Posted on 24th Sep 2024 09:30:06 AM Medicine
Literature Review
Cerebrospinal meningitis (CSM) is a major cause of morbidity and mortality in many parts of the world. (Peltola , 1983; Theodoridou et al., 2007) Despite the progress being made in treating the condition, the mortality rates continue to be high, ranging between 2% and 30% globally. (Chavez-Bueno and McCracken , 2005) In Ghana, the mortality rate of meningitis has been estimated to range from 36% to 50% . (Dash et al., 2008; Holliman et al., 2007).
Apart from epidemics, at least 1.2 million cases of meningitis are estimated to occur with estimated annual deaths of 170,000. (Tikhomirov et al., 1997)
Complications such as epilepsy, mental retardation, deafness and other related neurological defects are observed in 10% to 20% of those who survive. The estimated median risk of at least one major or minor sequel from bacterial meningitis after discharge from the hospital is 19.9% (range 12.3–35.3%). In middle and low-income countries, acute bacterial meningitis remains the fourth leading cause of disability. The prevalence of bacterial meningitis in these countries is higher compared to developed countries. (Edmond et al., 2010)
Bacterial meningitis is caused by a number of organisms but beyond the neonatal period, over 90% of infections are caused by Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenza (H. influenza) and Neisseria meningitidis (N. meningitidis). Over the last two decades however, the causative agents of meningitis has changed with the introduction of new highly effective vaccines. (Renner et al., 2007) Haemophilus influenzae type b (Hib) used to be a common cause of bacterial meningitis worldwide before the Hib vaccines.( Martin et al., 2004) However more recently, S. pneumoniae and N. meningitidis have become the major organisms causing meningitis. In countries with high HIV prevalence, Cryptococcus neoformans may also be significant.
In many African countries including Ghana which lie within the meningitis belt, epidemic cases of acute bacterial meningitis caused by different subtypes of N. meningitidis and S. pneumoniae have been reported. (Weber et al., 2002) However most of the data were collected during outbreaks as such the pathogens detected were skewed to S. pneumoniae and N. meningitidis. Information on pathogens contributing to meningitis in hospital based studies is limited. Two hospital based studies in Ghana reported S. pneumoniae, N. meningitidis and H. influenza as pathogens associated with meningitis. (Commey et al., 1994) However these studies were only conducted among few populations of infants and children. Furthermore the contributions of other bacterial and fungal agents were not indicated.
Cerebrospinal meningitis is a major cause of mortality and morbidity in both children and adults. In Ghana, cases of meningitis outbreaks are mostly reported in the northern part of the country and has been attributed to the low humidity in that area. In the years 1996-1997, the three northern regions of Ghana for instance recorded 18,703 cases of meningitis out of which 1,356 lost their lives during an outbreak. (Alandu, 2012). Similar cases of meningitis have been reported in other parts of Ghana. (Frimpong and Lartey, 1998) however hospital based information on the different etiological agents, antimicrobial susceptibility patterns and the seasonality is limited
In our study the prevalence of confirmed and probable meningitis was 3.3% and 2.1% respectively. Our result is similar to other surveillance (based on cultures) of meningitis in other parts of Africa. (Afifi et al., 2007) The prevalence however appears low compared to some reports from the northern part of Ghana. This is because our reports were from all patients suspected of meningitis while reports from northern Ghana were mostly obtained during outbreaks. We however believe the prevalence could have been higher if techniques using polymerase chain reactions were applied in testing the samples. Another reason that could contribute to the low meningitis prevalence is the possible use of antibiotics before hospital admission, a common practice in many developing countries. Even though we have no records on the number of patients on antibiotics before admission, our observation show that most of the admitted cases referred from other primary healthcare facilities had been managed with antibiotics before referral. Future studies are however needed to confirm this. (Kilpatrick et al., 1987)
The most prevalent bacteria was S. pneumoniae occurring mostly among patients less than 18 years of age. Neonates accounted for 8.7% and children from one month to less than 5 years accounted for 23%. Our result is similar to previous studies done by (Holliman et al., 2007) where they found majority of S. pneumoniae infections occurred in children and young patients. Adult pneumococcal meningitis which accounted for 41.8% of infections was equally significantly identified as reported in other studies. A possible reason for the predominant prevalence of pneumococcal meningitis could be as a result of auto-infection from colonizing bacteria in the nasopharynx. Previous studies have shown the prevalence of nasopharyngeal colonization with streptococcal pneumoniae to be 51.4% in Ghana. The auto-transmission from the nasopharynx into the meninges is therefore highly possible especially during the dry season when cracks and injuries tend to occur in the nasopharynx. Countries that introduced pneumococca conjugate vaccines have however reported a reduction in the cases of pneumococcal meningitis. (Cutts et al., 2005)
We found one case of H. influenzae over the three year period. This low prevalence is quite remarkable and could be explained by the introduction of Hib vaccines in Ghana in 2002. The impact of Hib vaccine on the reduction of meningitis has been reported by( Renner et al., 2007). Other developing countries such as Turkey have also reported low Hib meningitis prevalence. It is however possible that the infected child may not have been vaccinated against H. influenzae. Though the Hib immunization status of the child with the Hib meningitis could not be determined it is possible he might have been born in a rural area where access to healthcare and vaccination may be difficult. It is also possible that the under reporting of meningitis cases might have contributed to the low numbers. This is because some developed countries like the USA which introduced vaccines against Hib meningitis decades ago still reports prevalence of 6.7% .( Thigpen et al., 2011)
The contribution of other bacteria pathogens to meningitis apart from N. meningitidis, S. pneumoniae and Haemophilus influenzae has not been widely reported in many developing countries. The present study identified E.coli, Salmonella species, Pseudomonas species, Klebsiella species, Staphylococcus aureus and Enterobacter species as contributing to 12% of all bacterial isolates among children and infants. Some studies in developing countries have similarly reported these observations.( Milledge et al.,2005)Contrary to these findings however, children and neonates in developed countries have been reported to have predominance of Group B streptococcus and Lysteria monocytogenes. The reasons for the non-identification of Lysteria monocytogenes in our laboratory could be due to less attention given to the laboratory diagnosis of this pathogen. This is because Lysteria monocytogenes resembles diphtheroids and could easily be regarded as contaminants. Furthermore reagents such as esculin and hippurate hydrolysis or CAMP test (Christie, Atkins and Munch-Peterson) used for confirming Lysteria monocytogenes are not readily available in our laboratory.
Of interest in our study is the identification of Cryptococcus neoformans, occurring mostly in patients between the ages of 18 and 50 years. Previous studies in Ghana (Kumasi) did not identify Cryptococcus neoformans in meningitis patients perhaps due to the small number of study patients. (Frimpong and Lartey, 1998) The identification of Cryptococcus neoformans is however not surprising since the number of people living with HIV/AIDS continue to increase even though the national HIV prevalence had reduced from 1.8% in 2008 to 1.5% in 2010. The contribution of Cryptococcus neoformans to meningitis has similarly been reported to mostly occur in HIV endemic African countries .( Muyembe Tamfum et al., 1992)
All isolates tested with ceftriaxone were 100% susceptible with the exception of Staphylococcus aureus. Eighty three percent (83%) of S. pneumoniae isolates were susceptible to chloramphenicol whereas 98.9% were susceptible to penicillin. Our study found no evidence of high level resistance against chloramphenicol and penicillin. Previous studies in Ghana have however documented pneumococcal penicillin resistance rates varying from 8%-31% and chloramphenicol resistance rates of 5-20.6% . The difference in the resistance patterns could be due to the methodology used. The sensitivity patterns of our isolates were done using only the Kirby-Bauer method which could underestimate the resistance levels. On the other hand, the susceptibility of S. pneumoniae, N. meningitidis and H. influenzae to ceftriaxone has been mostly reported to be 100% . Appropriate treatment for meningitis depends on the local antimicrobial susceptibility patterns. In Ghana, the hospital antibiotic policy recommends penicillin and chloramphenicol as the first choice of meningitis treatment and ceftriaxone is considered as alternative. This study therefore emphasizes the need for clinicians to continuously rely on ceftriaxone as the best choice of drug for the treatment of meningitis (. Adjei and Agbemadzo, 1996)
Meningitis is an inflammation of the membranes that cover the brain and spinal cord. It is caused by a bacteria or virus and transmitted from person to person. College students, especially freshmen, living in dorms are at increased risk of contracting meningitis and should be vaccinated before entering college. A person’s life could be completely changed and even ended within 24 hours of exposure. This is why parent and student education about the contraction of meningitis and the availability of the vaccine is important.
A massive outbreak of meningitis in 1997 at Michigan State University gave researchers (Paneth et al., 2000) an opportunity to study factors that contribute to college students’ compliance with mass vaccination programs. The researchers compared the information about the vaccine recipients received at the time of mass vaccination to the student computer database, and then were able to assess the effect of student characteristics and the likelihood of students being vaccinated. What the researchers found was a steady decline in vaccination rates between the younger students and the older students. Women were found to be more likely than men to be vaccinated and students who were of a white or an asian ethnicity were more likely to be vaccinated than students of other ethnicities. Also, students who studied business or studied in the sciences were more likely to receive the vaccination than the students that were studying in the arts or humanities fields (Paneth et al., 2000).
In this review, we obtained comprehensive, up to date information on the burden of sequelae associated with bacterial meningitis in African children. We included 37 articles with sequelae data from 1980 to 2008, while an earlier review based sequelae estimates only on 10 articles published between 1970 and 2000. We estimated that the median risk of in-hospital sequelae was 25% for pneumococcal meningitis, 25% for Hib meningitis and 7% for meningococcal meningitis, while the median risk of post discharge sequelae was 25% for all pathogens combined. These estimates are slightly lower than those found in the earlier African literature review, (Peltola, 2001) but the higher risk of sequelae for pneumococcal and Hib meningitis compared to meningococcal meningitis is consistent across the two reviews. The median CFR estimates in our review were 35% and 25% for pneumococcal and Hib meningitis, respectively, and thus slightly lower than the findings from two previous reviews.( Knoll et al., 2009)
The next study examined the difference between meningococcal vaccination rates with and without education of students. The study identified that first year college students living in dorms were at a high risk of contracting meningitis. The findings of their research concluded that some students who were introduced to the educational information about the meningitis vaccine while they were still living at home and under parental encouragement and advice from their doctor were more likely to be vaccinated than students who waited until they moved away from home and onto the college campus (Collins et al., 2003)
The researchers conducted this study using a cross-sectional survey. What was found in this study was that people who were more likely to agree to vaccination consisted of students who were up to date on their MMR, DT and flu vaccinations, as well as students who had seen their doctor within the last 6 months. Students who were not likely to agree to vaccination were students who smoked, binge drank, hung out at bars, participated in active and passive cigarette smoking and cigarette or drink sharing (Heilly et al., 2006).
Past research has stated that broader, multi-institutional studies need to be performed to further identify those most at risk for the disease and for choosing not to be vaccinated. All studies reviewed pointed to the fact that education was vital in increasing vaccination rates.
Pneumococcal meningitis
A total of 10 studies had data on pneumococcal meningitis sequelae, including 676 children. These studies found one or more sequelae in 16% to 38% of children (median 25%, IQR 21% to 32%) . One study found hearing loss in 5% of cases, %).( Friedland and Klugman, 1992)
and another study examining hearing loss, vision loss, motor delay and seizures found that 2% to 7% of children had any one of these specific deficits. A total of 14 articles including 1,463 children with pneumococcal meningitis provided information on CFR, which ranged from 9% to 67% (median 35%, IQR 29% to 44%).( Thabet et al., 2007)
Bacterial meningitis is a serious, often disabling and potentially fatal infection resulting in 170,000 deaths Worldwide each year. Young children are particularly vulnerable to bacterial meningitis, and when exposed poor outcomes may occur due to the immaturity of their immune systems. Two thirds of meningitis deaths in low income countries occur among children under 15 years of age .( World Health Organization, 2004) The main bacterial pathogens causing meningitis beyond the neonatal period are Streptococcus pneumoniae (pneumococcus), Haemophilus influenzae type b (Hib) and Neisseria meningitidis (meningococcus) . Pneumococcal meningitis is associated with the highest case fatality ratios (CFRs) globally (Baraff et al., 1993). In Africa, pneumococcal meningitis CFRs attain 45% compared to 29% for Hib meningitis and 8% for meningococcal meningitis. (Peltola, 2009)
Serious, long-term neuropsychological sequelae further increase the population impact of paediatric meningitis. Sequelae comprise a range of findings with implications for child development and functioning and include such deficits as hearing loss, vision loss, cognitive delay, speech/language disorder, behavioural problems, motor delay/impairment, and seizures. Meningitis sequelae can present a long-term, serious hardship for families with limited means to care for a disabled child, especially in resource-poor settings. (Khan et al., 2006)
Africa experiences a disproportionately large burden of meningitis due to its young population, epidemics in the meningitis belt and high rates of endemic disease. The incidence and CFRs associated with paediatric Hib and pneumococcal meningitis were highest in Africa compared to all other regions in a recent global review. (Knoll et al., 2009)In addition, Africa is the only region with cyclic epidemics of meningitis that affect persons of all ages, with attack rates ranging from 100 to 800 per 100,000 population. Epidemics of meningitis are mostly associated with meningococcus, but there is some evidence that increases in pneumococcal meningitis cases occur in parallel during the hot and dry season .( Leimkugel et al.,2005)
CONTENTS
Abstract
CHAPTER 1: INTRODUCTION
1.1 General introduction
1.2 Definition of meningitis
1.3 Sign and symptoms of meningitis
1.4 Causes of meningitis
1.5 Diagnosis of meningitis
1.6 Management of meningitis
1.7 Prevention of meningitis
1.8 Prognosis of meningitis
1.9 Epidemiology
1.10 Objective of the study
CHAPTER 2: REVIEW OF LITERATURE
CHAPTER 3: MATERIALS AND METHODS
3.1 Design of the study
3.2 Setting, population, and sample of the study
3.3 The inclusion criteria
3.4 Instrumentation
3.5 Validity and reliability of the instrument
3.6 Data collection procedure
3.7 Statistical analysis
3.8 Translation of the instrument
CHAPTER 4: RESULTS
4.1 Demographic information for nurses
4.2 Knowledge related question to the nurse
4.3 Multiple questions to assess the nurse’s knowledge
CHAPTER 5: DISCUSSION
CHAPTER 6: CONCLUSION
CHAPTER 7: REFERENCES
CHAPTER 8: ANNEXURE
Consent letter
Questionnaire
LIST OF TABLES
Table 1: Demographic information for nurses
Table 2: Yes and No questions for nurse’s knowledge assessment
Table 3: Multiple questions for nurse’s knowledge assessment
Table 4: Right answers of multiple questions
LIST OF FIGURES
Figure-1: Graph showing the age distribution of the nurses
Figure-2: Graph showing the percentage of length of services of nurses
Figure-3: Graph showing the percentage of yes and no questions for nurses knowledge assessment
Thesis, Assessment, Nurses, Knowledge, Regarding, Cerebrospinal, Meningitis, Management, Rajshahi, Nursing, Medical, College, Hospital
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