History
Symptoms of neonatal bacterial meningitis are nonspecific and include the following:
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Poor feeding
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Lethargy
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Irritability
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Apnea
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Listlessness
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Apathy
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Fever
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Hypothermia
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Seizures
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Jaundice
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Bulging fontanelle
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Pallor
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Shock
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Hypotonia
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Shrill cry
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Hypoglycemia
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Intractable metabolic acidosis
The following symptoms are readily recognized as associated with meningitis in infants and children:
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Nuchal rigidity
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Opisthotonos
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Bulging fontanelle
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Convulsions
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Photophobia
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Headache
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Alterations of the sensorium
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Irritability
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Lethargy
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Anorexia
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Nausea
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Vomiting
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Coma
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Fever (generally present, although some severely ill children present with hypothermia)
The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
Meningitis in the neonatal period is associated with maternal infection or pyrexia at delivery. A child younger than 3 months may have very nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high-pitched cry, or seizures. Meningismus and a bulging fontanel may be observed but are not needed for diagnosis. A child who is quiet at rest but who cries when moved or comforted may have meningeal irritation (paradoxical irritability).
After the age of 3 months, the child may display symptoms more often associated with bacterial meningitis, with fever, vomiting, irritability, lethargy, or any change in behavior. After the age of 2-3 years, children may complain of headache, stiff neck, and photophobia.
The clinical course may be brief and fulminant with rapid progression of symptoms or may follow a more gradual course with several days of upper respiratory infection progressing to more severe symptoms. The fulminant course is more often associated with N meningitidis infection.
Signs and symptoms in patients with listerial meningitis tend to be subtle, and diagnosis is often delayed.
Note that patients also may have other foci of infection. The presenting symptoms may point toward those foci, causing unnecessary delay in diagnosis of bacterial meningitis.
Physical Examination
Physical examination findings vary widely, depending on the infecting organism and the patient’s age. In general, the younger the child, the less specific the symptoms. As the child grows older, the physical examination becomes more reliable.
Neonates
A high index of suspicion and awareness of risk factors usually results in early diagnosis and prompt treatment of bacterial meningitis in neonates. Cardinal signs of meningitis (eg, fever, vomiting, stiff neck) are rarely present. For neonatal meningitis, these signs are the exception rather than the rule.
Infants and children
Kernig and Brudzinski signs are helpful indicators when present, but they may be absent (along with nuchal rigidity) in very young, debilitated, or malnourished infants. Skin findings range from a nonspecific blanching, erythematous, maculopapular rash to a petechial or purpuric rash, most characteristic of meningococcal meningitis.
Patients may also have other foci of infection. Presenting symptoms may point toward those foci, causing unnecessary delay in diagnosis of bacterial meningitis.
Approximately 15% of patients have focal neurologic signs upon diagnosis. The presence of focal neurologic signs predicts a complicated hospital course and significant long-term sequelae.
Generalized or focal seizures are observed in as many as 33% of patients. Seizures that occur during the first 3 days of illness usually have little prognostic significance. However, prolonged or difficult-to-control seizures, especially when observed beyond the fourth hospital day, are predictors of a complicated hospital course with serious sequelae.
In later stages of the disease, a few patients develop focal central nervous system (CNS) symptoms and other systemic signs (eg, fever) indicating a significant collection of fluid in the subdural space. Incidence of subdural effusion is independent of the bacterial organism causing meningitis.
Obtundation and coma occur in 15-20% of patients and are more frequent with pneumococcal meningitis.
Approximately 6% of affected infants and children show signs of disseminated intravascular coagulation (DIC) and endotoxic shock. These signs are indicative of a poor prognosis.
Complications
Seizures 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 that can be seen during the course of bacterial meningitis include the syndrome of inappropriate antidiuretic hormone secretion (SIADH), subdural effusions, and brain abscesses. Subdural effusions are generally asymptomatic and resolve without neurologic sequelae.
Long-term sequelae are seen in as many as 30% of children; they vary according to the infecting organism, the patient’s age, the presenting features, and the hospital course. Long-term close follow-up care of children is crucial for the early detection of sequelae.
Although most patients have subtle CNS changes, serious complications are occasionally 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.
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 Hib meningitis. Severe hearing impairment interferes with the development of normal speech; thus, frequent audiologic evaluation and developmental assessment must be performed during healthcare visits.
Whenever motor sequelae are detected, physical, occupational, and rehabilitation services should evaluate the patient to prevent further damage and to provide optimal functional status.
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Acute bacterial meningitis. This axial nonenhanced CT scan shows mild ventriculomegaly and sulcal effacement.
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Acute bacterial meningitis. This axial T2-weighted MRI shows only mild ventriculomegaly.
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Acute bacterial meningitis. This contrast-enhanced, axial T1-weighted MRI shows leptomeningeal enhancement (arrows).
Tables
- Table 1. Antibiotic Dosages for Neonatal Bacterial Meningitis, Adjusted by Weight and Age
- Table 2. Antibiotics for Neonatal Bacterial Meningitis That Must Be Dosed According to Serum levels
- Table 3. Dosages and Dosing Intervals for Intravenous Antimicrobials in Infants and Children With Bacterial Meningitis
- Table 4. Chemoprophylaxis for Bacterial Meningitis Caused by Haemophilus influenzae or Neisseria meningitidis
Antibiotic |
Route |
Dosage |
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Birth Weight < 2000 g, Age 0-7 Days |
Birth Weight >2000 g, Age 0-7 Days |
Birth Weight < 2000 g, Age >7 Days |
Birth Weight >2000 g, Age >7 Days |
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Penicillins |
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Ampicillin |
IV, IM |
50 mg/kg q12h |
50 mg/kg q8h |
50 mg/kg q8h |
50 mg/kg q6h |
Penicillin G |
IV |
50,000 U/kg q12h |
50,000 U/kg q8h |
50,000 U/kg q8h |
50,000 U/kg q6h |
Oxacillin |
IV, IM |
50 mg/kg q12h |
50 mg/kg q8h |
50 mg/kg q8h |
50 mg/kg q6h |
Ticarcillin |
IV, IM |
75 mg/kg q12h |
75 mg/kg q8h |
75 mg/kg q8h |
75 mg/kg q6h |
Cephalosporins |
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Cefotaxime |
IV, IM |
50 m mg/kg g q12h |
50 mg/kg q8h |
50 mg/kg q8h |
50 mg/kg q6h |
Ceftriaxone |
IV, IM |
50 mg/kg qd |
50 mg/kg qd |
50 mg/kg qd |
75 mg/kg qd |
Ceftazidime |
IV, IM |
50 mg/kg q12h |
50 mg/kg q8h |
50 mg/kg q8h |
50 mg/kg q8h |
Antibiotic |
Route |
Desired Serum level, µg/mL |
Dosage |
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Birth Weight < 2000 g, Age 0-7 Days* |
Birth Weight >2000 g, Age 0-7 Days* |
Birth Weight < 2000 g, Age >7 Days* |
Birth Weight >2000 g, Age >7 Days* |
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Aminoglycosides |
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Amikacin† |
IV, IM |
20-30 (peak), < 10 (trough) |
7.5 mg/kg q12h |
10 mg/kg q12h |
10 mg/kg q8h |
10 mg/kg q8h |
Gentamicin† |
IV, IM |
5-10 (peak), < 2.5 (trough) |
2.5 mg/kg q12h |
2.5 mg/kg q12h |
2.5 mg/kg q8h |
2.5 mg/kg q8h |
Tobramycin† |
IV, IM |
5-10 (peak), < 2.5 (trough) |
2.5 mg/kg q12h |
2.5 mg/kg q12h |
2.5 mg/kg q8h |
2.5 mg/kg q8h |
Glycopeptide |
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Vancomycin*† |
IV, IM |
20-40 (peak), < 10 (trough) |
15 mg/kg q12h |
15 mg/kg q8h |
15 mg/kg q8h |
15 mg/kg q6h |
*The dosage stated is the highest within the dosage range. † Serum levels must be monitored when patient has kidney disease or is receiving other nephrotoxic drugs; adjust doses accordingly. |
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Antibiotic |
IV Dosage |
Maximum Daily Dose |
Dosing Interval |
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Ampicillin |
400 mg/kg/day |
6-12 g |
q6h |
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Vancomycin |
60 mg/kg/day |
2-4 g |
q6h |
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Penicillin G |
400,000 U/kg/day |
24 million U |
q6h |
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Cefotaxime |
200-300 mg/kg/day |
8-10 g |
q6h |
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Ceftriaxone |
100 mg/kg/day |
4 g |
q12h |
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Ceftazidime |
150 mg/kg/day |
6 g |
q8h |
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Cefepime* |
150 mg/kg/day |
2-4 g |
q8h |
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Imipenem† |
60 mg/kg/day |
2-4 g |
q6h |
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Meropenem |
120 mg/kg/day |
4-6 g |
q8h |
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Rifampin |
20 mg/kg/day |
600 mg |
q12h |
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*Experience with this agent in pediatric patients is minimal; it is not licensed for treatment of meningitis. † Because of possible seizures, this agent must be used with caution in treating meningitis. |
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Causative Organism |
Drug Name |
Age of Contact |
Dosage |
Haemophilus influenzae |
Rifampin |
Adults |
>600 mg PO qd for 4 days |
|
=1 month |
20 mg/kg PO qd for 4 days; not to exceed 600 mg/dose |
|
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< 1 month |
>10 mg/kg PO qd for 4 days |
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Neisseria meningitidis |
Rifampin |
Adults |
600 mg PO q12h for 2 days |
|
>1 month |
10 mg/kg PO q12h for 2 days; not to exceed 600 mg/dose |
|
|
=1 month |
>5 mg/kg PO q12h for 2 days |
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Ceftriaxone |
>15 years |
250 mg IM once |
|
|
=15 years |
>125 mg IM once |
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Ciprofloxacin |
=18 years |
>500 mg PO once |
