Factors Associated with the Death of Children Aged 0 to 15 Years with Bacterial Meningitis in the Pediatric Department of Donka National Hospital

Introduction: Bacterial meningitis is a serious, life-threatening infection; its diagnosis must be early and its management must be rapid. Bacteria commonly implicated in children are Neisseria meningitidis, Streptococcus pneumonia and Haemophilus influenzaetype b. The specific etiology is a function of age, immune function, vaccination status, genetics, and geographic location.

Objective: To identify the factors associated with death in children aged 0 to 15 with bacterial meningitis in the pediatric department of Donka National Hospital.

Methods: Prospective, descriptive and analytical study of 6 months (April 12 to October 12, 2022) including children aged 0-15 years with bacterial meningitis confirmed by cyto-bacteriological analysis of CSF.

Results: From of a total of 766 children, we collected 118 cases of bacterial meningitis, either frequency of 15.4%. The average age was 3.97 ± 4.06 years with extremes of 1 month and 15 years. The sex ratio was 1.5 in favor of boys. Altered consciousness (p < 0.001), delay in consultation > 3 days (p = 0.01), poor nutritional status (p = 0.0000063904), cloudy appearance of the CSF (p = 0.003) and presence of serious signs (p = 0.0000050753) such as shock, generalized hypertonia, signs of decortication and decerebration were poor prognostic factors. The mortality rate observed in this work was 23.7%.

Conclusion: Child hood bacterial meningitis often leads to death in children admitted to the pediatric ward of Donka National Hospital. Children who received this diagnosis and who also had an alteration of consciousness a consultation delay of more than 3 days with signs of severity had an increased risk of dying.

Bacterial meningitis is an infection of the meninges, of bacterial origin, which are the protective covering of the brain and spinal cord, resulting in inflammation. It is a serious and life-threatening condition that requires prompt diagnosis and treatment [1-3]. In children and outside the neonatal period, three bacteria are responsible for most cases of bacterial meningitis. These are Neisseria meningitidis (Nm), Streptococcus pneumoniae (Sp) and Haemophilus influenzaetype b (Hib) [4,5]. Meningitis is responsible each year for a high mortality rate (117,000 deaths per year worldwide) and serious neurosensory sequelae [6]. In children under five, the median incidence of this disease is 34 cases per 100,000 children per year. This incidence varies by region of the world, ranging from 143.6 per 100,000 children per year in the Africa region to 16.6 per 100,000 children per year in the Americas region. The median case fatality rate is 14.4%, varying between 31.3% in the Africa region and 3.7% in the Southeast Asia region.

In Guinea, bacterial meningitis continues to be a neuroclinical emergency associated with high morbidity and mortality requiring immediate assessment and management. The diagnosis is made at the advanced stage of the disease due to the delay in consultation of patients leading to a high risk of morbidity and mortality with neurological sequelae in children. It would be appropriate through this study to answer the question: what are the factors associated with death during bacterial meningitis in children.

This was a prospective, descriptive and analytical study of 6 months from April 12 to October 12, 2022 including all children aged 0 to 15 years hospitalized for bacterial meningitis confirmed by cyto-bacteriological analysis of CSF. The CSF analyzes were carried out at the laboratory of the National Institute of Public Health (INSP), which is the national reference laboratory in Guinea. Bacterial meningitis was considered to be: any cytology of more than 5 leukocytes/mm3 with identification of a bacteriological germ or any cytology of 10 or more leukocytes/mm3 without identified germ if previous antibiotic therapy with symptoms evoking possible meningitis. We did not include children hospitalized for other causes. Epidemiological variables (age, sex, vaccination status, residence), clinical (duration of consultation, reasons for consultation, physical signs, nutritional status, signs of seriousness), paraclinical (macroscopic appearance of CSF, bacteriology of CSF, scanner) were analyzed. Data were entered and presented using Word Excel and Power Point software from the 2016 pack. Statistical analysis was performed using Epi info version 7.2.4.0 software. The chi-square test was performed to assess the association between two categorical variables. Depending on the case, the Pearson or Fisher exact was used for the nominal variables. For continuous variables, the Student test was used for the comparison of means. The significance threshold was set at 5% and a value of p < 0.05 as significant.

We obtained the verbal consent of the parents of the patients under the guarantee of anonymity and the possibility of withdrawing from participation in the study without any constraint.

Out of 766 children, we collected 118 cases of bacterial meningitis (15.4%) (Figure 1). The male gender accounted for 60.2% (sex ratio of 1.5). The majority of the children resided in the communes of Ratoma and Matoto. 39.8% of children had unknown vaccination status, and 29.7% were unvaccinated and nutritional status was considered good in 74.6% of cases (Table 1). 59.3% of children had a consultation period more than three days. The reasons for consultation were dominated by fever (100%), vomiting (73.7%) and convulsions (68.6%) while the physical signs were dominated by neck stiffness with Brudzinski and Kernig positive. The most frequent signs of severity were coma (47.5%), generalized hypertonia of the limbs (32.2%), signs of decerebration and decortication (25%) (Table 2).

Figure 1: Organization chart of children hospitalized in the pediatric department of the Donka National Hospital (HND) from April 12 to October 12, 2022.

CSF was clear in the majority of cases (49.2%). The main germs identified were Haemophilus influenza type b, Streptococcus pneumoniae and Neisseria meningitides (Table 3). Alteration of consciousness, delay in consultation > 3 days, poor nutritional status, cloudy appearance of the CSF and the presence of serious signs such as generalized hypertonia, state of shock, signs of decortication and decerebration were factors poor prognosis (Table 4). The observed case fatality rate was 23.7% (Table 5).

This study was carried out in one of the reference services for the care of children and aimed to identify of the factors associated with death in children aged 0 to 15 suffering from bacterial meningitis in the pediatric department of the National Donka hospital (Table 6). During the study period, 766 children were hospitalized in the department, including 118 for bacterial meningitis, or 15.44% of hospitalizations (Figure 1). The male sex was dominant with a sex ratio of 1.5. The male predominance is unanimously accepted by several authors [7-11]. The most represented age group was that of 0-4 years with 63.5% (Table 1). Berthe IM [8] and Coulibaly MM [9] report respectively 84.3% and 71.6% in the under-5 age group. This result could be explained by the fact that young children do not have a defense system or an immune system more adapted against infections on the one hand, and on the other hand by the immaturity of the immune system. Breathing in young children [12]. We also note in this age group the introduction of complementary foods, with a decrease in breast-feeding as well as passive maternal immunity. This also highlights the importance of the protective immunoglobulin present in breast milk in the prevention of acute respiratory infections [13]. 30.5% of children were vaccinated while 39.8% had an unknown vaccination status and 29.7% unvaccinated (Table 1). The quality of vaccines against pneumococci and Haemophilus influenzaetype b is known to reduce the morbidity and mortality of acute respiratory infections in children [14], unfortunately the official extended vaccination program does not cover the pneumococcal vaccine. This result highlights the non-respect of the vaccination schedule by the mothers on the one hand and the insufficient vaccination coverage on the other hand. 59.3% of patients had consulted the service 3 days after the onset of symptoms (Table 2). Bakayoko MM [7] had reported a consultation delay of more than 3 days in 63.46% of the children in his study. This relatively long consultation time could be explained by the ignorance and the low socio-economic level of the parents who either minimize the disease, or are unable to cover childcare costs. Ignorance of the signs of meningitis and inappropriate self-medication commonly initiated by parents or health workers promote this delay. Almost all of the patients had consulted for fever, vomiting and convulsions (Table 2). El Fakiri K, et al. [15] reported a fever frequency of 95% as the reason for consultation. 49.2% had an altered general condition and meningeal signs were dominated by neck stiffness (54.2%), Brudzinski's and Kernig's signs representing respectively 37.3% and 33.9% (Table 2). Bakayoko MM [7] had reported neck stiffness in 61.53% of cases followed by Kernig's sign with 51.92%. Altered consciousness and the presence of signs of meningeal irritation are elements that facilitate the diagnosis of meningitis when they are present. The CSF was clear in 49.2% and cloudy in 36.4% (Table 3). Coulibaly MM [9] had reported 42% clear liquid and 48.5% cloudy liquid and Berthe IM [8] 53.4% ​​clear CSF. It should also be noted that in 17 children the fluid was hematic (Table 3), which reflects a frequency of traumatic lumbar puncture in the department. Haemophilus influenzaetype b was the most isolated germ with 36.4%, followed by Neisseria meningitidis 32.2% and Streptococcus pneumoniae with 31.4%. The predominance of Hib observed in our series could be explained by the fact that the patients were not vaccinated against Hib. Indeed, 29.7% of patients were not vaccinated and about 39.8% had an unknown vaccination status. The hospital evolution of the patients was generally favorable for (69, 5%) but we recorded 23.7% of deaths (Table 5). Pelkonen T, et al. [17] report a mortality rate of 33%, the finding is the same in the study Shrestha, et al. [18] in Nepal which reports a mortality rate of 33. 3% from bacterial meningitis in children. However, this is a higher mortality rate than the 5 to 10% reported in studies carried out in developed countries [19]. This could be linked to the delay in hospital consultation and the non-existence of pediatric resuscitation for patients who need it in poor countries. The factors significantly associated with death were impaired consciousness (p < 0.001), delay in consultation of more than 3 days (p = 0.01), severe malnutrition (p = 0.00), cloudy appearance CSF (p = 0.003) and the presence of serious signs (p = 0) (Table 4).

Roine I, et al. [20] reported that impaired consciousness was the strongest predictor of death in children with bacterial meningitis in South American hospitals. The finding was the same in the study by Rahimi BA [21] and Kuti BP [22]. These results confirm that impaired consciousness is an indicator of severe neuronal damage, which could be an important factor in the mortality associated with bacterial meningitis observed in resource-limited settings [16,23]. It is therefore essential to take early care of children with MB and to strengthen the follow-up of patients admitted with impaired consciousness.

In addition to impaired consciousness, a delay in admission of more than 3 days was associated with mortality in our study. In the study by Mioramalala S, et al. [24] in Madagascar, a delay in consultation of more than 3 days was also associated with death. According to Olson D, et al. [25] in Guatemala, children more than three days late had a 3.7 times higher risk of death. This delay is proportional to the severity of the signs and complications.

CSF cloudiness was significantly associated with death in the children in our study. In the study by Kuti BP, et al. [22], the cloudy aspect of the CSF was significantly associated with mortality. Cloudy CSF therefore reflects invasion of CSF by rapidly proliferating pathogens with reactive polymorphonuclear pleocytosis, hence the poor prognosis associated with it.

In the study by Peltola H, et al. [24], being underweight was associated with a poor prognosis in the Angolan and Latin American population. In contrast, in the study by Pelkonen T, et al. [18], underweight was of secondary importance. In our study, the state of shock was significantly associated with death. The finding was the same in the study by De Jong RCJ, et al. [26]. The presence of these clinical and diagnostic factors demonstrates that severe illness on admission contributes to bacterial meningitis-related mortality.

This study allowed us to confirm some data from the literature. However, a study with more resources and staff will provide more information.

Limit: we were not able to carry out the scanner in all our comatose children.

Bacterial meningitis remains a major concern in the pediatric department of Donka National Hospital. Its prevalence is still high and mainly affects male children under 4 years of age. Haemophilus influenzaetype b remains the most dominant germ and mortality remains high. Alteration of consciousness, a delay in consultation of more than 3 days, poor nutritional status, a state of dehydration and signs of seriousness such as a state of shock, generalized hypertonia, signs of decortication and decerebration were significantly associated with death in children. The precocity of the consultations, the good nutritional state of the children and the absence of signs of gravity and the respect of the VEP vaccination schedule could improve the prognosis of this disease.

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