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Pediatric Bacterial Meningitis

Practice Essentials

Pediatric bacterial meningitis is a life-threatening illness that results from bacterial infection of the meninges and leaves some survivors with significant sequelae. Therefore, meticulous attention must be paid to appropriate treatment and monitoring of patients with this disease.

Signs and symptoms

The 3 classic symptoms (less likely in younger children):

Fever

Headache

Meningeal signs

Symptoms in neonates:

Poor feeding

Lethargy

Irritability

Apnea

Listlessness

Apathy

Fever

Hypothermia

Seizures

Jaundice

Bulging fontanelle

Pallor

Shock

Hypotonia

Shrill cry

Hypoglycemia

Intractable metabolic acidosis

Symptoms in infants and children:

Nuchal rigidity

Opisthotonos

Bulging fontanelle

Convulsions

Photophobia

Headache

Alterations of the sensorium

Irritability

Lethargy

Anorexia

Nausea

Vomiting

Coma

Fever (generally present, although some severely ill children present with hypothermia)

See Clinical Presentation for more specific information on the signs and symptoms of pediatric bacterial meningitis.

Diagnosis

Definitive diagnosis is based on the following:

Bacteria isolated from the CSF obtained via lumbar puncture

Meningeal inflammation demonstrated by increased pleocytosis, elevated protein level, and low glucose level in the CSF

Bacterial meningitis score

Components of the bacterial meningitis score
are as follows:

Positive CSF Gram stain

CSF absolute neutrophil count 1000/µL or higher

CSF protein level 80 mg/dL or higher

Peripheral blood absolute neutrophil count 10,000/µL or higher

History of seizure before or at the time of presentation

Specific hematologic, radiographic (eg, computed tomography [CT] and magnetic resonance imaging [MRI]), and other studies assist in diagnosis. CT and MRI may reveal ventriculomegaly and sulcal effacement (see the image below).

Acute bacterial meningitis. This axial nonenhanced

Acute bacterial meningitis. This axial nonenhanced CT scan shows mild ventriculomegaly and sulcal effacement.

View Media Gallery

See Workup for more specific information on testing and imaging modalities for pediatric bacterial meningitis.

Management

IV antibiotics are required; if cause is unknown, agents can be based on child’s age, as follows:

< 30 days, ampicillin and an aminoglycoside or a cephalosporin

30-60 days, ampicillin and a cephalosporin; because Streptococcus pneumoniae may occur in this age range, consider vancomycin instead of ampicillin

In older children, a cephalosporin or ampicillin plus chloramphenicol with vancomycin (needs to be added secondary to the possibility of S pneumoniae)

Guidelines and recommendations

Infectious Diseases Society of America:

Vancomycin plus either ceftriaxone or cefotaxime

Duration of therapy:

Neisseria meningitidis – 7 days

Haemophilus influenzae – 7 days

Streptococcus pneumoniae – 10-14 days

S agalactiae (GBS) – 14-21 days

Aerobic gram-negative bacilli – 21 days or 2 weeks beyond the first sterile culture (whichever is longer)

Listeria monocytogenes – 21 days or longer

American Academy of Pediatrics:

Duration of therapy should not be shorter than 5 days for meningococcus, 10 days for H influenzae, and 14 days for S pneumoniae

Prevention

Preventive therapy has been shown to reduce mortality and morbidity and consists of the following:

Chemoprophylaxis: Rifampin, ceftriaxone, ciprofloxacin; ciprofloxacin and ceftriaxone are more effective against resistant strains of Neisseria meningitidis up to 4 weeks after treatment

Haemophilus influenzae type b (Hib): Rifampin chemoprophylaxis for contacts of index cases of invasive Hib disease; MenHibrix provides immunization against Hib and meningococcal serogroups C and Y

Neisseria meningitidis: Quadrivalent (ie, A, C, Y, W-135) meningococcal conjugate vaccine recommended for high-risk groups

See Treatment and Medication for more specific information on pharmacologic and other therapies for pediatric bacterial meningitis.

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