Pediatric emergency medicine trisk 2267 2267
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TABLE 94.5
IMMEDIATE MANAGEMENT STEPS FOR CHILDREN WITH SUSPECTED OR CONFIRMED
BACTERIAL MENINGITIS
Immediate
evaluation
Initiate hemodynamic monitoring and support
Achieve venous access; use cardiorespiratory monitors
Laboratory
evaluation
Ensure adequate ventilation and cardiac function
CSF for cell count and differential; Gram stain and culture; glucose; protein
Consider holding CSF in the laboratory for enteroviral or HSV PCR, AFB culture,
cryptococcal, or arboviral studies
CBC, blood culture, electrolytes, serum glucose, BUN and creatinine, prothrombin time
and partial thromboplastin time
Medications
Fluid resuscitation for septic shock, if present
If Mycobacterium tuberculosis or H. influenzae type b is the suspected cause of
meningitis, consider dexamethasone (0.15 mg/kg) before or with the first dose of
antibiotics
Antibiotics (see Table 94.7 )
Glucose (if serum glucose <50 mg/dL) 0.25–1 g/kg
Treat acidosis and coagulopathy, if present.
CSF, cerebrospinal fluid; HSV, herpes simplex virus; PCR, polymerase chain reaction; AFB, acid-fast bacilli; CBC, complete blood count.
Triage considerations: Children with fever and altered mental status or neck pain should be evaluated promptly
for meningitis. Associated tachycardia and hypotension can be seen in children with meningitis who are in
compensated or uncompensated shock, respectively. If meningococcus is suspected, providers should wear simple
face masks and utilize droplet precautions.
Clinical assessment: Initial considerations in the management of children with bacterial meningitis are listed in
Table 94.5 . Confirmation of meningitis is by sampling of the CSF. The most common CSF parameters associated
with various causes of meningitis are summarized in Table 94.6 . The CSF Gram stain will be positive for an
organism in approximately two-thirds (40% to 90%) of cases of bacterial meningitis and the results of Gram stain
should be used to add additional antimicrobial therapy when appropriate. It is prudent to await culture
confirmation before antibiotic coverage is narrowed. In certain patients, computed tomography (CT) should be
considered prior to LP. These criteria are not as well defined for pediatric patients, but in adult patients, they
include immunocompromised state; history of focal CNS disease; presence of papilledema; and focal neurologic
deficit.
Seizures occur in 20% of children with bacterial meningitis and, occasionally, in those with viral infections of
the CNS, such as meningoencephalitis due to HSV. One should always be suspicious of derangement of the
glucose or sodium as a cause of convulsive activity. However, most seizures are caused by irritation of the brain
from the infectious process. Subdural effusion and, less often, empyema occur in 20% to 40% of young children
with meningitis but usually appear later in the course.
Management: The optimal antibiotics for empiric treatment of acute bacterial meningitis would offer coverage
for the most common pathogens, be bactericidal, and cross the blood–brain barrier. Treatment options for
meningitis in normal hosts are described in Table 94.7 . Treatment of tuberculosis meningitis and HSV meningitis
is described elsewhere. Evaluation and treatment of meningitis in immunocompromised hosts (e.g., human
immunodeficiency virus [HIV]-infected children) should be undertaken with consultation with an ID specialist.
Consideration should be given to admitting children with suspected bacterial meningitis to an intensive care unit
setting for close initial monitoring. Standard precautions are indicated for most causes of bacterial meningitis,
except for meningococcus (droplet precautions) and tuberculosis meningitis (airborne precautions). Electrolyte
imbalances seen in bacterial meningitis and their treatment are discussed in Chapter 100 Renal and Electrolyte
Emergencies .
