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Meningitis

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Causative organisms

Neonatal Children > 2-3 months of age
Group B streptococcus, rarely enterococci, 
E. coli, other gram negative enteric bacilli, 
Listeria monocytogenes
Streptococcus pneumoniae 
Neisseria meningitidis 
Haemophilus influenzae type b (Hib) (in unimmunised children)

Remember, not all aseptic meningitis is viral. Consider an early or partially treated bacterial meningitis, a parameningeal focus (e.g. ear, sinus or cerebral abscess) with a "neighbourhood reaction" in the CSF, and tuberculosis. 

Clinical diagnosis

Symptoms and signs of meningitis vary with age, duration of illness and the child's response to infection. Findings in neonates may be minimal, and neck stiffness may be absent.

  • Special attention should be given to child's level of consciousness (GCS) and any focal neurology or signs of raised ICP assessed. See Starship Clinical Guideline on Coma
  • If there are localizing neurological signs, consider herpes encephalitis, TB meningitis or cerebral abscess.
  • Previous antibiotics make it difficult to exclude partially treated bacterial meningitis. 
  • There are no clinical signs which reliably distinguish between bacterial and viral meningitis.

Indications for urgent referral to PICU

  • Inadequate airway protection
  • Impaired, deteriorating or fluctuating level of consciousness, GCS < 13
  • Signs suggestive of severe increase in ICP e.g. hypertension, bradycardia, papilloedema, pupillary changes, focal neurology
  • Hypoventilation or respiratory failure
  • Oxygen saturation < 90% in > 4L/min oxygen
  • Uncontrollable or poorly controlled seizures
  • Hypotension or tachycardia not responsive to fluid resuscitation
  • Renal failure
  • Serum [Na+] <125 mmol/l
  • Children with significant purpura or rapidly progressive petechiae
  • Consider if still unstable after 40mls/kg resuscitation fluid

Frequent clinical reassessment is vital

Initial Investigations

Lumbar puncture is not a priority if the child needs resuscitation.

Antibiotics can be started without a lumbar puncture or neuroimaging. However, with increasing antimicrobial resistance, examination of the CSF is particularly important to guide therapy.

CT scan should be done if there are any focal neurological signs. Herniation may occur even in the presence of a normal scan. A normal head CT scan does not exclude presence of raised intracranial pressure and should not influence your decision to perform a lumbar puncture; this is a clinical decision. Use of sedation for lumbar puncture should be avoided as it impairs ability to assess neurological status post lumbar puncture. Continue to monitor child while doing lumbar puncture - pulse oximetry + heart rate

Contraindications to lumbar puncture
Deteriorating level of consciousness or GCS < 13 or fluctuating level of consciousness These are signs of raised intracranial pressure
Urgently discuss with PICU consultant to consider early ventilation
Avoid hypotonic fluids
See Coma Guideline for management of raised ICP
Focal neurological deficits e.g. pupillary dilatation, ocular palsy, asymmetry 
A recent fit within 30 minutes, focal or prolonged fit > 30 minutes duration
Abnormal posture or movement (decerebrate, decorticate, cycling)
Inappropriately low HR, elevated BP, irregular respirations (ie. signs of impending brain herniation) 
Papilloedema
Impaired oculocephalic reflexes (doll's eye reflexes)  
Abnormal coagulation tests - INR > 1.5 or Platelets < 50   
Septic shock or haemodynamic instability   
A bleeding diathesis or widespread purpura  
Skin sepsis at the LP site  

CSF should be sent for urgent

  • CSF cell count, protein and glucose
  • Gram stain, culture

Additional tests that can be performed :

  • Pneumococcal antigen test
  • Meningococcal/pneumococcal PCR
  • HSV PCR
  • Viral PCR pane l- should include enterovirus and parechovirus

Blood tests: FBC, glucose, electrolytes and creatinine, blood cultures, coagulation, capillary gas, + bld PCR meningococcus

Acute Management

Treat as bacterial until CSF culture returns negative and partially treated bacterial meningitis ruled out. Delay in antibiotics is associated with poorer outcomes.

Fluid management

See Intravenous fluids guideline

Seizure Management

Manage seizures as per Convulsions - status epilepticus guideline.

Children with meningitis are at risk for biochemical abnormalities, therefore in case of seizure check Sodium [Na+], Glucose [glucose]  and Calcium [Ca++] and correct as needed.

Ongoing anticonvulsant therapy should be instituted with Phenytoin - load then maintenance.

Antimicrobial therapy for bacterial meningitis

Age Antibiotic and  Dose Age (days)
< 1 month
Birth weight  > 2000g
Amoxycillin 50 mg/kg 12 hourly IV
PLUS
Cefotaxime 
50 mg/kg 12 hourly IV
0 - 7
Amoxycillin 50 mg/kg 8 hourly IV
PLUS
Cefotaxime 
50 mg/kg 8 hourly IV
8 - 28
1-2 months Amoxycillin 50 mg/kg 6 hourly IV
PLUS
Cefotaxime 
50 mg/kg 6 hourly IV
 
>2 months Cefotaxime  50 mg/kg 6 hourly IV (max 2g per dose)  
If pneumococcus suspected*
Cefotaxime 75 mg/kg 6 hourly IV (max 2g per dose)
PLUS
Vancomycin  15 mg/kg 6 hourly IV (give over 60 min) 
 
If no IV access
C
eftriaxone100 mg/kg 24 hourly IM (max 2g per dose)
 

*Suspected Pneumococcal Meningitis -Gram+ cocci or gram+ diplococci on CSF gram stain or pneumococcal antigen or PCR positive or unwell child when LP is contraindicated but pneumococcus is strongly suspected. This combination will cover the possible penicillin-resistant pneumococcus

Cefuroxime is not recommended as it can result in delayed sterilization of CSF

Children where a clinical diagnosis of herpes simplex meningo-encephalitis is possible, should also be treated with Aciclovir. The dose is:

Under 3 months 20 mg/kg/dose IV 8 hourly
3 months - 12 years 500 mg/m2/dose IV 8 hourly
Over 12 years 10 mg/kg/dose IV 8 hourly

Dexamethasone

For infants and children > 6 weeks old with presumed bacterial meningitis adjunctive therapy with Dexamethasone 0.15 mg/kg 6 hourly for 2 days may be considered after consideration of potential benefits and risks. The evidence for use of dexamethasone is strongest for Hib meningitis resulting in reduction risk of hearing loss. If used the first dose should be given before or concurrently with the first dose of antibiotic. Steroids are not to be used for infants < 6 weeks of age with presumed bacterial meningitis.

Isolation

Respiratory isolation is required for meningitis caused by H. influenzae, N. meningitidis or an unknown organism for the first 24 hours of therapy. S. pneumoniae does not require respiratory isolation.

Ongoing management

Monitor

  • Frequent clinical review, including a careful assessment of volume status/accurate fluid balance
  • Neurological observations 15-60min initially then determined by child's conscious state
  • Check serum [Na+] 6 -12 hourly, depending on the initial [Na+], ongoing fluid losses, clinical status and whether there is a fluid restriction in place.
  • NBM, or sips of water if fully conscious, thirsty and serum [Na+] normal. "Comfort" breast or bottle feeding on demand can begin when an infant is stable neurologically and wishes to feed.
  • Weight and head circumference(<2yr olds) daily.
  • Ensure adequate analgesia. Need for morphine is rare and may indicate other pathology. Patient needs careful review and discussion with consultant.
  • Persistent or recurrent fever - need to consider subdural effusion/empyema, other infective foci, nosocomial infection, rarely - infected thrombosis, inadequately treated meningitis, parameningeal focus, drugs
  • Clinical assessment of hearing and early audiology referral if concerns, otherwise audiology referral when clinically stable prior to discharge or at 6-8 weeks after discharge 

Continuing antimicrobial therapy

Once sensitivities are available, change to narrower spectrum monotherapy. Suggested durations based on uncomplicated clinical course

Organism Antibiotic Dose Duration
Hib (β lactamase negative) Amoxycillin 50 mg/kg/dose  (max. 2000 mg/dose) 6 hrly IV 7-10 days
Pneumococcus  If MIC≤0.06µg/ml Penicillin G 50 mg/kg/dose  (max. 2400 mg/dose) 4-6 hrly IV 10-14 days
Meningococcus Penicillin G 50 mg/kg/dose  (max. 2400 mg/dose) 4-6 hrly IV  Uncomplicated child > 12mths: 4 - 5 days
<12mths or complicated course: 7 days min
Group B streptococcus Penicillin G 50 mg/kg/dose  (max. 2400 mg/dose) 4-6 hrly IV
(Check newborn doses for infants < 4 weeks)
14-21 days

Gram negative organisms, Listeria or HSV encephalitis will require longer courses

Paediatric Infectious Diseases Team

In Starship, patients with confirmed bacterial meningitis will usually be under the ID Team, though the initial management may be under the general paediatric team. 

Notification to the Local Public Health Service

Notify cases of Meningococcal and H. Influenzae type b disease to Public Health Service as soon as possible to initiate prophylaxis for contacts. ARPHS prefers that hospital clinicians DO NOT directly dispense prophylaxis to relatives of cases in our care. For cases in the Auckland region, call Auckland Regional Public Health Service on 09 623 4600 (ARPHS' 24 hours per day, 7 days per week number).

Pneumococcal disease is also a notifiable disease via the laboratory but no prophylaxis is required.

References

  1. Chavez-Bueno S, McCracken GH. Bacterial meningitis in children. Pediatr Clin North Am. 2005;52:795-810.
  2. Vogev R, Guzman-Cottrill J. Bacterial meningitis in children: critical review of current concepts. Drugs. 2005;65:1097-112.
  3. Dalton M, Newton RW. Aseptic Meningitis. Dev Med Child Neurol 1991;33: 446 - 451
  4. 2000 Red Book Report of the Committee on Infectious Diseases, American Academy of Paediatrics, Twenty-fifth Edition

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Document Control

  • Date last published: 02 June 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Infectious Diseases
  • Author(s): Lesley Voss
  • Editor: Greg Williams
  • Review frequency: 2 years

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