infection, so it should always be performedif meningitis is suspected and in the absence of any of its few contraindications.

Cerebrospinal fluid sampling is a technique in which a sample is removedthrough a puncture in the lower back. It is usually performed under topical anaesthesia in the form of cream over the puncture site, although depending on the age and the specific case, it can also be performed under sedation with systemic mediation, generally, but not exclusively, intravenously.

With this technique, complications are infrequent and almost always local (pain after the puncture, local bleeding, etc.). In children, pain or stiffness in the back after the puncture is much less common than in adults. In some children, especially newborns and small infants (because of their small size) the technique may be somewhat more complicated and more than one attempt may be needed to obtain a valid sample (it may even be that no sample is obtainedat all).

Treatments for infectious meningitis

Viral meningitisrequires almost no specific treatment at all.It heals on its own after a few days, so the only treatment is theusual analgesicsto control possible symptoms (such as a headache, malaise). Many of the patients affected by viral meningitis do not even need hospital admission and can be treatedat home. A notable exceptionis the case of infection with the herpes virus(herpetic meningoencephalitis), which is a severe condition thatrequires hospital admission,often in paediatric ICU, and prolonged intravenous antiviral treatment.

In all cases, bacterial meningitisrequires hospital admission and intravenous antibiotic treatment, sometimes with more than one antibiotic until the causal germ is identified. Also, other treatments,such as corticosteroids, anti-epileptics or intravenous fluids, may be necessary.

Infectious Meningitis Prognosis

Viral meningitis heals itself, and the possibility of complications or sequelae is extraordinarily rare, except in the case of herpetic meningoencephalitis, which is associatedwith a high percentage of neurological sequelae and mortality, even with adequate treatment.

Bacterial Meningitishas a mortality of practically 100% of the cases if proper antibiotic therapy is not started, although with a correct treatment patient clinical progress is usually good. However, even in this case, it can also be associated with neurological sequelae and mortality.

Still, the actual prognosis depends on many factors(age of the patient, progress period, the presence of other risk factors, causal germ).

Can infectious meningitis be prevented?

Viral meningitis cannot be prevented.The viruses that cause it are multiple, and of constant circulation between humans, so it is impossible to avoid contact with them. The exception is herpetic meningoencephalitis,in which case there are some measures to avoid infection in the birth canal in newborns, although there is no real prevention option at a later age.

Most bacterial meningitis can be preventedby using vaccines.Severe meningitis caused by some bacteria very common a few years ago, such as those produced byHaemophilus influenza type B or meningococcus C, have decreased drastically today (they have almost disappeared in the case of Haemophilus) thanks to the vaccination of the entire population against these germs included in the vaccination calendar financed by the Public Health System. Another bacterium that causes many cases of meningitis is pneumococcus, whose vaccine (Prevenar 13^®) has also recently been includedin vaccination programs throughout Spain.

Finally, vaccines against the rest of the meningococcal serogroups are also available on the private market.In this respect, it is worth noting:

• Vaccinesagainst meningococcus B: Bexsero^®and Trumenba^®. The first type of vaccine can be administeredto infants sixweeks old and the second, to children from 10 years onward. They are recommendedfor all children, especially those under the age of 5, when the disease outbreak is most common.
• ACWY meningococcalvaccines: Nimenrix^®and Menveo^®. Recommended for teenagers who are going to travel to risk areas or who have some factors that make them especially susceptible to the disease. The administration of this particular vaccine can also be assessed in other adolescents to increase the degree of individual protection.

In some specific cases, such as in patients with risk factors, those under current outbreaks of the disease or laboratory personnel, these vaccines may be financed by Social Security.

In addition to vaccines, preventive antibiotic treatmentis recommendedwhen in close contact with confirmed cases of bacterial meningitis, which, in the event of school outbreaks, can be extended to all school staff and students.

Saturday 5th of May celebrates World Hand Hygiene Day. In that honour, we have asked some related questions at Vithas Xanit International Hospital to help us become more aware of the importance of keeping the hygiene of our hands, and this is what we found out:

• 1- Which hygienic method is better, the liquid disinfectants we see in hospitals or washing with soap and water?

Liquid alcohol-based disinfectants, such as those we see in the hospital, as long as the hands are not visibly dirty. Liquid disinfectants are faster, more effective method and better tolerated by hands.

• 2- When we wash with soap and water, what is better, hot or cold water?

It is better to wash our hands with cold water as hot water causes greater skin irritation.

• 3- In general, where can we find the most microbes in our houses?

On the remote controls, computer keyboards and smartphone screens. They can accumulate up to 450 bacteria per key.

Also, handles, doorknobs and switches usually carry the most germs in our houses. The bacteria and dirt carried on our handsaretransferred onto to these surfaces simply by touching them, and bacteria remainuntil we disinfect them.

Then, kitchen sponges and towelsare also objects that accumulate large amounts of bacteria.

• 4- Does having well-cared hands influence whether we are more or less prone to infections?

Yes, skin irritation of the hands and possible injuries caused by soaps or detergents should be avoided and combated with the use of creams.

• 5- How should our hand hygiene be when we have pets?

We should always wash our hands after touching a pet, its bed, or any object, such as food or food containers, that comes in contact with the pet.

Always wash hands before preparing or serving food and after touching a pet.

• 6- With the alarm that there were E Coli infections at the time, what is the correct way to handle fruits and vegetables?

Before handling fruits and vegetables, it is important to wash our hands, especially after using the toilet.

Fruits and vegetables should be washed with running water, especially if they are to be eaten raw.

It is also important to avoid cross-contamination of food by cleaning and disinfecting surfaces that come into contact with food, such as cutting boards, kitchen worktops or refrigerator shelves.

• 7- In the case of eggs and salmonella, what type of measure should we take?

Wash hands and objects that come in contact with raw eggs (dishes, utensils, cutting boards).

We should cook eggs until the egg white and yolk are firm. Dishes made with eggs should be cookedat an internal temperature of 71°C or higher.

Keep eggs refrigerated at 4°C or cooler at all times.

Eat or refrigerate foods containing eggs after cooking. Do not keep eggs, or foods made with eggs, at room temperature for more than 2 hours, or 1 hour if the temperature is elevated, for example in summer.

Throwing away dirty or broken eggs

We recommend that foods containing raw or undercooked eggs, such as Hollandaise sauce or mayonnaise, be made only with pasteurised eggs.

CDC Recommendations: Centres for Disease Control and Prevention

• 8- What practical measures, related to the hygiene of our hands, should we take when we go to a restaurant or bar?

Wash hands before starting to eat and always after going to the bathroom.

• 9- It seems that certain elements or circumstances related to our hands can increase the chances of having a sanitary problem. What’s worse in these cases?

1. Wearing jewellery
2. Skin lesions
3. False nails

They can all have a negative influence when it comes to adequate hand hygiene.

• 10- Are the railings of standard staircases and escalators hygienically dangerous?

Handrails on escalators and staircases are a point where germs can collect, no more dangerous than doorknobs or switches. If we do proper hand hygiene, they do not pose any danger.

• 11 – What specific hand hygiene measures do you have in a hospital when you come into contact with a patient?

Hand hygiene should always be carried out before and after contact with the patient according to WHO guidelines.