As health care professionals it is essential that Registered Nurses use well developed and tested theories to guide their practice. As put by McEwen (2011, p.375) “Theory provides the basis of understanding the reality of nursing; it enables the nurse to understand why an event happens.” Utilizing the research and theory of nurses is what makes us unique and an in disposable resource to the health care team. In fact, there is a two part study, the first by Murphy et al. (2010) and the second by Pridmore et al. (2010) in which the team analyzed the use of nursing models in contemporary nursing practice. In the first section the team talked about the use of theory in past and present nursing and determined that as nurses we are moving away from the use of nursing theory and simply completing skills for patient care. After careful research into the use of theory the study concluded that using nursing theory guides the nurse to use holistic assessments and approach their care in a systematic way. They also said the nursing models make the profession unique and distinct from other disciplines. Therefore, the purpose of this paper is to give the writer an opportunity to apply the Conceptual- Theoretical- Empirical (CTE) process to practice through a hypothetical case study. This will make the writer think about how to apply theory to their own practice and realize the importance of nursing theory. The paper will introduce the topic of the CTE process then introduce a case study that will incorporate the PEI Conceptual Model (PEICM). Following this, will be an analysis of the Theory of Community Empowerment and how it is currently being used in nursing practice as well as how it applies to the case study. To conclude the CTE process will be critiqued including a discussion of the strengths and weaknesses of using the CTE process for practice settings.

Introduction to the CTE Process

The CTE process is simply a way for the nurse to apply a conceptual model, middle range theory, and empirical indicator to their practice in an organized way. The nurse uses the process to guide their practice and in time the process should become second nature to the nurse. The process does not have to follow a certain sequential path such as CTE, if needed the process could be TCE or any other sequence. (Murnaghan, 2010) To begin we will look at what CM, MRT, and EI will be used throughout the paper.

Conceptual Model

When selecting the proper CM for the setting you are working in it is important to assess certain factors, such as, does the content (concepts) of the model match with the mission statement of the setting and is the philosophical background of the model congruent with the setting (Murnaghan, 2010). For the purpose of this paper the Prince Edward Island Conceptual Model for Nursing (PEICM) will be used. This model has its roots at the UPEI School of Nursing and was developed passed on the principles and philosophy of primary health care (PHC). Like all true nursing theories the PEICM defines the four metaparadigm concepts of nursing, but what makes it unique is that they are defined based on PHC. (Munro et al, 2000).

1) Person.

When practicing under the PEICM person can be an individual, family, group, or a community. The individual is seen as being a holistic being that is unique biologically, psychologically, socioculturally, spiritually, and developmentally. Family is two or more people brought together by birth, placement, or mutual consent and have unique characteristics. A group is two or more individuals that are brought together by a certain purpose. Finally a community is a large number of individuals that live in the same geographical location. However it is not simple location that makes a community, a community is brought together by a shared age, religion, culture, or occupation. Communities range from groups of families living together to a world community. (Munro et al, 2000).

2) Health.

In the PEICM health is viewed as a wellness and illness in a dynamic relationship in which the two can co-exist. This means that even if an individual is seen as ill they can still be well in other areas. For example after a successful surgery a person could be physically in pain but emotionally they could be fine, even happy. (Munro et al, 2000).

3) Environment.

The environment of an individual is directly linked to the influence of the determinants of health. In other words the environment is the socio-political factors that affect where an individual lives, works, plays, and learns. (Munro et al, 2000).

4) Nursing.

Nursing is the promotion of wellness and the prevention of disease by following the five principles of primary health care. Which are accessibility, public participation, appropriate technology, wellness promotion and illness prevention, and intersectoral collaboration. Nursing care is providing in a process beginning with assessing, followed by identifying the health concern, planning, implementation, and evaluation. (Munro et al, 2000).

Key Assumption of the PEICM. The PEICM outlines 16 key assumptions; there are a few however that are important to the application of the setting outlined later. They are; “Clients have the potential to become active participants in problem-solving on behalf of themselves or others” (Munro et al, 2000, pp.42 (Munro et al, 2000, pp.42), and “Clients are partners in their own health care.” (Munro et al, 2000, pp.42) For a list of all the assumptions of the PEICM refer to Appendix A. (Munro et al, 2000). As you will see the reason these assumptions are of particular interest is because they are all assumptions associated with empowerment.

Middle Range Theory

The MRT theory that will be used is The Theory of Community Empowerment, developed by Cynthia Armstrong Persily and Eugenie Hildebrandt. The theory was developed in hopes to aid communities in increasing their health care knowledge and decision making skills (Smith & Liehr, 2008). The theory originated when Persily approached Hildebrandt to discuss the possibility of developing a middle range theory based on the study by Hildebrandt (1996). In the study Hildebrandt used the Community Involvement in Health model to build community participation in an African community. In the conclusion of the study Hildebrandt states that empowerment was an effective way to increase participation however the model was too broad and a practice model may be needed (Hildebrandt, 1996). Since then they have developed the MRT and are currently working on expanding the theory through research and application to practice. Empowerment has many definitions and depending on the context it can be a complex concept. As far as community empowerment there are a few definitions in the literature. An older definition taken from Hildebrandt’s 1996 study stated that community empowerment is when the health care professional shares control with the community to make members effective managers of their own health. In a more recent study by Hildebrandt (2002) empowerment was explained in terms of the PHC principle of community participation, which is working with the community to develop skills that will allow them to gain mastery over their own health. It is also important to note that empowerment has been a key aspect of community health nursing in the literature and one text in particular outlined the barriers to empowerment. Some examples include, past intervention in a community that were not successful could hinder participation, cultural differences between community and health care workers could cause a lack of trust, resistance to change, and difficulty of measuring progress or outcomes (Israel et al., 2004).

To reach the goal of empowerment the theory is based on three major concepts, the use of community lay-workers in increasing health, community involvement, and reciprocal health. Community lay-workers are trained to work with members of the community to help the nurse increase self-care and participation in health care. Community involvement is the identification of health concerns by the community with assistance from the nurse. It also includes the planning, implementation, and intervening to overcome health concerns and reach goals. Reciprocal health is when a community reaches its full wellness potential their active participation. (Smith & Liehr, 2008)

Empirical Indicator

The empirical indicator (EI) that will be used is the REALM-R developed by Bass et al. (2003). This health education tool asses the health literacy of an individual in as little as 2-3 minutes making it a very quick and effective tool.

Case Study

As a public health nurse you have been assigned to a population health project focused on reducing the incidence of high blood pressure with your community. Through a community needs assessment completed it was determined that the community you are working in has a large population diagnosed with high blood pressure. As a nurse it is your job to work in partnership with the community as a whole to reduce the incidence of high blood pressure through empowerment. To complete this goal you will use the Theory of Community Empowerment and the PEICM to guide your practice. You will start your planning by setting up focus groups in the community to work with the members to determine what they feel is the best plan of action. Through the focus groups it was determined that more education was needed around the risk factors of high blood pressure as well as was to reduce blood pressure. Your first goal is to find members of the community that you can train as lay-workers. These lay-workers will be aimed with the task of determining what level of health literacy the community is at. Therefore you must train the workers to use the REALM-R screening tool. Then from the results of the screening tool the nurse will be aware as to what type of education tool will best fit the community’s needs.

Empirical Indicator

The Rapid Estimate of Adult Literacy in Medicine (REALM-R) is a short screening tool that is clinical tested and displays the potential to identify health illiteracy in patients (Bass, Wilson, and Griffith, 2003). Some strengths of the screening tool are that it is quick and easy to administer, can take as little as 2-3 minutes to explain and complete. This makes it easy to train the lay-workers to use the tool because no extensive training would be required. Also because it is quickly completed lay-workers can spend more time talking to the client about their health concerns and educating them about those concerns. The major limitation of this assessment tool is the fact that it only assess the patients health literacy level, it does not assess their comprehension level. One study suggested that a more in-depth assessment tool should be used such as the Test of Functional Health Literacy in Adults (TOFHLA) (Gannon, & Hildebrandt, 2002). Using a more elaborate test such as this would allow the nurse to assess the literacy of the individual as well as their reading comprehension. The downfall however is that due to the increased comprehensiveness of this tool it would take longer to complete and it would be harder to teach the lay-workers how to use it. This EI fits with the MRT because education is an excellent way to empower patients. In order to educate patients with the best possible outcomes it is important to have an understanding of their literacy level. This will determine what kind of educational material you provide as well as how you deliver your education. Also due to the simplicity of the screening tool it would be easy to train lay-workers to use the tool in the community, again linking the EI to the MRT. The EI also allows for community involvement which is another concept of the MRT as outline above. The information gathered from this screening tool will be used in the development of an intervention making the community involved in the planning process of the health promotion project.

Applying the CTE Process to Case Study

The first step that the public health nurse would take is to determine if the CM they have chosen is congruent with the mission statement of their practice setting. As a public health nurse one of the main goals of your facility is health promotion through education. This is congruent with the PEICM which has a strong emphasizes on wellness promotion. In fact wellness promotion is the act creating an environment in which the client can reach their full potential through gaining control over their health care (Munro et al., 2000). This then links the MRT to the practice setting as well due to the fact that wellness promotion is an act of empowerment.

So to tie it all together we will go through the steps of the nursing process outlined in the PEICM. First is your assessment. In this case a needs assessment was completed in the community and it was determined that high blood pressure was of concern to the community. This takes care of identifying the health concern which is the second step. The third step is planning and this is where the MRT comes in. In the planning phase the nurse needed to determine what the community felt was the greatest need to lower blood pressure. Focus groups would allow the nurse to get input from a large population in a short amount of time. This also allows the community to have some control as to what kind of intervention should be planned. As we learned giving control back to the community is key to empowerment. Next is implementing know that the community has decided that more education is needed the nurse can get started planning and implementing an educational tool. However before she can do this it is important to know the literacy level of the community. Using lay-workers at this point incorporates the MRT. Lay-workers can use the EI to quickly gain data as to the health literacy level of the community. After the data is collected the nurse can implement the intervention at the appropriate literacy level. Then when the program needs to be evaluated (the final step of the nursing process) the nurse can once again use the lay-workers to go into the community to determine if the community found the intervention helpful.

Analysis of MRT

There are several reasons as to why this MRT is congruent with the PEICM; first the main goal of the MRT is to empower the community to reach their full potential (Smith & Liehr, 2008). This concept is congruent with the PEICM and the underlying framework of PHC which has a philosophy of guiding individual, groups, and communities to control their own health (Munro et al., 2000). Also the MRT is focused on the health of the community and treats the community as a whole. The PEICM defines person as an individual, group, or community, person does not have to be a single being.

Like all things there are strengths to using the CTE process to guide nursing are and there are limitations. For this case example some of the strengths would include the strong congruence between the MRT and the PEICM. For a public health nurse working on PEI that has completed their education at UPEI it would be easy to utilize the MRT of Community Empowerment. The nurse would have used the PEICM throughout their education therefore; they would have a strong understanding of the CM and could easily apply the MRT to their practice because of this. However like all things there are also limitations to using theory to guide practice. Some nurses just don’t believe that theory should guide their practice therefore it would be difficult to apply the CTE process to that setting. Also if the nurse is not trained in the PEICM it would be difficult to implement the CTE process in this case example. Literature has shown that a significant barrier to application of theory is lack of training in the use of nursing models and resistance to change (Kenny, 1993). Another barrier to applying nursing theory is that some nurses believe that nursing theory is used largely to enhance the professionalism of nurse and is not really of benefit to patient care (Hodgson, 1992).

Conclusion

In the end the most important question a nurse needs to ask themselves is, what is best way to care for my patient? As this paper shows the answer to that question is through tested, researched, and sound nursing knowledge based on nursing theory and models. It really is common sense that the best way to provide “nursing” should be through the use of “nursing knowledge”. The CTE process is an excellent way for the nurse to determine what model, theory and empirical indicator would work best or their practice setting. At first it may seem like a lot of work to apply this process to every patient you care for, but, like nursing skills such as intramuscular injection or IV therapy the CTE process will be become instinctual. For example when a school of nursing utilizes a CM to guide the education of their students, the students start to use the CM in their everyday practice without much thought. As for the application of the theory of community empowerment there is still some work to be done. The theory has a great foundation and could be utilized in many practice settings in particular the public health sector of nursing. However, because the theory is relatively new there is not enough theory to back it up. In the future this theory would be an excellent choice to guide the practice of public health nurses. So what is the best way to care for your client? Well, just apply the CTE process to your situation and you will have your answer.

Vaccinations train the immune system in the body to fight against infectious diseases.  They contain a dead or weakened pathogen that will not cause any symptoms of the disease. The immune system will continue to produce antibodies due to the foreign antigens on the surface of the pathogen. Memory cells are produced and will remain in the body so when the same antigen triggers an immune response it will be faster and the pathogens are destroyed.(Pappas, 2010). The World Health Organisation have stated ” Vaccination is one of the most cost-effective health interventions available, saving millions of people from illness, disability and death each year.” (World Health Organization Regional office for Europe, 2019)

Vaccinations not only protect individuals who have them but also the people who surround them as the disease is less likely to occur if less people can catch the disease. This is called herd community. The more people are vaccinated the less likely it is for people to catch different diseases. (Pappas, 2010). For example, in the United states since the MMR vaccine was introduced it became unlikely for children across the country to have these diseases. However negative speculation in the media about vaccines particularly MMR  members of the general public to become wary and some have come to the belief that vaccinations are not necessary. (Smith et al., 2008).

Mrs Hall has seen negative comments in the media regarding vaccinations, particularly MMR and is unsure of whether it is necessary for her daughter Sophie (04/07/18) to receive the vaccinations required at 12 months ( one year ). Sophie received the routine vaccinations that all babies in the UK are given at eight, twelve and sixteen weeks old.

(Assets.publishing.service.gov.uk, 2018)

At the age of one Sophie will receive the routine vaccinations:

(Assets.publishing.service.gov.uk, 2018)

Haemophilus influenzae type b (Hib)

Haemophilus influenzae type B otherwise known as Hib is a type of bacterium that causes several different severe diseases such as:

• meningitis
• septicaemia
• pneumonia
• epiglottitis

These are just some of the numerous infections that people particularly children can develop due to Hib. Meningitis is the most serious illness that can develop as a consequence of Hib bacteria. At least 1 in every 20 children can die as a result of contracting meningitis from Hib bacteria. Despite the high statistics of children that survive many suffer from long term conditions such as hearing impairment and physical and mental disabilities.

The symptoms of Hib depend upon the infection that is developed from Hib bacteria for example if the infection was meningitis the symptoms may include headaches and vomiting whilst if it was pneumonia the symptoms may include coughing and having difficulty in breathing.

(nhs.uk, 2016)

Meningitis

” Meningitis is an infection of the protective membranes that surround the brain and spinal cord (meninges).”  It can become fatal quickly if not treated fast enough.  Meningitis can lead to septicaemia ( blood poisoning) and permanent damage to the nervous system. It can appear either as a viral or bacterial infection, of the two bacterial meningitis is more dangerous.

The symptoms of meningitis include:

• a fever
• vomiting
• headaches
• a rash
• seizures
• fatigue

There are other symptoms of meningitis and can appear in any order, however not all symptoms turn up. Meningitis vaccines can be used as protection against certain strains of meningitis.

(nhs.uk, 2019)

Pneumococcal Infections

The bacterium Streptococcus pneumonia causes pneumococcal infections which can cause septicaemia, pneumonia and meningitis. In the most severe cases they can lead to long term conditions and death. People that are most vulnerable to these infections are babies, seniors and people with long term illnesses.

Pneumonia is one of the illnesses that is caused by pneumococcal infections. it is a bacterial infection that can cause the tissue in the lungs becoming inflamed.

Symptoms of pneumonia can develop over one or two days. These can include:

• coughing – producing thick yellow, green, brown or blood stained mucus
• breathing difficulties
• fever
• Increased pulse
• chest pain

These symptoms are common. The more severe symptoms can include:

• coughing up blood
• headaches
• fatigue
• nausea
• being short of breath
• muscle and joint pain
• disorientation

The Pneumococcal vaccine helps to protect against pneumococcal infections and is offered as part of the routine immunisation for children at 8 weeks, 16 weeks and 12 months. Adults over the age of 65 will receive one shot of the pneumococcal vaccine whilst people with long term conditions may receive the vaccine every five years.

There are two types of pneumococcal vaccines one for children under two years called PCV whilst adults over the age of 65 will receive the pneumococcal vaccine PPV. The vaccine should not be given if people have a fever or an allergy to one or more of the ingredients in the vaccine whilst females who are pregnant or breast feeding should not have the vaccine.

(nhs.uk, 2019)

Measles

Measles are a viral illness that spreads quickly and is most common in children. However it clears up between 7- 10 days and is not very serious. Once having measles it is unlikely that you will get the virus again. Symptoms of measles appear around 10 days of being infected with the disease and can include:

• runny nose, sneezing
• cough
• sore, red eyes
• a fever
• small greyish white spots on the inside of the cheeks

A few days later after the symptoms a brown-red rash will appear and spread across the body. Complications can occur and lead to more severe illnesses like pneumonia. Common complications that can occur are:

• diarrhoea and vomiting, which can lead to dehydration
• middle ear infection, which can cause earache
• eye infection
• inflammation of the voice box
• infections of the airways and lungs (such as pneumonia, bronchitis and croup)
• fits caused by a fever

Less common complications can include hepatitis, meningitis and misalignment of the eyes. There is a greater risk if a pregnant female contracts measles as it can lead to miscarriage, stillborn, premature birth or a low birth weight.

(nhs.uk, 2018)

Mumps

Mumps is also a viral infection that can be very contagious. Mumps causes painful swelling on the sides of the faces under the ears. Other than the swellings symptoms of mumps can include:

• headaches
• joint pain
• high temperature
• nausea
• abdominal pain

Mumps is not a very serious illness but it can lead to more severe diseases like tonsillitis, meningitis, swollen testicles and ovaries. However these conditions improve once the infection passes.

(nhs.uk, 2018)

Rubella

Rubella otherwise known as German measles is a disease that causes a spotty rash which people normally recover from within 7 days. Complications occur when a pregnant female contracts the disease which can lead to miscarriage or problems after birth.

The main symptom for rubella is a red-brown rash that is easily spotted after 2-3 weeks of contracting rubella. Other symptoms of rubella can include:

• aching fingers, wrists or knees
• a high temperature of 38C or above
• coughs
• sneezing and a runny nose
• headaches
• a sore throat
• sore, red eye

Measles, Mumps and Rubella can be prevented by taking the vaccination MMR at or around 12 months and a second dose at around 36 -40 months ( 3 years 4 months).

(nhs.uk, 2018)

Vaccinations and the media

In recent years, the rate of vaccinations has been vastly influenced by both the media and literature, whether the information is positive or negative. The anti vaccine content causes concern for members of the general public particularly parents with young children. This leads parents to consider whether vaccinations are completely necessary. However, despite the growing concern of a small percentage of parents believing in anti vaccination, a vast majority believe the benefits outweigh the risks. Modern vaccines are safe and cost effective and the side effects that occur are mild at best and short lived. The most severe side effect is likely to be an allergic reaction to one or more of the ingredients in the vaccine. This is incredibly rare with ‘ less than 1 in a million’ (Giroir, Redfield and Adams, 2019) (Vk.ovg.ox.ac.uk, 2019) NHS (2019).

The more people vaccinated the rarer the disease becomes and even those that have not been vaccinated are less likely to contract the disease as the people around them are immune to them. This is called herd community. (Pappas, 2010).However due to the increasing concern of side effects, parents are less likely to have their children vaccinated, which can lead to the increase of these diseases occurring, for example the global measles outbreak. The vaccine for measles is part of the MMR vaccine and requires two doses. However for the last several years, the vaccination for the first dose has stopped at around 85% globally, whilst the second dose stops at 67%. According to the WHO a 95% global coverage is needed to prevent outbreaks. (World Health Organization, 2019). However the controversial thoughts in the media and forms of literature discourages parents from inoculating their children not just against MMR but various types of diseases.

For example, social media. Brunson 1 found peoples’ decisions are influenced heavily through what is called the people ‘s network as they are more likely to look at social media and therefore base their decisions on what they read on online blogs, twitter or face book regardless whether the information is true or false. (Wachob and Boldy, 2019).

For instance MMR and its link to autism. It began with the study by Dr Andrew Wakefield in 1998 who claimed that MMR might cause autism or bowel disease. However since then his work has been discredited and his title as a doctor has been rescinded. (nhs.uk, 2018).  In addition, critics pointed out flaws in his study such as his small sample size. (Sathyanarayana Rao and Andrade, 2011). Furthermore several studies over the last nine years such as the Danish study (

Hviid et al., 2019

)conducted with over 650,00 children have proven there is no link between autism and MMR. Despite this the publicity gained caused fear to grown and stop both children and adults being vaccinated, and the measles outbreak that occurred has been linked to the decreased rate of vaccinations. (Sathyanarayana Rao and Andrade, 2011).This shows how an incorrect portrayal of vaccination led to a global negative impact regarding vaccinations.

On the other hand, despite the negative speculations regarding vaccinations the WHO continue to campaign about global vaccination and many other articles and journals continue to be published about the positive effects of vaccinations for instance ‘This Is The Truth About Vaccines’ published by the New York Times highlighting the positive impact of vaccines and the negative impact the decrease of vaccines can and will have.

In addition the negative portrayal of vaccines highlights the importance of healthcare professionals in giving guidance to the public and providing the accurate information to increase the uptake of vaccinations. As pharmacists are at the frontline and one of the first points of contact for the public, they could provide leaflets on up to date information regarding vaccines, the diseases they protect against and their side effects in particular. As side effects are one of the main concerns of parents. This would help ease parents and comfort them knowing the benefits which heavily outweigh the risks.

In addition pharmacists could provide several routine vaccinations that both adults and children require to increase the uptake of vaccinations to make it easier for the public to access as the GP are often booked particularly around the summer season due to holiday vaccinations. The collaboration between GP’s and Pharmacies would increase the uptake of different vaccinations similar to the flu vaccination. (Collaboration between GPs and pharmacists key to increased flu vaccine uptake, 2017).

In conclusion, Mrs Hall should have Sophie inoculated. Routine vaccinations are important in babies and young toddlers as they protect them against diseases.

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  , [online] 16(1), pp.e13056-1,5. Available at: http://file:///C:/Users/user/Downloads/13056-25279-1-PB.pdf [Accessed 10 Jul. 2019].

Introduction

Bacterial meningitis is an acute inflammation of the meninges (dura mater, arachnoid mater, and the pia mater) due to bacterial infection, namely that of

Streptococcus pneumoniae

and

Neisseria meningitidis

. Bacterial meningitis is spread through droplets or secretion of mucous from the throat between close contact of people. It is a highly significant disease with over 1.2 million cases occurring globally which may result in neurological damage, disability, or fatality if left untreated (Center for Disease Control and Prevention, 2016). Meningitis is a concerning disease as survival depends on the early diagnosis and treatment of the disease. A delayed diagnosis can result in death within 24 to 48 hours of clinical manifestations. There is also a high risk of complications that can occur in association with the immune response to infection such as sepsis (Center for Disease Control and Prevention, 2019).

Nonetheless, medical research has improved the prevention and treatment of the disease, leading to a significant decrease in cases in developed countries through vaccine programs and antibiotic treatment. This is evident in the reduction of cases of meningitis caused by

Haemophilius influenzae

with 45 – 48% down to 7% due to the introduction of the

H. influenzae

type b vaccine (Brouwer, Tunkel, & van de Beek, 2010). However, there is still up to 34% mortality rate with up to 50% of survivors presenting with long-term neurological damage. (Hoffman & Weber, 2009). This can be attributed to the intensity of the inflammatory response to current use of bacteriolytic antibiotic paired with the resistance to penicillin which raises the concern for further research into alternative antibiotic treatments.

The report highlights the cause of bacterial meningitis and generally covers the pathogenesis, diagnosis, and treatment of the disease in the background information. It then goes into the identification of key features present in bacterial meningitis through an annotated image of a specimen with the disease. It then proposes a research question on the efficiency of the alternative use of nonbacteriolytic antibiotic in treatment and finally reflects on the challenge of research and understanding of the topic.

Background

Meningitis is an inflammation of the meninges, especially within the subarachnoid space. The meninges are the membrane of the brain and spinal cord and consist of the dura mater, arachnoid mater, and the pia mater. Meningitis affects people globally but is predominant in developing countries, especially those within the ‘meningitis belt’, an area spreading 26 countries from Senegal to Ethiopia. The risk of infection is increased in people younger than 5 years and older than 60 years. Other risk factors may include large gathering of people, pre-existing conditions such as immunodeficiency and travelling to areas of high occurrence of meningitis such as the sub-Saharan Africa (Center for Disease Control and Prevention, 2019). It is most commonly caused by

Streptococcus pneumoniae

(41.2%) and

Neisseria meningitidis

(9.1 – 36.2%). However, it may also be caused by Group B

Streptococcus

,

Haemophilus influenzae

,

Listeria monocytogenes

, and

Escherichia coli

(OordtSpeets et al, 2018).

The brain is usually protected from bacterial invasion through cellular barriers; the blood-brain barrier and the blood-cerebrospinal fluid barrier. These are physical barrier against microbial infection while also allowing for the transport of nutrients for brain function via various transport mechanisms. It is through the breakdown of the blood-brain barrier and invasion through the bloodstream that causes bacterial meningitis (Dando et al, 2014, p. 694). Bacteria spread from close contact with a person who carries the bacteria and it can enter the body via the nose or mouth. The bacteria are then allowed to colonise in the nasopharyngeal where it can be encapsulated which helps prevent the bacteria from being phagocytized by neutrophils. It then invades the vascular system and can enter the central nervous system (CNS) due to epithelial cell injury. Once in meninges of the brain, it can cause headaches and activates the inflammatory response by releasing cytokines that can lead to fever and subsequently increases the permeability of the blood-brain barrier to proteins and neutrophils which can cause neck stiffness. This increases the intensity of the inflammatory response causing swelling of the brain which leads to increased pressure in the skull which can impair blood flow. The vascular system also dilates and gets congested and may lead to neurologic injury leading to complications such as disabilities and loss of function (Tunkel & Scheld, 1993).

Diagnosis of bacterial meningitis is mainly through the identification of gram-stains which may be either positive or negative depending on the bacterial strain in cerebrospinal fluid (CSF) through extraction of CSF by lumbar puncture. This is then viewed microscopically or using polymerase chain reaction (PCR) to amplify small amounts presents. For areas with limited access to resources, urine dipsticks are also used to identify glucose and leukocyte concentration because a decreased glucose and elevated white blood cell count indicate blood-barrier disruption. Further diagnosis of meningitis can also be conducted through CT scan for complications such as swelling and infarction (Hoffman & Weber, 2009). During diagnosis, treatment of empiric antibiotics is immediately administered and after diagnosis, specific antibiotic can be administered for the bacteria identified. If the particular bacterial agent is not identifiable, the choice of antibiotic is done based on age and health status because the bacterial agents tend to infect specific age groups. Corticosteroids may also be given to treat complications and signs of inflammation such as swelling (El Bashir, Laundy & Booy, 2003).

Macroscopic Specimen

The specimen is a brain with meningitis. The superior view of the brain shows signs of acute inflammation of the meninges. The brain has a diffuse lesion of white/milky coloured exudate that largely covers the surface of the brain particularly within the sulci, indicating the meninges to be infected. This exudate is most likely caused by

Streptococci

during infection however due to the small size of the brain, it indicates it belonged to that of a young individual which suggest that the bacterial may have been

E. coli

as that is the most common in newborns. The phagocytosis of the bacteria by neutrophils in the subarachnoid space and its prevalence around the sulci indicate the disease to be meningitis. The blood vessels of the brain are also dilated which is suggests congestion of the blood vessels, especially in the occipital lobe. The gyri of the brain also appear enlarged with few spaces between each, indicating swelling of the brain.

Current medical research

A key area of current research has been in the study of the effectiveness of treatments to reduce the high mortality rate of bacterial meningitis as well as to reduce the incident of neuronal damage. These studies are conducted on mice and rabbits as the outcomes are similar to those that humans present. The main focus of current research has been in the additional effect of corticosteroids and has led to the treatment of bacterial meningitis as a combined treatment of a bacteriolytic antibiotic such as penicillin or ceftriaxone and an adjunctive agent such as dexamethasone to eliminate the bacterial agent while also reducing the inflammatory response within the subarachnoid space. These investigations have led to the extremely significant discovery of dexamethasone being an effective adjuvant agent in improving the outcome of bacterial meningitis in more wealthy countries (de Gans & van de Beek, 2002). It has improved the treatment of bacterial meningitis and allows for further investigation into the use more stronger corticosteroids for the reduction of inflammatory response for the decreased rate of long-term neural damage in developed countries such as the U.S. and Europe. However, there are issues with the effectiveness of dexamethasone as it has only been beneficial for teens and adults in developed countries whereas young children and newborns, elderly, and individuals that are affected by HIV did not show an improvement compared to in developed countries with the combined treatment (Scarborough et al, 2007). Nevertheless, the research into anti-inflammatory drugs and treatments is highly significant in a bid to reduce the cases of neural damage.

Although the rate of occurrence and mortality of bacterial meningitis has been significantly reduced since the introduction of vaccination and antibiotic treatment, it is currently still extremely high with a rate of up to 34% (Hoffman & Weber, 2009). One area in particular which needs further research is the current administration of bacteriolytic antibiotics such as penicillin for the treatment of bacterial meningitis, although effective in killing the bacteria, can cause further damage and increase complications to brain function. This is because the use of bacteriolytic antibiotics cause an increased intensity of the inflammatory response as the breakdown of the cell wall and lysis products causes the immune system to send out more cytokines and neutrophils to combat the bacterial components. This increase in intensity cause further damage to the brain as its response can damage blood vessels and neurons due to increased permeability and swelling. This can result in high rate of complications such as loss of hearing, brain function, seizures in surviving individuals. In addition, the increase in resistance to current antibiotics further highlights the need for continued research into alternative antibiotic treatment for bacterial meningitis (Woehrl et al, 2011).

It is through the potential of non-bacteriolytic antibiotics such as daptomycin in treating bacterial meningitis that the risk of fatality may be lowered. Daptomycin is a lipopeptide antibiotic which is effective against gram-positive bacteria. It works by disrupting the membrane potential through depolarization via calcium-dependent pore formation which leads to cell death. An investigation comparing the treatment of daptomycin against ceftriaxone in mice infected with bacterial meningitis showed that daptomycin was more beneficial for memory retention of objects for short-term and long-term as opposed to treatment with ceftriaxone which required increased stimulation for memory retention. Thus, indicating the preservation of neural function. Another benefit of the use of daptomycin over ceftriaxone is that it has a higher clearance of bacterial components in the CSF compared to ceftriaxone (Barichello et al, 2013). For a highly effective treatment for the prevention of bacterial meningitis complication, daptomycin could also be combined with a matrix metalloproteinases inhibitor to reduce the risk of hearing loss. This is effective because an inhibitor of matrix metalloproteinases stops the blood-brain barrier from being disrupted and therefore reduces the intensity of the inflammatory response because it would not be initiated and the vascular parts of the brain would remain functional (Muri et al, 2018). Thus, the research into the use of daptomycin instead of penicillin for the treatment of bacterial meningitis is highly significant for the decrease in mortality and increase in full term recovery from meningitis.

The problem with the treatment of bacterial meningitis is the lack of a single efficient empiric antibiotic which will not cause host inflammatory damage and is not at the risk of resistance. Although daptomycin is very efficient at eliminating bacterial components from CSF, it is only efficient at removing gram-positive bacteria, so any gram-negative bacteria would be able to persist. The increasing risk of resistant bacteria to the current empiric antibiotic is another major concern because if the invading bacteria is resistant to the empiric antibiotic, there is an increased risk of mortality as the first dose of antibiotics is meant to be given at the same time as lumbar puncture to stop the risk of progressing bacteria. Therefore, it is imperative to research for alternative treatments against bacterial meningitis.

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