Meningitis in Children: Essential Clinical Notes
Immediate Management Principles
Administer empiric intravenous antibiotics within 1 hour of clinical suspicion—do not delay for lumbar puncture, imaging, or any diagnostic procedures. 1, 2, 3
Critical Timing
- Time from hospital entry to antibiotic administration must not exceed 60 minutes, as delays are strongly associated with increased mortality and poor neurological outcomes 1, 2, 3
- Obtain blood cultures before antibiotics, but never postpone treatment to obtain them 1, 2
- If lumbar puncture is delayed for any reason (imaging, coagulopathy, clinical instability), start antibiotics immediately 1, 2
Empiric Antibiotic Regimens by Age
Neonates (≤ 4 weeks)
< 1 week of age:
- Ampicillin 50 mg/kg IV every 8 hours PLUS Cefotaxime 50 mg/kg IV every 8 hours PLUS Gentamicin 2.5 mg/kg IV every 12 hours 2, 3
- Alternative aminoglycosides: Tobramycin 2.5 mg/kg IV every 8 hours or Amikacin 10 mg/kg IV every 8 hours 2
1-4 weeks of age:
- Ampicillin 50 mg/kg IV every 6 hours PLUS Cefotaxime 50 mg/kg IV every 6-8 hours PLUS Gentamicin 2.5 mg/kg IV every 8 hours 2, 3
- Rationale: Covers Group B Streptococcus, E. coli, and Listeria monocytogenes 2, 3
Infants and Children (1 month - 18 years)
Standard empiric regimen:
- Ceftriaxone 50 mg/kg IV every 12 hours (maximum 2g per dose) OR Cefotaxime 75 mg/kg IV every 6-8 hours PLUS Vancomycin 10-15 mg/kg IV every 6 hours 1, 2, 3
- Target vancomycin trough: 15-20 µg/mL 2, 3
- Rationale: Covers S. pneumoniae (including resistant strains), N. meningitidis, and H. influenzae 2, 3
Alternative in low-resistance settings:
Adjunctive Dexamethasone Therapy
Dosing for Children
Administer dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days, given with or within 24 hours of the first antibiotic dose 4, 1, 2, 3
Critical Timing
- Give dexamethasone with or 10-20 minutes before the first antibiotic dose 2, 3
- If omitted initially, may still start up to 4 hours after antibiotics 3
Indications
- Strongly recommended for suspected or proven S. pneumoniae or H. influenzae meningitis to reduce mortality and hearing loss 4, 1, 2
- Reduces neurological sequelae, particularly hearing loss 4, 2, 3
Contraindications
- Do NOT use in neonates ≤ 4 weeks (insufficient evidence, may be harmful) 3
- Do NOT use for meningococcal septicemia unless inotrope-resistant shock develops 4
- Discontinue if Listeria is identified (associated with increased mortality in neurolisteriosis) 3
Lumbar Puncture Considerations
When to Perform CT Before Lumbar Puncture
Obtain head CT before lumbar puncture if ANY of the following are present: 4, 1, 2
- Immunocompromised state
- History of CNS disease (mass lesion, stroke, focal infection)
- New-onset seizure
- Papilledema
- Altered consciousness or inability to follow commands
- Focal neurological deficits (gaze palsy, facial weakness, limb drift)
Important Exception for Children
Seizures occur in up to 30% of children with bacterial meningitis before admission, so brief seizures alone should NOT delay lumbar puncture in children 4
If No CT Indications Present
- Proceed directly to lumbar puncture after starting antibiotics 1, 2
- Send CSF for: cell count with differential, glucose, protein, Gram stain, and culture 2
CSF Diagnostic Findings in Bacterial Meningitis
Expected CSF Parameters
| Parameter | Typical Finding | Clinical Significance |
|---|---|---|
| Opening pressure | 200-500 mm H₂O (may be lower in neonates/infants) | Indicates raised intracranial pressure [4] |
| WBC count | 1,000-5,000 cells/mm³ (range 100-110,000) | Reflects inflammatory response [4] |
| Differential | Neutrophils 80-95% (≈10% may be lymphocyte-predominant) | Supports bacterial etiology [4] |
| CSF glucose | <40 mg/dL in 50-60% of cases | Bacterial consumption of glucose [4] |
| CSF/serum glucose ratio | <0.4 in children >12 months (80% sensitive, 98% specific) | Distinguishes bacterial from viral [4] |
| <0.6 in term neonates | Higher ratio normal in neonates [4] | |
| Protein | Elevated in virtually all cases | Blood-brain barrier disruption [4] |
Gram Stain Diagnostic Yield
Fluid Management and Shock Treatment
Initial Resuscitation
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 4, 1
Advanced Support
- Fluid resuscitation beyond 60 mL/kg plus inotropic support is often required 4
- Consider early ventilatory support after inotropes are started for fluid-resistant shock 4
- Use anaesthetic agents that maintain cardiovascular stability during intubation 4
Refractory Shock
- For inotrope-resistant shock, consider intravenous vasopressin and steroid dose titration 4
- Consider continuous venovenous hemofiltration for inotrope-dependent septic shock with severe metabolic acidosis or renal failure 4
Intensive Care Transfer Criteria
Arrange immediate transfer to pediatric intensive care if: 4, 1
- Patient continues to deteriorate despite appropriate supportive treatment
- Rapidly evolving petechial or purpuric rash
- Cardiovascular instability or hypoxia
- Glasgow Coma Scale ≤12
- Requiring organ support or intensive monitoring
Treatment Duration by Pathogen
| Pathogen | Duration | Notes |
|---|---|---|
| Unknown (empiric) | 7-10 days minimum | Assuming satisfactory clinical progress [4,1] |
| N. meningitidis | 5-7 days | If clinically recovered [2,3] |
| S. pneumoniae | 10-14 days | Even with clinical improvement [2,3] |
| H. influenzae | 10 days | Standard duration [3] |
| Listeria monocytogenes | 21 days | Extended course required [3] |
| Gram-negative bacilli | 14-21 days | Extended course required [1,2] |
Prevention of Secondary Transmission
Chemoprophylaxis Indications
Offer prophylaxis to close contacts who had prolonged close contact in a household setting during the 7 days before onset of illness 4
Close Contacts Defined As:
- Those living or sleeping in the same household (including extended household) 4
- Pupils in the same dormitory 4
- Boyfriends and girlfriends 4
- University students sharing a kitchen in a hall of residence 4
NOT Indicated For:
- Pupils in the same nursery, school, or class (unless they are a close contact as defined above) 4
Effective Prophylactic Antibiotics:
- Ciprofloxacin, rifampicin, minocycline, or ampicillin 4
Follow-Up Care and Potential Morbidities
Consider the following potential complications depending on case severity: 4
- Hearing loss (most common neurological sequela)
- Neurological complications
- Psychiatric, psychosocial, and behavioral problems
- Bone and joint complications (may not be apparent for years)
- Post-necrotic scarring requiring amputations or skin grafting
- Renal impairment (particularly in those requiring acute renal replacement therapy)
- Post-traumatic stress disorder in both children and families
Critical Pitfalls to Avoid
Timing Errors
- Never delay antibiotics for imaging—give antibiotics first, then obtain CT if indicated 1, 2, 3
- Never delay antibiotics for lumbar puncture—start treatment immediately on clinical suspicion 1, 2, 3
Coverage Errors
- Never use vancomycin monotherapy—must be combined with third-generation cephalosporin 2
- Never omit vancomycin in areas with pneumococcal resistance 2, 3
- Never use ceftazidime for community-acquired meningitis—reserve for Pseudomonas coverage 2
Dosing Errors
- Never underdose—meningitis requires high-dose therapy for adequate CSF penetration 2, 3
- Insufficient dosing leads to treatment failure 2
Dexamethasone Errors
- Never give dexamethasone more than 12 hours after first antibiotic dose—timing is critical 3
- Never use dexamethasone in neonates 3
- Never continue dexamethasone if Listeria is identified 3