Pediatric Bacterial Meningitis Treatment & Management

  • Author: Martha L Muller, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jun 15, 2011
 

Medical Care

Treatment for bacterial meningitis includes the following:

  • Neonatal
    • Initiate treatment as soon as bacterial meningitis is suspected. Ideally, blood and cerebrospinal fluid (CSF) cultures should be obtained before antibiotics are administered. If a newborn is on a ventilator and clinical judgment dictates that a spinal tap may be hazardous, it can be deferred until the infant is stable. A spinal tap performed a few days following initial treatment still reveals cellular and chemical abnormalities but culture results may be negative.
    • Establish intravenous access, and meticulously monitor fluid administration. Neonates with meningitis are prone to develop hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). These electrolyte changes also contribute to the development of seizures, especially during the first 72 hours of disease.
    • Increased intracranial pressure secondary to cerebral edema is rarely a management problem in infants. Monitor blood gas levels closely to ensure adequate oxygenation and metabolic stability.
    • MRI with gadoteridol, ultrasonography, or CT scanning with contrast is needed to delineate intracranial pathology. A Pediatric Academic Societies meeting in resulted in the recommendation that MRIs with contrast should be performed for neonates with uncomplicated meningitis 7-10 days after treatment initiation to ensure that no complicating pathology is present. All newborns recovering from meningitis should have auditory evoked potential studies to screen for hearing impairment.
  • Infants and children: Management of acute bacterial meningitis involves both appropriate antimicrobial therapy and supportive measures. All patients should have an audiologic evaluation upon completion of therapy.
  • Fluid and electrolyte management
    • Closely monitor patients by checking vital signs and neurologic status and by ensuring an accurate record of intake and output.
    • By prescribing the correct type and volume of fluid, the risk of development of brain edema can be minimized. The child should receive fluids sufficient to maintain systolic blood pressure at around 80 mm Hg, urinary output of 500 mL/m2/d, and adequate tissue perfusion. Although care to avoid SIADH is important, underhydrating the patient and risk of decreased cerebral perfusion are equally concerning as well.
    • Dopamine and other inotropic agents may be necessary to maintain blood pressure and adequate circulation.
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Martha L Muller, MD  Associate Professor of Pediatrics, Division of Infectious Diseases, University of New Mexico School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David Jaimovich, MD  Chief Medical Officer, Joint Commission International and Joint Commission Resources

David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Acute bacterial meningitis (same patient as in the other two images). This axial nonenhanced CT scan shows mild ventriculomegaly and sulcal effacement.
Acute bacterial meningitis (same patient as in the other two images). This axial T2-weighted MRI shows only mild ventriculomegaly.
Acute bacterial meningitis (same patient as in the other two images). This contrast-enhanced, axial T1-weighted MRI shows leptomeningeal enhancement (arrows).
Table 1. Antibiotic Dosages for Neonatal Bacterial Meningitis to be Adjusted by Weight and Age Dosage (mg/kg/dose or U/kg/dose for Highest Dose Within Dosage Range) and Intervals of Administration
AntibioticAdmin-istration



Route



Dose for birth weight < 2000g and age 0-7 dDose for birth weight >2000g and age 0-7 dDose for birth weight < 2000g and age >7 dDose for birth weight >2000g and age >7 d
Penicillins
AmpicillinIV, IM50 mg q12h50 mg q8h50 mg q8h50 mg q6h
Penicillin-GIV50,000 U q12h50,000 U q8h50,000 U q8h50,000 U q6h
OxacillinIV, IM50 mg q12h50 mg q8h50 mg q8h50 mg q6h
TicarcillinIV, IM75 mg q12h75 mg q8h75 mg q8h75 mg q6h
Cephalosporins
CefotaximeIV, IM50 mg q12h50 mg q8h50 mg q8h50 mg q6h
CeftriaxoneIV, IM50 mg once daily50 mg once daily50 mg once daily75 mg once daily
CeftazidimeIV, IM50 mg q12h50 mg q8h50 mg q8h50 mg q8h
Table 2. Antibiotics for Neonatal Bacterial Meningitis That Need to be Dosed According to Serum levels
AntibioticAdmin-istration RouteDesired Serum level (mcg/mL)Initial dose



for birth weight < 2000g and age 0-7 d (mg/kg / dose)*



Initial dose



for birth weight >2000kg and age 0-7 d (mg/kg / dose)*



Dose for



birth weight < 2000g and age >7 d (mg/kg / dose)*



Dose for



birth weight >2000g and age >7 d (mg/kg / dose)*



Aminoglycosides
Amikacin†IV, IM20-30 (peak), < 10 (trough)7.5 q12h10 q12h10 q8h10 q8h
Gentamicin†IV, IM5-10 (peak), < 2.5 (trough)2.5 q12h2.5 q12h2.5 q8h2.5 q8h
Tobramycin†IV, IM5-10 (peak), < 2.5 (trough)2.5 q12h2.5 q12h2.5 q8h2.5 q8h
Glycopeptide
Vancomycin*†IV, IM20-40 (peak), < 10 (trough)15 q12h15 q8h15 q8h15 q6h
*Dose stated is highest within dosage range.



† Serum levels must be monitored when patient has kidney disease or is receiving other nephrotoxic drugs; adjust doses accordingly.



Table 3. Dose Guidelines of Intravenous Antimicrobials in Infants and Children With Bacterial Meningitis
AntibioticDose (mg/kg/d) IVMaximum Daily DoseDosing Interval
Ampicillin4006-12 gq6h
Vancomycin602-4 gq6h
Penicillin G400,000 U24 millionq6h
Cefotaxime200-3008-10 gq6h
Ceftriaxone1004 gq12h
Ceftazidime1506 gq8h
Cefepime*1502-4 gq8h
Imipenem†602-4 gq6h
Meropenem1204-6 gq8h
Rifampin20600 mgq12h
*Minimal experience in pediatrics and not licensed for treatment of meningitis.



† Caution in use for treatment of meningitis because of possible seizures.



Table 4. Chemoprophylaxis for Contacts of Patients and Index (Case of H influenzae type b and contacts of meningococcal disease)
Drug NameAge of ContactDosage
H influenzae disease
RifampinAdults<>600 mg PO qd for 4 d
≥ 1 month20 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
RifampinAdults600 mg PO q12h for 2 d
>1 month10 mg/kg PO q12h for 2 d;



not to exceed 600 mg/dose



≤ 1 month5 mg/kg PO q12h for 2 d
Ceftriaxone>15 years250 mg IM once
≤ 15 years125 mg IM once
Ciprofloxacin≥ 18 years500 mg PO once
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