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.

References
  1. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. May 26 2011;364(21):2016-25. [Medline].

  2. Levine OS, Knoll MD, Jones A, Walker DG, Risko N, Gilani Z. Global status of Haemophilus influenzae type b and pneumococcal conjugate vaccines: evidence, policies, and introductions. Curr Opin Infect Dis. Jun 2010;23(3):236-41. [Medline].

  3. Byington CL, Kendrick J, Sheng X. Normative cerebrospinal fluid profiles in febrile infants. J Pediatr. Jan 2011;158(1):130-4. [Medline]. [Full Text].

  4. [Guideline] 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].

  5. [Best Evidence] Karageorgopoulos DE, Valkimadi PE, Kapaskelis A, Rafailidis PI, Falagas ME. Short versus long duration of antibiotic therapy for bacterial meningitis: a meta-analysis of randomised controlled trials in children. Arch Dis Child. Aug 2009;94(8):607-14. [Medline].

  6. AAP. Pickering LK, Baker CJ, Kimberlin DW, et al eds. 2009 Red Book. 28th ed. American Academy of Pediatrics; 2009.

  7. van de Beek D, Brouwer MC. No difference between short-course and long-course antibiotics for bacterial meningitis in children, but available evidence limited. Evid Based Med. Feb 2010;15(1):6-7. [Medline].

  8. Molyneux E, Nizami SQ, Saha S, et al. 5 versus 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Lancet. May 28 2011;377(9780):1837-45. [Medline].

  9. van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2007;(1):CD004405. [Medline].

  10. [Guideline] 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].

  11. [Guideline] 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].

  12. Ahmed A. A critical evaluation of vancomycin for treatment of bacterial meningitis. Pediatr Infect Dis J. Sep 1997;16(9):895-903. [Medline].

  13. 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].

  14. 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].

  15. 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].

  16. Balagtas RC, Levin S, Nelson KE. Secondary and prolonged fevers in bacterial meningitis. J Pediatr. Dec 1970;77(6):957-64. [Medline].

  17. 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].

  18. 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].

  19. 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].

  20. 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].

  21. Chavez-Bueno S, McCracken GH. Bacterial meningitis in children. Pediatr Clin North Am. Jun 2005;52(3):795-810, vii. [Medline].

  22. 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].

  23. Erickson L, DeWals P. Complications and sequelae of meningococcal disease in Quebec, Canada, 1990-1994. Clin Inf Dis. 1998;26:1159-1164. [Medline].

  24. Franco SM, Cornelius VE, Andrews BF. Long-term outcome of neonatal meningitis. Am J Dis Child. May 1992;146(5):567-71. [Medline].

  25. Kaplan SL, Fishman MA. Supportive therapy for bacterial meningitis. Pediatr Infect Dis J. Jul 1987;6(7):670-7. [Medline].

  26. 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].

  27. 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].

  28. Kumar A, Kumar K. Rapid laboratory diagnosis of infectious diseases. Prim Care. Dec 1981;8(4):593-604. [Medline].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

  33. 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].

  34. 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].

  35. 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].

  36. Nelson JD, McCracken GH. Treatment of neonatal meningitis. Pediatr Infect Dis J. Jul 2005;24(7).

  37. [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].

  38. 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].

  39. 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].

  40. Prasad K, Karlupia N. Prevention of bacterial meningitis: an overview of Cochrane systematic reviews. Respir Med. Oct 2007;101(10):2037-43. [Medline].

  41. 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].

  42. 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].

  43. 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].

  44. 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].

  45. 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].

  46. Segal S, Pollard AJ. The future of meningitis vaccines. Hosp Med. Mar 2003;64(3):161-7. [Medline].

  47. Segal S, Pollard AJ. Vaccines against bacterial meningitis. Br Med Bull. 2004;72:65-81. [Medline].

  48. 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].

  49. Sivakmaran M. Meningococcal meningitis revisited: normocellular CSF. Clin Pediatr (Phila). Jun 1997;36(6):351; discussion 351-5. [Medline].

  50. 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].

  51. Swartz MN. Bacterial meningitis--a view of the past 90 years. N Engl J Med. Oct 28 2004;351(18):1826-8. [Medline].

  52. 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].

  53. 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].

  54. Tauber MG. To tap or not to tap?. Clin Infect Dis. Aug 1997;25(2):289-91. [Medline].

  55. 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].

  56. 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].

  57. 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].

  58. Yogev R, Guzman-Cottrill J. Bacterial meningitis in children: critical review of current concepts. Drugs. 2005;65(8):1097-112. [Medline].

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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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