The presentation of a child with meningitis varies with age. Infants with meningitis frequently present with non-specific signs and symptoms such as fever, irritability, lethargy, poor feeding and vomiting. The fontanelle may or may not be full. Older children may complain of headache or photophobia. Neck stiffness may be present (although this is not a reliable sign in young children). A purpuric rash is suggestive of meningococcal septicemia. It is important to examine for spinal and cranial abnormalities such as dermal sinuses, which may have predisposed the child to meningitis.
Note: This guideline is not for use in children with spinal abnormalities or ventriculoperitoneal shunts where the neurosurgical team should be consulted.
Assessment
Assess airway, breathing and circulation. Monitor pulse, blood pressure, respiratory rate, oxygen saturation and consciousness. Insert intravenous line and take blood for glucose, FBC and blood cultures and U&Es, meningococcal PCR, and CRP (C-reactive protein). Do nose and throat swabs, as occasionally the organism is isolated from these. If the clinical diagnosis is meningitis and there are contraindications for a lumbar puncture give intravenous antibiotics without delay.
Lumbar puncture (LP)
An LP is used to confirm the diagnosis of bacterial meningitis and to identify the organism and its antibiotic sensitivities. In some cases it should be postponed because of the risk of coning. There are contraindications to performing an LP, including:
• Coma—Glasgow Coma Scale (GCS) <13 or rapid deterioration in conscious state or absent or non-purposeful responses to painful stimuli (squeeze earlobe hard for up to 1 minute. Children should localise response and seek a parent)
• Focal neurological signs
• Papilledema
• Cardiovascular compromise
• Evidence of coagulopathy.
If any of these signs are present the patient is in danger of coning, and management in Intensive Care is usually required. Notify a PICU immediately (for retrieval or transfer), perform blood cultures, commence antibiotics.
Remember cerebrospinal fluid (CSF) findings in early bacterial meningitis may mimic a viral pattern or even be normal (see Table 6.1). In a traumatic tap, allow 1 white blood cell for every 500 red blood cells, and 0.01 gl−1 of protein for every 1000 red cells. Request culture and analysis for bacterial antigens (this is non-urgent as it does not change immediate management and there is no need for it to be performed out of hours).
Management
a. Admission to a PICU
Admission to PICU should be discussed with the consultant in the following circumstances:
Meningitis: Factors requiring consultant opinion
•Age less than 2 years
•Coma
•Cardiovascular compromise
•Intractable seizures
•Hyponatremia
b. Antibiotics
In a child aged over 2 months the usual organisms causing bacterial meningitis are Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b (HiB—uncommon after the age of 6 and the incidence is reduced following HiB vaccination).
Empirical treatment consists of cefotaxime (50 m g/kg weight per dose up to a maximum of 3 g, 6 hourly) given prior to determination of the organism responsible and its sensitivities. Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins. You may need to consider the addition of vancomycin if pneumococcus is suspected in an area of high incidence of penicillin-resistant pneumococcus.
Continue empirical treatment until cultures are known to be negative or an organism and its sensitivity pattern are known. A positive culture result with sensitivities should lead to narrower spectrum treatment.
In a child aged under 2 months, the organisms to consider in this age group include group B streptococcus, Escherichia coli and other Gram negative organisms, Listeria monocytogenes, Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b.
Initial therapy is with i.v. benzylpenicillin (50mg/kg weight per dose, 6 hourly), and i.v. cefotaxime (50 mg/kg weight per dose, 6 hourly), and i.v. gentamicin (dose according to age). Ongoing therapy is modified according to culture and sensitivity results. Consult local guidelines.
Treatment in meningjtis with positive cultures with sensitivities
- Neisseria meningitidis—give i.v. benzylpenicillin 50 mg/kg weight per dose up to a maximum of 3 g, 4 hourly for 7 days (in penicillinsensitive cases)
- Streptococcus pneumoniae—give i.v. benzylpenicillin 50 mg kg−1 per dose up to a maximum of 3 g, 4 hourly for minimum of 10 days (in penicillinsensitive cases)
- Hemophilus influenzae—give i.v. cefotaxime 50 mg/kg weight per dose up to a maximum of 3 g, 6 hourly for 7–10 days, or i.v. amoxycillin 50 mg/kg weight per
- dose 4 hourly for 7–10 days (depending on sensitivities)
- Other—if an organism is not isolated, but significant CSF pleocytosis is present, a minimum of 7 days treatment with i.v. cefotaxime is recommended.
c. Fluid management
Careful fluid management is important in the treatment of meningitis as many children have increased antidiuretic hormone (ADH) secretion. The degree to which fluid should be restricted varies considerably from patient to patient depending primarily on their clinical state.
Shock should be corrected with 20 ml/kg weight of normal saline. A patient who is not in shock and whose serum sodium is within the normal range should be given 50% of maintenance fluid requirements as initial management. If the serum sodium is less than 135 mmol/l give 25–50% of maintenance requirements. The serum sodium should be repeated every 6–12 hours for the first 48 hours and the total fluid intake altered accordingly. If the serum sodium is less than 135 mmol/l, reduce the fluid intake.
d. General measures
• Neurological observations including blood pressure should be performed every 15 minutes for the first 2 hours and then at intervals determined by the child’s conscious state.
• Weight and head circumference should be monitored on a daily basis.
• Control seizures.
• Early consultation with intensive care unit is necessary for any child who is experiencing a deterioration in conscious state, hemodynamic instability or seizures.
• Electrolytes should be checked every 6–12 hours until the serum sodium is normal.
• Ensure adequate analgesia (e.g. paracetamol) for children in the recovery phase who may have significant headache.
• The role of steroids is still controversial and we have opted generally not to use them, although they may be indicated in Hemophilus meningitis.
Isolation
Children with meningococcal disease require isolation until they have had 24 hours treatment. Other children with meningitis can be nursed on the open ward.
Fever persisting for more than 7 days
This may be due to nosocomial infection, subdural effusion or other foci of suppuration. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.
Contact chemoprophylaxis
Practice differs in different countries. Below is one regime used in Australia. It is important that prophylaxis be given early to both the index case and contacts as follows:
• Index Case and all household contacts if household includes other children under 4 years of age who are not fully immunized.
Index Case and all household contacts in households with any infants under 12 months of age, regardless of immunization status.
• Index Case and all household contacts in households with a child 1–5 years of age who is inadequately immunized.
• Index Case and all room contacts including staff in a child-care group if Index Case attends over 18 hours per week and any contacts under 2 years of age who are inadequately immunized. (NB. Inadequately immunized children should also be immunized.)
• Index Case (if treated only with penicillin) and all intimate, household or day-care contacts who have been exposed to the Index Case within 10 days of onset.
• Any person who gave mouth-to-mouth resuscitation to the Index Case.
Australian contact chemoprophylaxis regimen
- Hemophilis influenzae type b—give rifampicin 20 mg/kg weight orally as a single daily dose to a maximum 600 mg) for 4 days. For infants <1 month give rifampicin 10 mg/kg weight orally daily for 4 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight i.m. (<12 years) or 250 mg/kg weight i.m. (>12 years) as a single dose.
- Neisseria meningitidis—give either: rifampicin 10 mg/kg weight orally 12 hourly up to a maximum 600 mg for 2 days. For infants <1 month give rifampicin 5 mg/kg weight orally 12 hourly for 2 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight i.m. (<12 years) or 250mg/kg weight i.m. (>12 years) as a single dose. or ciprofloxacin 500 mg orally as a single dose.
- Streptococcus pneumoniae—there are no increased risks to contacts, so no antibiotic required.
- Rifampicin may cause orange-red discoloration of tears, urine and contact lenses, skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy or severe liver disease.
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