Pediatrics 9: Meningitis Portal
PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.
Children 0 to 3 months of age:
Signs and symptoms may be nonspecific, as in the newborn, or may include more classic symptoms such as stiff neck, fever, or a bulging fontanelle.
The most common causative organisms in this age group are Strep pneumoniae, menigococci, H influenzae, Group B Strep, Listeria, and enteric gram-negative rods.
Diagnostic tests: The lumbar puncture (LP) is the most essential test. If the child has an open fontanelle, no head CT is needed. If any diagnostic test (such as the LP) is likely to cause significant delay in treatment, immediately start antibiotics, then proceed with the diagnostic tests.
The cerebrospinal fluid (CSF) should be examined for:
Tube 1—Protein (normal is 112 to 25 mg/dL) and glucose (normal is 2/3 the simultaneous blood level)
Tube 2—Gram stain and bacterial culture
Tube 3—White blood cell count and differential
Tube 4—Extra tube to save. Strongly consider herpes PCR or other viral studies.
Other tests that should be obtained include a CBC, blood culture, glucose, and electrolytes.
Start dexamethasone 0.15 mg/kg IV 15 to 20 minutes before the antibiotics. (Continue every 6 hours for 4 days.) By starting dexamethasone early, hearing loss and other neurologic complications can be decreased.
Start antibiotics before the bacterial pathogen is known. Administer via IV route if feasible. Drugs of choice:
First choice: Ampicillin 50 mg/kg IV every 6 hours, plus either cefotaxime (Claforan) 50 mg/kg IV every 8 hours or gentamicin PLUS vancomycin 10-15 mg/kg/dose.
Children 3 months to 7 years of age:
Signs and symptoms may include headache, fever, stiff neck, bulging fontanelle, irritability, or poor feeding.
The most common causative organisms in this age group are S pneumoniae, meningococci, and H influenzae.
Diagnostic tests: The most important test is the lumbar puncture (LP). In a child with an open fontanelle, it is not necessary to order a head CT before the LP. In older children, a head CT should be done if there is suspicion of increased intracranial pressure or focal neurologic signs. If diagnostic tests are likely to cause a delay, proceed to antibiotic therapy before performing the tests. Cerebrospinal fluid should be collected for:
Tube 1—Protein (normal is 12 to 25 mg/dL) and glucose (normal is 2/3 the simultaneous blood level)
Tube 2—Gram stain and bacterial culture
Tube 3—White blood cell count and differential
Tube 4—May be collected for additional studies such as latex agglutination, countercurrent immunoelectrophoresis, or fungal/viral cultures.
Other tests that should be obtained include a CBC, blood culture, glucose, and electrolytes.
Start dexamethasone 0.15 mg/kg IV 15 to 20 minutes before the antibiotics. (Continue every 6 hours for 4 days.) The early use of dexamethasone may decrease the incidence of hearing loss and other neurologic complications.
Start antibiotics before the bacterial pathogen is known. Administration by IV route is preferable if feasible. Drugs of choice:
First choice: Cefotaxime (Claforan) 50 mg/kg IV or IM every 6 hours or ceftriaxone (Rocephin) 50 mg/kg IV or IM every 12 hours PLUS Vancomycin.