Treatment of Bacterial Meningitis in Children
The recommended first-line treatment for bacterial meningitis in children is intravenous ceftriaxone or cefotaxime plus vancomycin when pneumococcal meningitis cannot be ruled out, with adjunctive dexamethasone administered with or before the first antibiotic dose. 1
Age-Specific Antibiotic Regimens
Neonates (0-1 month)
- First-line therapy:
- Rationale: Provides coverage for Group B streptococci, E. coli, and Listeria monocytogenes 2
- Alternative therapy: Ampicillin plus an aminoglycoside (gentamicin 2.5 mg/kg IV q12h for <1 week; q8h for 1-4 weeks) 1
Infants and Children (1 month to 18 years)
- First-line therapy:
- Alternative therapy: In areas with high pneumococcal resistance, add rifampicin 10 mg/kg IV q12h (up to 600 mg/day) 1, 6
Adjunctive Therapy
Corticosteroids
- Recommendation: Dexamethasone 0.15 mg/kg IV q6h for 2-4 days 7, 1
- Timing: Start with or before the first antibiotic dose, or within 24 hours of the first dose 7, 1
- Indications:
- Children with suspected bacterial meningitis of unknown etiology
- Children with confirmed meningococcal meningitis 7
- Contraindication: Not recommended for children with meningococcal septicemia except in cases of inotrope-resistant shock 7
Treatment Duration
- Standard duration: 7-14 days depending on the pathogen 1
- Pneumococcal meningitis: 10-14 days
- Meningococcal meningitis: 7 days
- Staphylococcal meningitis: at least 14 days
- Culture-negative cases: at least 14 days 1
Initial Management Approach
- Immediate action: Upon suspicion of bacterial meningitis, obtain blood cultures and start antibiotics within 1 hour of hospital entry 1
- Lumbar puncture: If delayed, start empiric antibiotics before the procedure 7, 1
- Fluid management: For signs of shock, administer rapid infusion of intravenous fluids as isotonic crystalloid or colloid solution up to 60 ml/kg, given as three boluses of 20 ml/kg, with reassessment after each bolus 7
Special Considerations
Antimicrobial Resistance
- If pneumococcal resistance is suspected or confirmed:
- Adjust therapy based on culture results and susceptibility patterns 1
Intensive Care Management
- For patients with deteriorating condition despite appropriate treatment, arrange transfer to pediatric intensive care 7
- For fluid-resistant shock, consider early ventilatory support after inotropes are started 7
- In refractory hypotension (inotrope-resistant shock), intravenous vasopressin and steroid dose titration are appropriate rescue strategies 7
Prevention of Secondary Transmission
- Liaise with local public health department for appropriate public health actions 7
- Offer prophylaxis to close contacts who had prolonged contact in a household setting with a child with meningococcal disease during the seven days before onset of illness 7
Common Pitfalls to Avoid
- Delayed antibiotic administration: Never delay antibiotics to wait for diagnostic confirmation 1, 8
- Inadequate dosing: Ensure appropriate weight-based dosing, particularly in infants and young children 1
- Failure to adjust therapy: Modify treatment based on culture results and clinical response 1
- Premature discontinuation: Complete the full recommended course of antibiotics based on the identified pathogen 1
- Neglecting adjunctive therapy: Consider dexamethasone with or before the first antibiotic dose 7, 1
Bacterial meningitis is a neurologic emergency requiring prompt recognition and treatment to reduce morbidity and mortality. The therapeutic approach should be tailored to the patient's age and likely pathogens, with modifications based on clinical response and microbiological findings.