What is the treatment for a 2-year-old with fulminant meningitis?

Treatment of Fulminant Meningitis in a 2-Year-Old

Immediately administer intravenous cefotaxime (75 mg/kg every 6-8 hours) or ceftriaxone (50 mg/kg every 12 hours, maximum 2g per dose) plus vancomycin (10-15 mg/kg every 6 hours) within 1 hour of presentation, without waiting for lumbar puncture or imaging. 1, 2

Immediate Management (Within First Hour)

Antibiotic Administration

• Start empiric antibiotics immediately upon clinical suspicion—do not delay for any diagnostic procedures. 1, 2
• The time from hospital entry to antibiotic administration must not exceed 60 minutes. 1, 2
• Obtain blood cultures before antibiotics, but do not delay treatment to obtain them. 1, 2

Empiric Antibiotic Regimen for Age 1 Month to 18 Years

• Cefotaxime 75 mg/kg IV every 6-8 hours (or ceftriaxone 50 mg/kg IV every 12 hours, maximum 2g per dose) PLUS vancomycin 10-15 mg/kg IV every 6 hours to achieve serum trough concentrations of 15-20 μg/mL. 1, 2
• This combination covers Streptococcus pneumoniae (including penicillin-resistant strains), Neisseria meningitidis, and Haemophilus influenzae. 1, 3
• Ceftriaxone should be infused over 60 minutes in children under 3 years to reduce risk of bilirubin encephalopathy. 4

Critical Pitfall to Avoid

• Never use ceftriaxone with calcium-containing IV solutions (Ringer's, Hartmann's, parenteral nutrition) due to fatal precipitation risk. 4
• If calcium-containing solutions are needed, use cefotaxime instead. 4

Adjunctive Dexamethasone Therapy

• Administer dexamethasone 0.15 mg/kg IV every 6 hours for 4 days, given with or within 24 hours of the first antibiotic dose. 1, 5
• This recommendation applies to empiric treatment of bacterial meningitis of unknown etiology in children. 1
• Do NOT use steroids for meningococcal septicemia unless inotrope-resistant shock develops. 1

Fluid Management and Shock Treatment

Assess for Septic Shock

• In fulminant meningitis, signs of septicemia (purpura, shock) are common. 1, 6
• If signs of shock are present, administer rapid IV fluid boluses of 20 mL/kg isotonic crystalloid or colloid, up to 60 mL/kg total, with reassessment after each bolus. 1, 5
• Fluid resuscitation beyond 60 mL/kg plus inotropic support is often required. 1

When to Avoid Aggressive Fluids

• Do NOT give aggressive fluid resuscitation if shock is absent, as this may worsen cerebral edema in fulminant meningitis. 5, 6

Lumbar Puncture Considerations

Indications to Delay Lumbar Puncture (Perform CT First)

• Perform CT before lumbar puncture if any of the following are present: 1, 2
  • Focal neurologic deficits (excluding cranial nerve palsies)
  • New-onset seizures
  • Severely altered mental status (Glasgow Coma Scale <10)
  • Severely immunocompromised state

If Lumbar Puncture is Delayed

• Start antibiotics immediately—do not wait for imaging or CSF results. 1, 2
• CSF findings (elevated WBC, decreased glucose, elevated protein) will still provide diagnostic evidence even after antibiotics. 1, 2
• Lumbar puncture may be performed later if diagnostic uncertainty persists and there are no contraindications. 1, 5

Special Considerations for Fulminant Presentation

Understanding Fulminant Meningitis

• Fulminant bacterial meningitis is characterized by sudden onset, rapid deterioration, abrupt cerebral edema, and refractory intracranial hypertension with mortality exceeding 50%. 6
• This aberrant host response occurs with all bacterial pathogens and at all ages. 6
• The explosive cerebral edema cannot be predicted and has not been modified by advanced intensive care interventions. 6

Intensive Care Transfer

• Arrange immediate transfer to pediatric intensive care if the patient deteriorates despite appropriate treatment. 1, 5
• Early consultation with intensive care is warranted given the fulminant presentation and potential need for inotropic and ventilatory support. 1

Treatment Duration and Monitoring

• Continue antibiotics for 7 days minimum, assuming satisfactory clinical progress. 1
• For gram-negative meningitis (if identified), extend treatment to 14-21 days. 5
• Perform repeat lumbar puncture if clinical progress is unsatisfactory or diagnostic uncertainty persists. 5
• Once pathogen is identified and sensitivities known, narrow antibiotic therapy accordingly. 1, 3

Antibiotic Adjustment Based on Organism

If Streptococcus pneumoniae with MIC <0.5 mg/L

• Continue third-generation cephalosporin alone for 10 days total. 3

If Streptococcus pneumoniae with Higher MIC

• Continue combination therapy (cephalosporin plus vancomycin) for 14 days, consider adding rifampicin. 3
• Perform second lumbar puncture to assess response. 3

If Neisseria meningitidis or Haemophilus influenzae

• Third-generation cephalosporin alone is sufficient. 3