Clinical Outcome of Meningitis and Its Risk Factors Among Children Admitted in Debre Markos Referral Hospital Pediatric Ward, Northwest Ethiopia,2019

Background:Meningitis remains a major cause of mortality and morbidity in patients in many countries of the world including Ethiopia. This study aimed to assess clinical outcomes and associated risk factors of meningitis among children who were admitted to Debre Markos Referral Hospital from January 2017 to December 2018.A backward stepwise multivariable logistic regression was applied with 95% condence interval of odds ratio (OR) andstatistical signicance less than 0.05 p-value were taken as cut off value. Methods:A retrospective cross-sectional study was conducted. The study includesAll pediatric meningitis 211 cases from the age of one month to fourteen who were admitted due to meningitis in Debre Markos Referral Hospitalfrom January 2017 to December 2018.Data were entered, cleaned, and analyzed using SPSS for Windows, version 20. Results:The study showed that 18.9% of children with meningitis developed bad outcomes. In this study, children who were a worse clinical condition at admission 6 times more likely to develop bad outcomes [AOR= 6.321(2.121, 18.837)] and having a seizure at admission almost 19 times more likely to develop bad outcomes [AOR=18.953(6.677, 53.799)]. Conclusions:About one in ve children with meningitis developed bad outcomes. The health care team should due attention to improving care for patients with severe conditions at admission and seizures were the alarming signs for poor outcomes in children.

Meningitis caused by bacteria is a medical emergency. The therapeutic goal is to initiate antibiotic therapy within 60 minutes of patient arrival in the emergency room. In patients suspected of having bacterial meningitis, CSF should be obtained for cultures and empirically antimicrobial therapy should be initiated without delay [5,6].
A region in sub-Saharan Africa, extending from Ethiopia in the east to the Gambia in the west and containing 15 countries with > 260 million people, is known as the "meningitis belt" because of its high prevalence of endemic diseases with periodic epidemics caused by N.meningitidis [7,8] Pediatric meningitis is a life-threatening illness in children [9]. Beyond the neonatal period, since the routine use of Hib, conjugate pneumococcal, and conjugate meningococcal vaccines in the United States, the incidence of meningitis has dramatically decreased [10,11]. Until recently, meningitis was a greatly feared infectious disease because it struck and killed many of its victims among children with mortality rates of up to 30%.
Moreover, 20-50% of pediatric patients who survive the infection have serious and permanent neurological sequelae, which include deafness, mental retardation, and learning impairment, sensorymotor de cits, seizure disorders, and cerebral palsy. The incidence of neurologic sequelae of bacterial meningitis in children has not signi cantly improved over the last decade. Hearing impairment is the most common neurological sequel following meningitis [1,9].
Although antibiotics are often administered before the laboratory results of CSF culture and sensitivity, however, there is limited information available on the risk factors and clinical outcomes of meningitis.
Therefore, this study aimed to identify the risk factors and clinical outcomes of meningitis among children admitted with meningitis to Debre Markos Referral Hospital, Northwest Ethiopia.

Exclusion criteria
Children admitted with a diagnosis of meningitis with incomplete medical records weren't included. The initial diagnosis of meningitis changed to others like urinary tract infection malaria and pneumonia, were not included.
3.5. Sampling size determination and sampling techniques 3.5.1. Sample size determination The sample size (n) of this study was determined based on a single population proportion (p) formula by considering a 5% margin of error, 15% prevalence, and 95% con dence interval. The total sample size was 196.
3.5.2. Sampling procedures /Techniques/ Systematic sampling was used to assess the outcomes and associated risk factors of pediatric meningitis. All 211 pediatric meningitis patients aged from one month to fourteen years who were admitted in the study period will be taken, and 15 cases were excluded based on the criteria.

Data collection tool
Data were collected from the patient les and recordings using checklists.

Data collection procedure
Data were collected from the secondary data which was obtained from patient les and registration books in DMRH March 8/2019-April 6/2019 G.C. Data were collected by 2 health professionals who had degree holders and one supervisor who observed the data collection process.

Data quality control
The record was checked for its completeness using a checklist. The training was given to the data collectors and the supervisor for 1 day. discharge, refer to a higher level care and left against medical advises with no improvement after initiation of treatment.

Pediatrics
Age less than or equal to fourteen years.

Data analysis
Data were entered, cleaned, and analyzed using SPSS for Windows, version 20. To ensure the quality of data entry, it entered into two computers. Frequencies and cross-tabulations were used to summarize the data. Bivariate analysis was done for all independent variables. Associated variables with statistical signi cance of p-value less than 0.25 in the bivariate analysis were entered in the nal multivariable logistic regression model. A backward stepwise multivariable logistic regression was applied. Lastly, an odds ratio (OR)was presented with a 95% con dence interval and the level of statistical signi cance was presented based on a p-value less than 0.05.

Socio-demographic characterization
One hundred ninety-six pediatric les were reviewed. Of the total, 125(63.8%) were males and 71 (36.2%) were females. Overall, 101 (51.5%) were between one month and one-year-old and 95 (48.5%) were between one and fourteen years, as shown in Table 1.

Possible risk factors for meningitis
From the selected factors, 83(45.4%) completed their immunization. Among pediatric meningitis cases, 124(79%) were recorded as no sign of a nutritional problem and 72(36.7%) of them took corticosteroid drugs before the initiation of antibiotics. In most patients, 72(36.7%) were admitted in the spring season, as shown in Table 2. Among the total cases of the study, 6(3.1%), 10(5.1%), and 3(1.5%) had bulged fontanel, nerve palsies, and paralysis, respectively.

Investigations
From one hundred ninety-six patients, cerebrospinal uid (CSF) analysis was done for 135(68.9%); among them, 84(62.2%) had con rmed meningitis. A gram stain was done for 77(57%), and acid-fast bacilli (AFB) test was done for 55 patients there were no positive ndings. From the total participants, 2 (1%) cases were developed hydrocephalus, as shown in Table 3.  Table 4.

Discussion
In this study, meningitis was common from 1 month to 1 year of age, which accounted for 52% of pediatric meningitis cases. A similar study conducted in Pakistan showed that 68.3% were infants [12], and a study in Turkey showed that the highest incidence was in children 1-12 months of age. [7].
The current study indicates that 56.6% of the study participants lived in rural areas. This is different from the study conducted in Felege Hiwot Referral Hospital [13], the residents of pediatric patients were urban (67%) and Nepal was urban (88.1%) [14]. This may be due to demographic, socio-cultural, and economic differences between people in the study area.
This study showed that most of pediatric meningitis were admitted in the spring season, which was 36.7%. A similar study conducted in Iran showed that most meningitis patients were admitted in the spring season [15]. This may be due to temperature, humidity level, pressure, wind, and dust during the season.
Malnutrition is one of the risk factors that can expose to the development of meningitis [6]. This study indicated that about 21% of the patients were malnourished. A similar study was conducted in Felege Hiwot Referral Hospital indicated that 18% of the patients were malnourished [13]. In the study conducted in Libya and India [8], only 0.2% and 2.4%, respectively, were malnourished. This showed that there was a relatively high rate of malnutrition in the current study. This difference might be due to demographics, socio-cultural and economic differences between people in the different study areas and community awareness about childhood feeding practices in a different area.
In this study, 45.4% of the participants completed their vaccination. A similar study was conducted in the Felege Hiwot Referral hospital, and 49.4% of children completed their vaccination [13]. In contrast, in a study conducted in Turkey [7], 91.3% of the immunization status was completed. This difference might be due to community awareness about the risk factors of pediatric meningitis.
Different infections or diseases can be a risk for the development of meningitis. Among these, HIV/AIDS, tuberculosis, cerebral malaria, and sepsis are the most common. This study indicated that 0.5% of the patients were co-infected with HIV/AIDS. Research done at Felege Hiwot Referral Hospital showed that 4.5% & 2.2% and in Nigeria, 2.1% and 4.5% were co-infected with HIV/AIDS and tuberculosis, respectively, [13,16,17]. The difference might be a variation in socio-demographic and study design.  [13].
Laboratory investigations of CSF specimens in suspected cases of meningitis are extremely important for prompt diagnosis and management of patients [8]. In this study, 135(68.9%) patients were investigated for their CSF, and among them, 84 (62.2%) of meningitis patients had an elevated level of WBC. Similar studies were done Felege Hiwot Referral Hospital [13], and in Taiwan [18] indicated that most admitted patients tested their CSF, which was about 69.8% and 88%, respectively. Among them, 98.3% and 83.8% had elevated WBC, respectively.
Gram stain examination of CSF permits rapid, accurate identi cation of the causative bacterium in 60-90% of patients with meningitis [8]. In contrast to this, the current research gram stain on CSF provided 11(14.3%) meningitis pediatric patients were positive. It was less than that of Felege Hiwot Referral Hospital, which was about 32(30.2%). The difference might be due to the variation of etiology and difference in the study area.
The outcomes of this study were good or bad. In this regard, 157(81.1%) of them were improved and discharged after improvement (good outcome) and 18.9% were a bad outcome. Among these, 10(5.1%) developed complications, 2(1%) referred to higher-level for brain imaging (CT scan), 17(8.7%) left against medical advice after the clinical conditions worsened and 8(4.1%) died. The factors that contributed to these complications were nerve palsies, 10(5.1%) and paralysis 3(1.5%). A similar study was conducted in Felege Hiwot Referral Hospital and Brazil, 19(10.6%) and 2(5.7%) had complications of cranial nerve involvement that led to an oculomotor problem (nerve palsies), and 0.6% and 2.9% were for paralysis respectively [13,15]. Also, a study conducted in Felege Hiwot Referral Hospital showed that 15% of pediatric meningitis cases developed poor outcomes and referred to higher facility 4.5%, and death 3.4% was stated thus, it was a better outcome than this study area [13]. This different outcome could be the difference in institutional capacity and other risk factors in the study area.  [13]. This is also comparable may be due to the effect of a difference in ethological and cases of demographic variation.

Conclusion
In summary, the clinical outcomes of pediatric meningitis in this study area was poorer than that in reviewed hospitals. One in ve pediatric meningitis cases in this study area had a bad outcome. seizures and worse clinical conditions at admission were associated factors for poor pediatric meningitis outcomes.
8. Recommendation 1. Hospital and Health Department should create awareness among the health care team to give due attention to pediatric patients presenting with a worse clinical presentation at admission and seizure.
2. Health workers should create community awareness about each risk factor and early health seeking-practice to improve clinical outcomes.
3. Researchers should do further study on identi cation of bacterial species and antibiotic susceptibility to improve outcomes related to causative agents.

Limitation Of The Study
The study was based on secondary data (chart review) and may not display all factors that were not documented in the patient's les. There were no identi ed bacterial species that helped to see the outcomes related to causative agents.