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 CT scan shows mild ventriculomegaly and sulcal effacement.
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.