Pediatric Meningitis: Definition and Treatment
What is Meningitis?
Meningitis is an acute inflammation of the protective membranes (meninges) covering the brain and spinal cord, caused by bacterial, viral, or other pathogens. Bacterial meningitis is a neurologic emergency requiring immediate antimicrobial therapy to prevent death and severe neurologic sequelae including hearing loss, seizures, motor deficits, and cognitive impairment. 1
Immediate Management
Timing of Antibiotic Administration
Antibiotics must be initiated as soon as bacterial meningitis is suspected—this is a neurologic emergency where delays directly worsen mortality and neurologic outcomes. 1
- Administer antimicrobials immediately upon suspicion, even before lumbar puncture if imaging or other delays are anticipated 1
- Early treatment reduces mortality and prevents neurologic deterioration, particularly before Glasgow Coma Scale drops below 10 1
- For vitally unstable children, start empiric antibiotics within 6 hours of admission regardless of CSF findings 2
Empiric Antibiotic Regimens by Age
Neonates (≤28 days)
Cefotaxime PLUS ampicillin (or amoxicillin) is the required regimen to cover gram-negative organisms (E. coli, Klebsiella) and Listeria monocytogenes. 3, 2
- Ceftriaxone is contraindicated in neonates due to risk of bilirubin encephalopathy and ceftriaxone-calcium precipitation 4
- Administer intravenous doses over 60 minutes in neonates to reduce bilirubin encephalopathy risk 4
Infants and Children (>28 days to <18 years)
Vancomycin PLUS ceftriaxone (or cefotaxime) is the standard empiric regimen covering S. pneumoniae (including resistant strains), N. meningitidis, and H. influenzae. 1, 2
- Ceftriaxone dosing for meningitis: Initial dose 100 mg/kg (maximum 4 grams), then 100 mg/kg/day (maximum 4 grams daily) given once daily or divided every 12 hours 4
- Vancomycin is essential due to increasing pneumococcal resistance 1
- For infants <3 months, add ampicillin to cover Listeria 3, 2
Special Consideration: Vitally Unstable Patients
Even if viral meningitis is suspected, vitally unstable children require immediate acyclovir (500 mg/m² IV every 8 hours for ages 3 months-12 years) PLUS empiric antibiotics (ceftriaxone and vancomycin) until bacterial meningitis and HSV encephalitis are definitively excluded. 2
- HSV encephalitis has 70% mortality without acyclovir, reduced to 20-30% with treatment 2
- Delays beyond 48 hours significantly worsen outcomes 2
- A lymphocytic CSF does not exclude bacterial meningitis (partially treated bacterial meningitis, TB, and Listeria can present with lymphocytic pleocytosis) 2
Adjunctive Dexamethasone Therapy
Dexamethasone 0.15 mg/kg IV every 6 hours for 4 days should be administered with or within 24 hours of the first antibiotic dose when treating empiric bacterial meningitis. 1, 3, 2
- Dexamethasone attenuates the subarachnoid inflammatory response that contributes to cerebral edema, increased intracranial pressure, and neuronal injury 1
- Must be given early (with or just after first antibiotic dose) to be effective 3
Treatment Duration
Continue antibiotics for minimum 14-21 days for gram-negative meningitis (E. coli, Klebsiella); 7-14 days for pneumococcal and meningococcal meningitis; minimum 10 days for Streptococcus pyogenes. 1, 3, 4
- Repeat lumbar puncture is indicated only if clinical progress is unsatisfactory or diagnostic uncertainty persists—routine repetition is not recommended 1, 3
Fluid Management and Shock
Avoid aggressive fluid resuscitation unless signs of septic shock are present, as excessive fluids worsen cerebral edema. 3
- If shock develops: administer 20 mL/kg boluses of isotonic crystalloid, reassess after each bolus, maximum 60 mL/kg total 3, 2
- Transfer to pediatric intensive care if patient deteriorates despite appropriate treatment 3, 2
Common Pitfalls to Avoid
- Never use ceftriaxone in neonates ≤28 days due to bilirubin displacement and calcium precipitation risk 4
- Never delay antibiotics for lumbar puncture or imaging—give antibiotics first if any delay is anticipated 1
- Never assume viral meningitis in a vitally unstable child—always cover bacterial meningitis and HSV until excluded 2
- Never use diluents containing calcium (Ringer's, Hartmann's) with ceftriaxone due to precipitation 4
- Never assume adequate coverage without vancomycin in areas with pneumococcal resistance 1
Mandatory Follow-Up
Hearing Assessment
Perform hearing evaluation during admission using otoacoustic emission screening, followed by formal audiometry at 6-12 months post-treatment. 1, 3
- Bacterial meningitis is the most common cause of acquired hearing loss in children 1
- 5-35% of survivors develop sensorineural hearing loss; 4% have severe bilateral hearing loss 1
Neuropsychological Evaluation
Assess for neurologic sequelae at follow-up, as one-third of survivors have persisting complaints. 1, 3
- Common sequelae: hearing loss (34%), seizures (13%), motor deficits (12%), cognitive defects (9%), hydrocephalus (7%), visual loss (6%) 1
- One in five children have multiple sequelae 1
Monitoring for Complications
Half of children with bacterial meningitis develop complications requiring cranial imaging (MRI preferred over CT), EEG, or neurosurgical intervention. 1
- Common complications: focal neurologic deficits, seizures, hydrocephalus, cerebral infarctions, subdural empyema, brain abscess 1
- Obstructive hydrocephalus requires external ventricular drain placement 1
- Cerebrovascular complications (infarctions, hemorrhage, venous sinus thrombosis) occur frequently 1