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Central Nervous System,

Eye, and Urinary TractInfections

Mary Y. Mancao, M.D.

University of South AlabamaDept. of Pediatrics

Mobile, AL

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CNS Infections

Meningitis

Encephalitis

Focal infections of the CNS

Transverse myelitis, Guillaine-Barre

Syndrome

Spongiform Encephalopathy

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Pathogenesis of CNS infections

Nasopharyngeal Colonization

Local Infection

Bacteremia

Seeding other sites

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MENINGITIS

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Epidemiology of Bacterial

Meningitis in the United States

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Meningitis: Microbial Etiology

Neonates: Group B streptococcus, Gramnegative enterics, Herpes simplex

Older child: Streptococ cus pneumoniae,Neisseria meningit id is, Haemophi lusinf luenzaetype B, Viral

Sickle disease: S. pneumon iae

Asplenia: S. pneumon iae, N. mening i t id is ,Salmonel la sp .

T-cell defects: Lister ia monocytogenes

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Other Causes of CNS Infections

Chronic granulomatousinfection Mycobacterium tuberculosis

Coccid iodes imm it is

Cryptococcus neoformans

Histoplasma capsu latum

Protozoan infection

Toxoplasma gondi i Trypanosoma

Acanthamoebaspecies

Nematodes Toxoc ara species

Trich inel la sp iral is

Angiost rongy lus

cantonensis

Cestodes Taenia solium

Others Leptospira species

Trepon ema pal l idum

Bo rrel ia burg dorfer i

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Meningitis: Clinical Manifestations

Infants: Inconsolable crying,

irritability, refusal to feed, fever

Child: Fever, poor appetite and

activity, vomiting, headache,

photophobia

Physical examination: altered

sensorium, stiff neck, poor

perfusion, skin rashes

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Meningitis: Clinical Signs

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Meningitis: Diagnosis

Lumbar puncture (LP)

CSF indices: cell count, protein,

glucose CSF gram stain and culture

Contraindications to LP:

Signs of increased intracranial pressure

Patient unstable

Clotting/Platelet disorder

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Guidelines for Cerebrospinal Fluid Analysis

Clinical

Situation

WBC

Cells/mm3% Polys Glucose

mg/dL

Protein

mg/dL

Normal 0-5 0 > 60 < 30

Viral 2-2000 < 50 > 60 30-80

Bacterial 5-5000 > 60 < 45 > 60

TB 5-2000 < 50 < 45 > 60

Neonate 0-32 < 60 > 60 20-170

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Meningitis: Treatment

Bacterial meningitis

3 months of age: Cefotaxime orCeftriaxone

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Meningitis: Empiric Treatment

Viral meningitis: Acyclovir

Tuberculous meningitis: INH, RIF,ETH, STM, PZA

Fungal menigitis: Amphotericin, 5-

FC

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Encephalitis

Neonate: Acute vs. Congenital

Beyond the neonatal period: Virus

(Enterovirus, Herpes simplex virus,Epstein Barr virus, and Arbovirus California encephalitis), Bacteria(Bartonella hens lae)

Postinfectious: Varicella zoster virus,Mycoplasma

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Focal infections of the CNS

Brain Abscess

Subdural empyema Epidural abscess

Cranial

Spinal

Staphy lococcus

aureus

Staphy lococcus

epidermidis

Streptococcus

pneumoniae

Other Gram negative

and positive bacteria

Anaerobic bacteria

Etiologic Agents

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CT Findings: Subdural Empyema

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Eye Infections

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Common Clinical Conditions

Blepharitis

Dacrocystitis

Conjunctivitis

Endophthalmitis

Uveitis

Chorioretinitis

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Conjunctivitis: Viral

Adenoviral Conjunctivitis

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Conjunctivitis: Bacterial

Gonococcal conjunctivitis Pneumococcal conjunctivitis

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Chorioretinitis: Toxoplasmosis

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Major Infectious Causes of Eye Disease

Disease Bacteria Viruses Fungi Parasite

Blepharitis Staph

aureusDacrocystitis Strep

pneumoniae

Conjunctivitis Strep pneum

H. Inf luenzae

GC,

Chlamydia*

Neisseria

meningi t id is

Adenovirus**

Herpes

simplex

Measles

Varicella

zoster

Fusar ium

Asperg i l lus

Acantha-

moeba

*Usually occurs in less than 3 months of age** Can cause har n ocon unctival fever

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Major Infectious Causes of Eye Disease

Disease Bacteria Viruses Fungi Parasite

Ophthalmia

Neonatorum

GC

C. trachomatis

HSV

Endophthalmitis S. aureus

Pseudomonas

Other Gm neg

Candida

Aspergillus

Iridocyclitis Treponema

pallidum

HSV, VZV

Chorioretinitis M.

tuberculosis

CMV, HSV

VZV

Histoplasma

C. Immitis

Candida sp.

Toxo-

plasma

Toxocara

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Eye Infections: Diagnosis and Treatment

Diagnostic approach Gram stain

Culture

Immunofluorescent stain

Serologic tests

Blood cultures

Ophthalmologic evaluation and slit lamp exam

Management Topical antimicrobial agents

Specialized treatment including systemictherapy

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Urinary Tract Infections

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Urinary Tract Infections

Infection of the

kidneys and its

pelvis:Pyelonephritis

Infection of the

bladder: Cystitis

Infection of theurethra: Urethritis

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UTI: Pathogenesis

Bacteria ascendfrom perineal flora

Sexual activity candisplace bacteria

Catheterizationincreases risk

Young womenmost commonlyaffected

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Clinical Manifestations of UTI

Variable presentation, can be asymptomatic

Cystitis Dysuria

Frequency of urination

Urgency

Pyelonephritis Fever

Flank Pain

Prostatitis High Fever and signs of cystitis

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Diagnosis of UTI

Collection of sterile urine

Clean-voided midstream urine

Microscopic examination

Pyuria: >10 WBC/mm3

Chemical Screening tests

Leukocyte esterase

Urine Culture: > 105 bacteria/mL

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Management of UTI

Guided by results of culture andantimicrobial susceptibility tests

Most common pathogen:Escherichia coli

Empiric antibiotic choices include:

Sulfamethoxazole/trimethoprim Ampicillin

Fluroquinolone (>18 years of age)