What is the management of neonatal and pediatric meningitis?

Management of Neonatal and Pediatric Meningitis

Early recognition and prompt administration of appropriate antibiotics within 1 hour of presentation is the cornerstone of management for neonatal and pediatric meningitis to reduce mortality and morbidity. 1

Etiology and Epidemiology

Neonatal Meningitis

• Incidence: 0.2-0.5 per 1000 live births 2
• Common pathogens:
  • Group B Streptococcus (48.5% of confirmed cases) 3
  • Escherichia coli (18.2% of confirmed cases) 3
  • Listeria monocytogenes 4

Pediatric Meningitis

• Common pathogens:
  • Streptococcus pneumoniae
  • Neisseria meningitidis
  • Haemophilus influenzae (declining due to vaccination) 1

Pathophysiology

Bacterial pathogens typically reach the central nervous system through:

1. Hematogenous spread (most common)
2. Direct extension from contiguous infections
3. Retrograde neuronal transport

Once in the CSF, bacteria multiply rapidly due to limited host defense mechanisms, leading to inflammation, increased intracranial pressure, and potential neurological damage.

Clinical Findings

Neonatal Meningitis

• Often presents with non-specific symptoms:
  • Irritability (common)
  • Poor feeding
  • Temperature instability (fever present in only 6-39% of cases)
  • Respiratory distress (72% in early-onset GBS meningitis)
  • Lethargy
  • Seizures (9-34% of cases)
  • Hyper- or hypotonia 1

Pediatric Meningitis

• Classic triad of fever, neck stiffness, and altered mental status (less common in younger children)
• Fever (92-93% of cases)
• Headache (2-9% in children <1 year; 75% in children >5 years)
• Vomiting (55-67%)
• Photophobia
• Altered mental status (13-56%)
• Seizures (10-56%)
• Petechial/purpuric rash (particularly with meningococcal disease) 1

Evaluation

Initial Assessment

1. Rapid clinical assessment with attention to:
   • Vital signs
   • Mental status (Glasgow Coma Scale)
   • Signs of increased intracranial pressure
   • Presence of rash
   • Assessment for shock 1

Laboratory Studies

1. Lumbar puncture - critical for diagnosis 5

   • CSF analysis: cell count, glucose, protein, Gram stain, culture
   • Important: Normal CSF parameters do not rule out meningitis in neonates 5
   • 38% of culture-proven neonatal meningitis cases have negative blood cultures 5

2. Blood cultures - obtain before antibiotics when possible 1

3. Other tests:

   • Complete blood count
   • Electrolytes, BUN, creatinine
   • Coagulation studies
   • Blood glucose

Imaging

• Consider neuroimaging if:
  • Focal neurological signs
  • Persistent seizures
  • Persistent positive CSF cultures
  • Clinical deterioration 1

Treatment/Management

Initial Management

1. Stabilization:

   • Secure airway, breathing, circulation
   • Consider intubation for GCS <12 6
   • Treat seizures if present

2. Empiric Antibiotics - administer within 1 hour of presentation 1, 6

   For neonates (0-28 days):

   • Ampicillin (for Listeria and Group B strep coverage) PLUS
   • Cefotaxime or gentamicin (for gram-negative coverage) 4, 7
   • Dosing:
     • Ampicillin: 50-100 mg/kg/dose IV
     • Gentamicin: 2.5 mg/kg/dose IV 8
     • Cefotaxime: 50 mg/kg/dose IV

   For infants and children (>28 days):

   • Ceftriaxone or cefotaxime PLUS
   • Vancomycin (if S. pneumoniae resistance is a concern) 1
   • Dosing:
     • Ceftriaxone: 100 mg/kg/day (up to 2g) IV divided q12h 9
     • Vancomycin: 15 mg/kg/dose IV q6h

3. Fluid Management:

   • If signs of shock present, administer rapid infusion of isotonic crystalloid or colloid up to 60 ml/kg (three boluses of 20 ml/kg with reassessment after each) 1
   • Maintain euvolemia; fluid restriction is not recommended 6

4. Corticosteroids:

   • For bacterial meningitis in children: dexamethasone 0.15 mg/kg IV q6h for 4 days, given with or within 24 hours of first antibiotic dose 1
   • Not recommended for neonatal meningitis or meningococcal septicemia except in inotrope-resistant shock 1

Targeted Therapy

• Adjust antibiotics based on CSF culture and susceptibility results
• Typical duration:
  • Group B streptococcal or Listeria meningitis: 14-21 days
  • Gram-negative meningitis: at least 21 days 4
  • Repeat CSF examination at 48-72 hours to ensure sterilization 4

Supportive Care

• Monitor for and treat:
  • Seizures
  • Increased intracranial pressure
  • Shock
  • Electrolyte abnormalities
  • SIADH

Intensive Care Considerations

• Transfer to PICU if:
  • Rapidly evolving rash
  • GCS ≤12
  • Need for specific organ support
  • Uncontrolled seizures
  • Evidence of severe sepsis 1
• For fluid-resistant shock, consider early ventilatory support after starting inotropes 1

Differential Diagnosis

• Viral meningitis/encephalitis
• Intracranial hemorrhage
• Brain abscess
• Sepsis without meningitis
• Drug reactions
• Metabolic disorders
• Non-infectious inflammatory conditions

Prognosis

• Mortality:

  • Neonatal meningitis: 8.3-19.4% overall, higher in very low birth weight infants (33.3%) 3
  • Pediatric meningitis: varies by pathogen

• Morbidity:

  • 13-18.5% of survivors have neurological sequelae 3
  • Common sequelae: hearing loss, cognitive deficits, seizures, motor deficits

Complications

• Subdural effusions
• Hydrocephalus
• Cerebral infarction
• Brain abscess
• Ventriculitis
• Seizure disorders
• Hearing loss
• Developmental delay

Pearls and Pitfalls

Pearls

1. Always perform lumbar puncture in neonates with suspected sepsis, as meningitis can occur without bacteremia in up to 38% of cases 5
2. CSF parameters may be normal in early neonatal meningitis - culture is critical for diagnosis 5
3. Early administration of antibiotics (within 1 hour) is associated with improved outcomes 1
4. Consider meningitis in any neonate with non-specific symptoms like irritability, poor feeding, or temperature instability 1

Pitfalls

1. Relying on classic signs of meningitis (neck stiffness, Kernig's/Brudzinski's signs), which are often absent in neonates and young infants 6
2. Delaying antibiotics while waiting for CSF results - antibiotics should be given immediately if meningitis is suspected 1
3. Failing to recognize atypical presentations, especially in neonates 6
4. Inadequate fluid resuscitation or inappropriate fluid restriction 6
5. Missing the diagnosis due to normal CSF parameters - no single CSF value can reliably exclude meningitis in neonates 5
6. Failure to involve critical care teams early for patients with concerning signs 1

Prevention

• Chemoprophylaxis for close contacts of patients with meningococcal disease 1
• Vaccination strategies (Hib, pneumococcal, meningococcal vaccines)
• Intrapartum antibiotic prophylaxis for GBS-positive mothers