Meningitis (peds)

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Background

Risk Factors

Clinical Features

Following features in the correct clinical context should raise suspicion

  • Fever
  • Headache
  • Meningeal signs
  • Poor feeding
  • Irritability
  • Apnea
  • Lethargy
  • Fever
  • Hypothermia
  • Seizures
  • Bulging fontanelle
  • Hypotonia
  • Weak cry
  • Hypoglycemia

Differential Diagnosis

Pediatric fever

Pediatric Rash

Evaluation

Work-Up

  1. CBC
  2. Chem
  3. Blood culture
  4. ?CT head: See CT Before Lumbar Puncture
  5. CXR (50% of patients with pneumoccocal meningitis have evidence of pneumonia on CXR)
  6. Lumbar Puncture

CSF interpretation by age

  • In general neutrophils are abnormal in pediatric CSF and should increase the suspicion for bacterial meningitis. Meningitis can also occur in children with normal CSF microscopy.
CSF interpretation by age
' Neutrophils Lymphocytes Protein Glucose
(x 106 /L) (x 106/L) (g/L) (CSF:blood ratio)
Normal
(>1 month of age)
0 ≤ 5 < 0.4 ≥ 0.6 (or ≥ 2.5 mmol/L)
Normal neonate
(<1 month of age)
0 < 20 <1.0 ≥ 0.6 (or ≥ 2.5 mmol/L)

CSF Interpretation by Diagnosis

  • If the CSF is abnormal the safest course is to treat as if it is bacterial meningitis until cultures return negative growth.'[1]
  • PCR is available for Neisseria meningitidis, Herpes Simplex and Enterovirus and will with inpatient diagnosis. PCR is most helpful for patients with encephalitis and has poor sensitivity and specificity for bacterial antigens.
Interpretation of abnormal CSF lab values
' Neutrophils Lymphocytes Protein Glucose
(x 106 /L) (x 106/L) (g/L) (CSF:blood ratio)
Normal (>1 month of age) 0 ≤ 5 < 0.4 ≥ 0.6 (or ≥ 2.5 mmol/L)
Normal term neonate 0* < 20 < 1.0 ≥ 0.6 (or ≥ 2.5 mmol/L)
Bacterial meningitis 100-10,000 Usually < 100 > 1.0 < 0.4
Viral meningitis Usually <100 10-1000 0.4-1 Usually normal
TB meningitis Usually <100 50-1000 1-5 < 0.3

Pediatric Bacterial Meningitis Score[2]

Bacterial Meningitis Score '
Criteria Point Score
Positive CSF Gram Stain 2
CSF protein > 80mg/dL 1
Blood Absolute neutrophil count > 10,000 cells/mm3 1
Incidence of seizures with illness 1
CSF neutrophil count ≥ 1000 cells/mm3 1
  • 0 points: Aseptic meningitis likely[3]
  • 1 point: Aseptic meningitis less likely[4]
  • ≥2 points: Bacterial Meningitis more likely[5]

Delay in LP

  • CSF cultures are negative 2 hrs after parenteral antibiotics in meningococcal meningitis, and 6 hrs in pneumococcal meningitis[6][7]
  • 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[8]

Management

"Steroids are unlikely to be beneficial for children with bacterial meningitis in the post-PCV7 era"[9]

<1 month old[10][11]

MRSA is uncommon in the neonate

> 1 month old[12]

Children with Predisposing Factors[13]

Risk Factor Therapy
Basilar skull fracture Vancomycin + third-generation cephalosporin
Penetrating trauma or recent neurosurgery Vancomycin + cefepime, ceftazidime, or meropenem
Ventricular shunt Vancomycin alone; if Gram stain reveals presence of gram-negative bacilli, then add cefepime, ceftazidime, or meropenem

Disposition

  • Admit despite negative meningitis score if:
    • Age <2mo with any degree of pleocytosis
    • Appear ill
    • Infants with aseptic meningitis

See Also

References

  1. Brouwer MC et al. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet. 2012 Nov 10. 380(9854):1684-92.
  2. Chavanet P, Schaller C, Levy C, et al. Performance of a predictive rule to distinguish bacterial and viral meningitis. J Infect 2007;54: 328–36.

  3. Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60.

  4. Fine AM, Nigrovic LE, Reis BY, Cook EF, Mandl KD. Linking surveillance to action: incorporation of real-time regional data into a medical decision rule. J Am Med Inform Assoc 2007;14: 206–11.
  5. Dubos F, Korczowski B, Aygun DA, et al. Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules. Arch Dis Child 2010;95:963–7.

  6. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74
  7. Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497
  8. Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794
  9. Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
  10. van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  11. Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
  12. van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  13. Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766