What are the Nelson-recommended assessment and empiric therapy guidelines for a child with suspected meningitis?

Meningitis in Children: Assessment and Management

Immediate Recognition and Time-Critical Actions

Antibiotic therapy must be initiated within 1 hour of hospital arrival in all children with suspected bacterial meningitis, as treatment delay is strongly associated with increased mortality and poor neurological outcomes. 1, 2, 3

Initial Assessment Steps (First 60 Minutes)

• Obtain blood cultures immediately before antibiotics, but never delay antibiotic administration beyond 1 hour to obtain cultures 1, 2, 4

• Assess for contraindications to immediate lumbar puncture, including: 1

  • Signs of septicaemia with purpuric rash
  • Cardiovascular instability or shock
  • Respiratory compromise requiring intubation
  • Coagulopathy or thrombocytopenia
  • Focal neurological deficits
  • Severely altered consciousness (GCS ≤12)
  • New-onset seizures within the past week
  • Signs of raised intracranial pressure (papilledema)

• If any contraindications exist, start empiric antibiotics immediately and defer lumbar puncture until the child is stabilized 1, 2

• If no contraindications are present, perform lumbar puncture immediately after obtaining blood cultures, then start antibiotics 2, 4

Age-Specific Empiric Antibiotic Regimens

Neonates (0-3 months)

• Ampicillin 100 mg/kg IV every 6 hours PLUS cefotaxime 50 mg/kg IV every 6 hours 2, 5
• This combination covers Group B Streptococcus, E. coli, and Listeria monocytogenes 2, 6
• Do NOT use ceftriaxone in neonates due to risk of fatal calcium-ceftriaxone precipitation 1

Infants and Children (3 months to 18 years)

• Cefotaxime 75 mg/kg IV every 6 hours (maximum 300 mg/kg/day) OR ceftriaxone 50 mg/kg IV every 12 hours (maximum 100 mg/kg/day) PLUS vancomycin 15 mg/kg IV every 6 hours (maximum 60 mg/kg/day) 2, 5
• This regimen covers S. pneumoniae (including penicillin-resistant strains), N. meningitidis, and H. influenzae 2, 6, 5
• Vancomycin is essential in areas with high pneumococcal resistance to penicillin and cephalosporins 1, 2

Adjunctive Dexamethasone Therapy

Dexamethasone 0.15 mg/kg IV every 6 hours should be administered immediately before or simultaneously with the first antibiotic dose in all children with suspected bacterial meningitis. 1, 2, 7

• Continue dexamethasone for 4 days if pneumococcal meningitis is confirmed or highly probable 1, 2
• Discontinue if an alternative etiology (viral, tuberculous) is identified 2
• Dexamethasone must be given within the first hour—ideally 10-20 minutes before antibiotics—to be effective in reducing mortality and neurological morbidity 2, 7
• The benefit is most pronounced in pneumococcal meningitis and H. influenzae type B meningitis 1, 7

Fluid Resuscitation in Meningococcal Septicaemia

If signs of shock are present (tachycardia, prolonged capillary refill >2 seconds, hypotension, altered consciousness), administer rapid intravenous fluid boluses of 20 ml/kg isotonic crystalloid or colloid, with reassessment after each bolus. 1

• Fluid resuscitation up to 60 ml/kg is often required in the first hour 1
• If more than 40 ml/kg is needed or the child remains unstable, consult pediatric intensive care immediately for inotropic and ventilatory support 1
• Evidence of circulatory failure requiring repeated fluid boluses mandates early ICU involvement 1

Expected Cerebrospinal Fluid Findings

Bacterial Meningitis (Typical Pattern)

• Opening pressure: 200-500 mm H₂O (elevated) 2
• White blood cell count: 1,000-5,000 cells/µL (range 100-10,000) 2
• Differential: 80-95% neutrophils (though 10% may be lymphocyte-predominant early) 2
• CSF glucose: <40 mg/dL in 50-60% of cases 2
• CSF/serum glucose ratio: <0.4 in children >12 months; <0.6 in neonates 2
• Protein: Elevated (typically >100 mg/dL) 2
• Gram stain: Positive in 60-90% overall; 90% for S. pneumoniae, 86% for H. influenzae, 75% for N. meningitidis 2

The presence of hypoglycorrhachia (low CSF glucose) is the most critical distinguishing feature that mandates treating for bacterial meningitis, as this finding strongly suggests bacterial etiology. 2

Definitive Antibiotic Therapy (After Organism Identification)

Streptococcus pneumoniae

• Continue cefotaxime or ceftriaxone for 10-14 days 4, 5
• If MIC to ceftriaxone is <0.5 mg/L, discontinue vancomycin and continue cephalosporin alone 5
• If MIC ≥0.5 mg/L or clinical response is poor, continue combination therapy and consider adding rifampicin 10 mg/kg every 12 hours 5
• Perform repeat lumbar puncture at 48 hours if resistant strain or poor clinical response 5

Neisseria meningitidis

• Continue cefotaxime or ceftriaxone for 5-7 days 4, 5
• Discontinue vancomycin once meningococcus is confirmed 5
• Administer single-dose ciprofloxacin for nasopharyngeal eradication (dose varies by age) 4

Haemophilus influenzae

• Continue cefotaxime or ceftriaxone alone for 7-10 days 5
• Discontinue vancomycin once H. influenzae is confirmed 5

Listeria monocytogenes (rare in children >3 months)

• Switch to ampicillin 100 mg/kg IV every 6 hours PLUS gentamicin 2.5 mg/kg IV every 8 hours for 21 days 5
• Cephalosporins are NOT effective against Listeria 6, 5

Critical Care Transfer Criteria

Transfer to pediatric intensive care immediately if the child has: 1, 4

• Rapidly evolving purpuric rash (meningococcal septicaemia)
• Glasgow Coma Scale ≤12
• Cardiovascular instability requiring >40 ml/kg fluid resuscitation
• Respiratory compromise (hypoxia, increased work of breathing)
• Seizures that are prolonged or recurrent
• Signs of raised intracranial pressure

Common Pitfalls to Avoid

• Never delay antibiotics for imaging or lumbar puncture—empiric therapy must begin within 1 hour even if CSF cannot be obtained 1, 2
• Never use ceftriaxone in neonates due to risk of fatal calcium-ceftriaxone precipitation, especially if receiving parenteral nutrition or calcium-containing IV fluids 1
• Never omit vancomycin from the empiric regimen in areas with pneumococcal resistance—cephalosporin monotherapy is inadequate 2, 5
• Never give dexamethasone more than 12-24 hours after the first antibiotic dose—timing is critical for efficacy 2, 7
• Never use ceftazidime as empiric therapy for community-acquired meningitis—it has poor pneumococcal coverage and is reserved for Pseudomonas infections 2, 6
• Never fail to cover Listeria in neonates—cephalosporins alone are insufficient in the first 3 months of life 2, 5

Follow-Up of Survivors

• Evaluate all survivors for hearing loss within 4 weeks of discharge, as sensorineural hearing loss occurs in 10-30% of children with bacterial meningitis 1
• Provide pneumococcal vaccination to prevent recurrences 1
• Assess for neuropsychological sequelae (cognitive deficits, behavioral problems) at 3-6 months 1

Chemoprophylaxis for Close Contacts

Offer chemoprophylaxis to household contacts and other close contacts (those sharing sleeping quarters, kissing contacts) within 24 hours of index case diagnosis for N. meningitidis and H. influenzae type B. 1

• Rifampicin is the standard prophylactic agent (dose varies by age) 1
• Ciprofloxacin or ceftriaxone are alternatives 1
• Prophylaxis is NOT routinely indicated for pneumococcal meningitis contacts 1