Pediatric Meningitis Treatment
Immediate Antibiotic Therapy
Antibiotics must be administered within 1 hour of hospital arrival or as soon as bacterial meningitis is suspected, without waiting for lumbar puncture or imaging. 1
Blood cultures should be obtained before antibiotics, but treatment must never be delayed for diagnostic procedures. 1
Empiric Antibiotic Regimens by Age
Neonates (<28 days)
- Ampicillin PLUS cefotaxime 1
- Dosing: Ampicillin for Listeria coverage plus cefotaxime 200-300 mg/kg/day 2, 3
- Critical warning: Ceftriaxone is contraindicated in neonates due to risk of fatal calcium-ceftriaxone precipitation 4
- Gentamicin may be substituted for cefotaxime in some protocols 5
Infants 1-3 months
- Ampicillin PLUS cefotaxime (or ceftriaxone) 1
- This covers Listeria, Group B Streptococcus, E. coli, and other gram-negatives 6
- Cefotaxime 200-300 mg/kg/day or ceftriaxone 100 mg/kg/day 3
- Ampicillin must be included as 6 of 60 infants in one cohort had Listeria or organisms resistant to cephalosporins alone 6
Children >3 months
- Vancomycin PLUS ceftriaxone (or cefotaxime) 2, 1, 7
- Ceftriaxone 100 mg/kg/day (max 4g/day) OR cefotaxime 300 mg/kg/day (max 4g/day) 2, 3
- Vancomycin 60 mg/kg/day to cover penicillin-resistant Streptococcus pneumoniae 3
- This combination covers S. pneumoniae (including resistant strains), N. meningitidis, and H. influenzae 7
Adjunctive Dexamethasone
Dexamethasone 0.15 mg/kg every 6 hours should be given with or within 24 hours of the first antibiotic dose, continued for 4 days. 2
- This applies to both empirical treatment of unknown bacterial meningitis and confirmed meningococcal meningitis 2
- Dexamethasone reduces hearing loss and neurological sequelae, particularly in H. influenzae type b and pneumococcal meningitis 2
- Do NOT use dexamethasone in meningococcal septicaemia (without meningitis) except for inotrope-resistant shock 2
- Benefits are most pronounced in high-income countries with advanced medical care 2
Fluid Management
If signs of shock are present:
- Administer 20 ml/kg boluses of isotonic crystalloid or colloid, up to 60 ml/kg total 2
- Reassess after each bolus 2
- Fluid resuscitation often exceeds 60 ml/kg and requires inotropic support 2
- Early consultation with intensive care is essential for repeated fluid boluses 2
Pathogen-Specific Treatment Duration
Once pathogen is identified, adjust therapy:
- N. meningitidis: 7 days 2, 8
- S. pneumoniae: 10-14 days (extend to 14 days if not recovered by day 10) 8
- H. influenzae: 10 days 8
- Listeria monocytogenes: 21 days 8
- Group B Streptococcus: 14 days 8
Critical Pitfalls to Avoid
- Never delay antibiotics for CT imaging or lumbar puncture 1
- Never use ceftriaxone in neonates due to fatal calcium precipitation risk 4
- Never omit ampicillin in infants <3 months as Listeria coverage is essential 1, 6
- Never use inadequate vancomycin dosing in areas with pneumococcal resistance 1
- Never shorten pneumococcal therapy if patient hasn't improved by day 10 8
- Never use rifampicin or fosfomycin as monotherapy due to resistance development 8
Intensive Care Indications
Transfer to pediatric intensive care for: 2
- Continued deterioration despite appropriate treatment
- Fluid-resistant shock requiring inotropes
- Refractory hypotension (inotrope-resistant shock)
- Severe metabolic acidosis or impending renal failure
Special Considerations
Ceftriaxone-calcium interactions: Do not mix ceftriaxone with calcium-containing solutions (Ringer's, Hartmann's, parenteral nutrition) in neonates or via Y-site in any age group. 4
Intravenous administration: Ceftriaxone should be given over 60 minutes in neonates to reduce bilirubin encephalopathy risk, and over 30 minutes in older children. 4