eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Meningitis, Bacterial: Follow-up
Updated: Jan 4, 2008
Follow-up
Deterrence/Prevention
Prevention is an important aspect of care in bacterial meningitis because it has been shown to reduce mortality and morbidity. It can be divided into 2 categories: chemoprophylaxis and immunization.
H influenzae type b
- Chemoprophylaxis
- Risk of invasive disease is increased among unimmunized household contacts younger than 4 years. Rifampin eradicates the organism from the pharynx of approximately 95% of carriers. The efficacy of rifampin in preventing disease in childcare groups is not established.
- Recommendations for rifampin chemoprophylaxis for contacts of index cases of invasive H influenzae type b disease include the following:
- All household contacts with at least one contact younger than 4 years who is unimmunized or partially immunized; those with a child younger than 12 months who has not received the primary series; and those with an immunocompromised child (even if aged > 4 y), regardless of immunization status
- Nursery and childcare center contacts regardless of age, when 2 or more cases of invasive disease have occurred within 60 days
- For index case if younger than 2 years old or with a susceptible household contact and treated with ampicillin or chloramphenicol
- Immunization: Immunizations should be administered as per American Academy of Pediatrics guidelines. Universal immunization against H influenzae type b infection has led to a dramatic decline in the incidence of invasive H influenzae disease.
N meningitidis
- Chemoprophylaxis
- Antimicrobial administration to contacts is divided into high- and low-risk categories. Only those stratified as high risk require prophylaxis.
- Candidates for prophylaxis include the following:
- All household contacts
- Childcare or nursery school contact during 7 days before illness onset
- Direct exposure to index case secretions through kissing or sharing toothbrushes or eating utensils, markers of close social contact during 7 days before illness onset
- Mouth-to-mouth resuscitation, unprotected contact during endotracheal intubation during 7 days before illness onset
- Frequently slept or ate in the same dwelling as index patient during 7 days before illness onset
- Outbreaks or clusters need to be managed as per local public health authorities.
- Immunization: A quadrivalent (ie, A, C, Y, W-135) meningococcal conjugate vaccine is recommended for high-risk groups, including patients with immunodeficiency, patients with functional or anatomic asplenia, and patients with deficiencies of terminal components of complement. The vaccine is also valuable in controlling the epidemics of meningococcal disease. The Advisory Committee on Immunization Practices (ACIP) has recommended this vaccine for all children aged 11-12 years and first-year college students who will be living in a dormitory or dormitorylike setting, and other high-risk groups.
S pneumoniae
- Chemoprophylaxis: Routine chemoprophylactic measures for invasive disease secondary to this organism are limited to people with specific medical conditions.
- Immunizations: The heptavalent pneumococcal conjugate vaccine has been introduced into the primary childhood vaccination schedule. Immunizations should be administered as per American Academy of Pediatrics guidelines. The polysaccharide vaccine is generally used for those with specific medical conditions.
Table 4. Chemoprophylaxis for Contacts of Patients and Index (Case of H influenzae type b and contacts of meningococcal disease)
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Table
| Drug Name | Age of Contact | Dosage |
| H influenzae disease | ||
| Rifampin | Adults | 600 mg PO qd for 4 d |
| >1 month | 20 mg/kg PO qd for 4 d; not to exceed 600 mg/dose | |
| <1 month | 10 mg/kg PO qd for 4 d | |
| N meningitidis disease | ||
| Rifampin | Adults | 600 mg PO q12h for 2 d |
| >1 month | 10 mg/kg PO q12h for 2 d; not to exceed 600 mg/dose | |
| <1 month | 5 mg/kg PO q12h for 2 d | |
| Ceftriaxone | >15 years | 250 mg IM once |
| <15 years | 125 mg IM once | |
| Ciprofloxacin | >18 years | 500 mg PO once |
| Drug Name | Age of Contact | Dosage |
| H influenzae disease | ||
| Rifampin | Adults | 600 mg PO qd for 4 d |
| >1 month | 20 mg/kg PO qd for 4 d; not to exceed 600 mg/dose | |
| <1 month | 10 mg/kg PO qd for 4 d | |
| N meningitidis disease | ||
| Rifampin | Adults | 600 mg PO q12h for 2 d |
| >1 month | 10 mg/kg PO q12h for 2 d; not to exceed 600 mg/dose | |
| <1 month | 5 mg/kg PO q12h for 2 d | |
| Ceftriaxone | >15 years | 250 mg IM once |
| <15 years | 125 mg IM once | |
| Ciprofloxacin | >18 years | 500 mg PO once |
Complications
- Seizures: These are a common complication of bacterial meningitis, affecting almost one third of the patients. Persistent seizures, seizures late in the course of disease, and focal seizures are more likely to be associated with neurologic sequelae.
- Other complications: Numerous other complications that can be seen during the course of bacterial meningitis include SIADH, subdural effusions, and brain abscesses. Subdural effusions are generally asymptomatic and resolve without neurologic sequelae.
- Long-term sequelae: These are seen in as many as 30% of children and vary with etiologic agent, patient's age, presenting features, and hospital course. Long-term, close follow-up care of children is crucial for the early detection of sequelae.
- CNS sequelae: Although most patients have subtle CNS changes, serious complications occasionally are observed. These complications include nerve deafness, cortical blindness, hemiparesis, quadriparesis, muscular hypertonia, ataxia, complex seizure disorders, mental motor retardation, learning disabilities, obstructive hydrocephalus, and cerebral atrophy.
- Hearing impairment
- Mild-to-severe impairment of hearing is noted in as many as 20-30% of affected children with H influenzae disease but is less common with other pathogens.
- Early administration of dexamethasone reduces the incidence of audiologic complications in H influenzae type b meningitis.
- Severe hearing impairment interferes with the development of normal speech; thus, frequent audiologic evaluation and developmental assessment must be performed during healthcare visits.
- Motor sequelae: Whenever motor sequelae are detected, physical, occupational, and rehabilitation services should evaluate the patient to prevent further damage and to provide optimal functional status.
Prognosis
- Prolonged or difficult-to-control seizures, especially after the fourth hospital day, are predictors of a complicated hospital course with serious sequelae. On the other hand, seizures that occur during the first 3 days of illness usually have little prognostic significance.
- Approximately 6% of affected infants and children show signs of disseminated intravascular coagulopathy and endotoxic shock. These signs are indicative of a poor prognosis
Patient Education
- For excellent patient education resources, visit eMedicine's Children's Health Center and Procedures Center. Also, see eMedicine's patient education articles Meningitis in Children and Spinal Tap.
Miscellaneous
Medicolegal Pitfalls
- Meningitis is a life-threatening illness and leaves some survivors with significant sequelae. Therefore, pay meticulous attention in treating and monitoring these patients.
- Promptly administer antibiotics.
- Patients must be in a facility where emergencies can be managed and nursing and medical staff are experienced in caring for critically ill patients.
- Careful neurologic examination and visual and hearing screening tests (brainstem evoked potentials) should be obtained and reviewed with parents so that parents are aware of any deficits. Early detection of deficits should result in initiating appropriate physical and occupational therapy and in acquiring other devices or modalities required by the patient to achieve the maximum possible benefit.
- The primary care physician must coordinate the follow-up care and keep all involved specialists informed so that prompt action can be taken if any concerns exist.
- Respond promptly to parents' concerns with adequate documentation. Patients also may have other foci of infection. Presenting symptoms may point toward those foci, causing unnecessary delay in diagnosis of bacterial meningitis.
- Signs and symptoms in patients with listerial meningitis tend to be subtle, and diagnosis is often delayed.
More on Meningitis, Bacterial |
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| Treatment & Medication: Meningitis, Bacterial |
 Follow-up: Meningitis, Bacterial |
| References |
| « Previous Page |
References
van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2007;(1):CD004405. [Medline].
Ahmed A. A critical evaluation of vancomycin for treatment of bacterial meningitis. Pediatr Infect Dis J. Sep 1997;16(9):895-903. [Medline].
Ahmed A, Hickey SM, Ehrett S, et al. Cerebrospinal fluid values in the term neonate. Pediatr Infect Dis J. Apr 1996;15(4):298-303. [Medline].
Albanyan EA, Baker CJ. Is lumbar puncture necessary to exclude meningitis in neonates and young infants: lessons from the group B streptococcus cellulitis- adenitis syndrome. Pediatrics. Oct 1998;102(4 Pt 1):985-6. [Medline].
Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics. Nov 1998;102(5):1087-97. [Medline].
Balagtas RC, Levin S, Nelson KE. Secondary and prolonged fevers in bacterial meningitis. J Pediatr. Dec 1970;77(6):957-64. [Medline].
Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. May 27 2005;54(RR-7):1-21. [Medline].
Bradley JS. Meropenem: a new, extremely broad spectrum beta-lactam antibiotic for serious infections in pediatrics. Pediatr Infect Dis J. Mar 1997;16(3):263-8. [Medline].
Bradley JS, Scheld WM. The challenge of penicillin-resistant Streptococcus pneumoniae meningitis: current antibiotic therapy in the 1990s. Clin Infect Dis. Feb 1997;24 Suppl 2:S213-21. [Medline].
Bridy-Pappas AE, Margolis MB, Center KJ, Isaacman DJ. Streptococcus pneumoniae: description of the pathogen, disease epidemiology, treatment, and prevention. Pharmacotherapy. Sep 2005;25(9):1193-212. [Medline].
CDC. Direct and indirect effects of routine vaccination of children with 7-valent pneumococcal conjugate vaccine on incidence of invasive pneumococcal disease--United States, 1998-2003. MMWR Morb Mortal Wkly Rep. Sep 16 2005;54(36):893-7. [Medline].
Chavez-Bueno S, McCracken GH. Bacterial meningitis in children. Pediatr Clin North Am. Jun 2005;52(3):795-810, vii. [Medline].
Cohen-Wolkowiez M, Laufer M. Enhanced culture detection of Citrobacter koseri from cerebrospinal fluid in BacTec. Pediatr Infect Dis J. Aug 2005;24(8):750. [Medline].
Erickson L, DeWals P. Complications and sequelae of meningococcal disease in Quebec, Canada, 1990-1994. Clin Inf Dis. 1998;26:1159-1164. [Medline].
Franco SM, Cornelius VE, Andrews BF. Long-term outcome of neonatal meningitis. Am J Dis Child. May 1992;146(5):567-71. [Medline].
Kaplan SL, Fishman MA. Supportive therapy for bacterial meningitis. Pediatr Infect Dis J. Jul 1987;6(7):670-7. [Medline].
Kornelisse RF, Hazelzet JA, Hop WC, et al. Meningococcal septic shock in children: clinical and laboratory features, outcome, and development of a prognostic score. Clin Infect Dis. Sep 1997;25(3):640-6. [Medline].
Kornelisse RF, Westerbeek CM, Spoor AB, et al. Pneumococcal meningitis in children: prognostic indicators and outcome. Clin Infect Dis. Dec 1995;21(6):1390-7. [Medline].
Kumar A, Kumar K. Rapid laboratory diagnosis of infectious diseases. Prim Care. Dec 1981;8(4):593-604. [Medline].
Lebel MH, Freij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis. Results of two double- blind, placebo-controlled trials. N Engl J Med. Oct 13 1988;319(15):964-71. [Medline].
Lutsar I, McCracken GH Jr, Friedland IR. Antibiotic pharmacodynamics in cerebrospinal fluid. Clin Infect Dis. Nov 1998;27(5):1117-27, quiz 1128-9. [Medline].
Malley R, Inkelis SH, Coelho P, et al. Cerebrospinal fluid pleocytosis and prognosis in invasive meningococcal disease in children. Pediatr Infect Dis J. Oct 1998;17(10):855-9. [Medline].
McCracken GH Jr, Mize SG. A controlled study of intrathecal antibiotic therapy in gram-negative enteric meningitis of infancy. Report of the neonatal meningitis cooperative study group. J Pediatr. Jul 1976;89(1):66-72. [Medline].
McCracken GH Jr, Mize SG, Threlkeld N. Intraventricular gentamicin therapy in gram-negative bacillary meningitis of infancy. Report of the Second Neonatal Meningitis Cooperative Study Group. Lancet. Apr 12 1980;1(8172):787-91. [Medline].
McCullers JA, English BK, Novak R. Isolation and characterization of vancomycin-tolerant Streptococcus pneumoniae from the cerebrospinal fluid of a patient who developed recrudescent meningitis. J Infect Dis. Jan 2000;181(1):369-73. [Medline].
McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta- analysis of randomized clinical trials since 1988. ALYSIS. Sep 17 1997;278(11):925-31. [Medline].
Nelson JD, McCracken GH. Treatment of neonatal meningitis. Pediatr Infect Dis J. Jul 2005;24(7).
[Best Evidence] 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. Jan 3 2007;297(1):52-60. [Medline].
Nigrovic LE, Kuppermann N, McAdam AJ, Malley R. Cerebrospinal latex agglutination fails to contribute to the microbiologic diagnosis of pretreated children with meningitis. Pediatr Infect Dis J. Aug 2004;23(8):786-8. [Medline].
Pomeroy SL, Holmes SJ, Dodge PR. Seizures and other neurologic sequelae of bacterial meningitis in children. N Engl J Med. Dec 13 1990;323(24):1651-7. [Medline].
Prasad K, Karlupia N. Prevention of bacterial meningitis: an overview of Cochrane systematic reviews. Respir Med. Oct 2007;101(10):2037-43. [Medline].
Puopolo KM, Madoff LC, Eichenwald EC. Early-onset group B streptococcal disease in the era of maternal screening. Pediatrics. May 2005;115(5):1240-6. [Medline].
Ray P, Badarou-Acossi G, Viallon A, et al. Accuracy of the cerebrospinal fluid results to differentiate bacterial from non bacterial meningitis, in case of negative gram-stained smear. Am J Emerg Med. Feb 2007;25(2):179-84. [Medline].
Rodriguez CA, Atkinson R, Bitar W, et al. Tolerance to vancomycin in pneumococci: detection with a molecular marker and assessment of clinical impact. J Infect Dis. Oct 15 2004;190(8):1481-7. [Medline].
Rubino CM, Gal P, Ransom JL. A review of the pharmacokinetic and pharmacodynamic characteristics of beta-lactam/beta-lactamase inhibitor combination antibiotics in premature infants. Pediatr Infect Dis J. Dec 1998;17(12):1200-10. [Medline].
Saari TN. Immunization of preterm and low birth weight infants. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics. Jul 2003;112(1 Pt 1):193-8. [Medline].
Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med. Oct 2 1997;337(14):970-6. [Medline].
Segal S, Pollard AJ. The future of meningitis vaccines. Hosp Med. Mar 2003;64(3):161-7. [Medline].
Segal S, Pollard AJ. Vaccines against bacterial meningitis. Br Med Bull. 2004;72:65-81. [Medline].
Singhi SC, Singhi PD, Srinivas B, et al. Fluid restriction does not improve the outcome of acute meningitis. Pediatr Infect Dis J. Jun 1995;14(6):495-503. [Medline].
Sivakmaran M. Meningococcal meningitis revisited: normocellular CSF. Clin Pediatr (Phila). Jun 1997;36(6):351; discussion 351-5. [Medline].
Spangler SK, Jacobs MR, Appelbaum PC. Activities of RPR 106972 (a new oral streptogramin), cefditoren (a new oral cephalosporin), two new oxazolidinones (U-100592 and U-100766), and other oral and parenteral agents against 203 penicillin-susceptible and -resistant pneumococci. Antimicrob Agents Chemother. Feb 1996;40(2):481-4. [Medline].
Swartz MN. Bacterial meningitis--a view of the past 90 years. N Engl J Med. Oct 28 2004;351(18):1826-8. [Medline].
Swingle HM, Bucciarelli RL, Ayoub EM. Synergy between penicillins and low concentrations of gentamicin in the killing of group B streptococci. J Infect Dis. Sep 1985;152(3):515-20. [Medline].
Syrogiannopoulos GA, Nelson JD, McCracken GH Jr. Subdural collections of fluid in acute bacterial meningitis: a review of 136 cases. Pediatr Infect Dis. May-Jun 1986;5(3):343-52. [Medline].
Tauber MG. To tap or not to tap?. Clin Infect Dis. Aug 1997;25(2):289-91. [Medline].
Tauber MG, Moser B. Cytokines and chemokines in meningeal inflammation: biology and clinical implications. Clin Infect Dis. Jan 1999;28(1):1-11; quiz 12. [Medline].
Taylor HG, Mills EL, Ciampi A, et al. The sequelae of Haemophilus influenzae meningitis in school-age children. N Engl J Med. Dec 13 1990;323(24):1657-63. [Medline].
Temime L, Boelle PY, Valleron AJ, Guillemot D. Penicillin-resistant pneumococcal meningitis: high antibiotic exposure impedes new vaccine protection. Epidemiol Infect. Jun 2005;133(3):493-501. [Medline].
Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. Nov 1 2004;39(9):1267-84. [Medline].
Yogev R, Guzman-Cottrill J. Bacterial meningitis in children: critical review of current concepts. Drugs. 2005;65(8):1097-112. [Medline].
Further Reading
Keywords
pyogenic meningitis, bacterial meningitis, bacterial infection of the meninges, acute bacterial meningitis, Streptococcus pneumoniae, S pneumoniae, Neisseria meningitidis, N meningitidis, Haemophilus influenzae type b, Hib, H influenzae, community-acquired bacterial meningitis, conjugate pneumococcal vaccine, conjugate meningococcal vaccine, Hib vaccine, pneumococcal meningitis, respiratory infection, otitis media, mastoiditis, head trauma, hemoglobinopathy, human immunodeficiency virus infection, HIV infection, immune deficiency, neonatal meningitis, bacterial sepsis, Listeria monocytogenes, group B streptococci, GBS, listerial meningitis, pneumococcal meningitis
