What is the recommended treatment for meningitis in a 2-year-old?

Treatment of Meningitis in a 2-Year-Old Child

For a 2-year-old child with bacterial meningitis, the recommended first-line treatment is cefotaxime (75 mg/kg every 6-8 hours) or ceftriaxone (50 mg/kg every 12 hours) plus vancomycin (10-15 mg/kg every 6 hours) started immediately upon clinical suspicion, with antibiotics administered within 1 hour of presentation. 1, 2

Initial Assessment and Management

Immediate Actions

• Obtain blood cultures before starting antibiotics if possible, but do not delay antibiotic administration
• Start empiric antibiotics within 1 hour of presentation 1
• Assess for signs requiring cranial imaging before lumbar puncture:
  • Focal neurologic deficits (excluding cranial nerve palsies)
  • New-onset seizures
  • Severely altered mental status (Glasgow Coma Scale score <10)
  • Severely immunocompromised state 1

Fluid Management

• If signs of shock are present, administer rapid infusion of isotonic crystalloid or colloid solution up to 60 ml/kg, given as three boluses of 20 ml/kg, with reassessment after each bolus
• Fluid resuscitation in excess of 60 ml/kg plus inotropic support may be required 1
• Evidence of circulatory failure should prompt early consultation with pediatric intensive care 1

Antibiotic Therapy

Empiric Antibiotic Selection

• For a 2-year-old child (age 1 month to 18 years):
  • Cefotaxime (75 mg/kg every 6-8 hours) or ceftriaxone (50 mg/kg every 12 hours) plus
  • Vancomycin (10-15 mg/kg every 6 hours to achieve serum trough concentrations of 15-20 μg/mL) or rifampicin (10 mg/kg every 12 hours up to 600 mg/day) 1

Duration of Therapy

Based on isolated pathogen:

• Neisseria meningitidis: 7 days
• Haemophilus influenzae: 7 days
• Streptococcus pneumoniae: 10-14 days
• Streptococcus agalactiae: 14-21 days
• Aerobic gram-negative bacilli: 21 days
• Listeria monocytogenes: 21 days 1

Pathogen-Specific Adjustments

• If pneumococcal strain has MIC <0.5 mg/L, third-generation cephalosporin can be continued alone for 10 days
• For other cases, a second lumbar puncture is necessary and the initial regimen, with or without rifampicin, should be continued for 14 days 3
• For meningococcal or H. influenzae meningitis, third-generation cephalosporin monotherapy is sufficient 3

Adjunctive Therapy

Corticosteroids

• For bacterial meningitis of unknown etiology or confirmed meningococcal meningitis:
  • Administer parenteral dexamethasone (0.15 mg/kg every six hours)
  • Start with or within 24 hours of the first antibiotic dose
  • Continue for four days 1
• Steroids are not recommended for treating meningococcal septicemia except in inotrope-resistant shock 1

Intensive Care Considerations

• For patients who continue to deteriorate despite appropriate supportive treatment, arrange transfer to pediatric intensive care
• Consider early ventilatory support after inotropes are started for children with fluid-resistant shock 1

Prevention of Secondary Transmission

• Liaise with the local public health department to ensure appropriate public health actions
• Offer prophylaxis to those who had prolonged close contact in a household setting with the child during the seven days before onset of illness 1

Monitoring and Complications

• Common complications in pediatric meningitis include hearing loss (34%), seizures (13%), motor deficits (12%), cognitive defects (9%), hydrocephalus (7%), and visual loss (6%) 1
• Monitor for neurologic deterioration which may require cranial imaging (MRI preferred when available)
• Cerebrovascular complications can include cerebral infarctions, subarachnoid hemorrhage, intracranial hemorrhage, and venous sinus thrombosis 1

Key Pitfalls to Avoid

1. Delayed antibiotic administration: Studies show that delayed initiation of antibiotic treatment is strongly associated with death and poor outcomes. Antibiotics must be started within 1 hour of presentation 1

2. Performing lumbar puncture before antibiotics in septicemic patients: In patients with suspected meningococcal disease and features of septicemia, start antibiotics before lumbar puncture 1

3. Inadequate fluid resuscitation: Children with meningitis and shock often require aggressive fluid resuscitation and may need inotropic support 1

4. Failing to adjust therapy based on culture results: Once the pathogen is identified, therapy should be tailored to the specific organism 1, 3

5. Missing complications: Regular neurological assessment is essential to detect early signs of complications that may require additional interventions 1