Diagnostic Considerations

A definitive diagnosis of meningitis requires examination of cerebrospinal fluid (CSF) via lumbar puncture. The presence or absence of classic meningeal signs and symptoms should not be used as the sole criteria for referring patients for further diagnostic testing.^[16]

Missed meningitis is one of the most frequent lawsuits in pediatrics, leading to large claims. Therefore, a high index of suspicion is needed and accurate charting of pertinent positive and negative findings is crucial. Missed meningitis is second only to missed myocardial infarction in total damages per year. Many lawsuits are filed even though treatment was promptly instituted because of the frequency of neurologic sequelae.

Delay in initiating antibiotic therapy has resulted in lawsuits. Even though morbidity is known to be associated with even the most prompt and appropriate therapy, if there are sequelae and antibiotics were delayed, the clinician will be at a disadvantage if legal action is taken.

Partially treated meningitis is difficult to diagnose; therefore, children on antibiotics should be carefully evaluated. Children who have partially treated meningitis or develop it while on antibiotics have modified signs and symptoms, and the diagnosis is usually delayed.

Besides the conditions listed in the differential diagnosis, other problems to be considered include the following:

Brain abscess
Subdural/epidural abscess
Brain tumors
Central nervous system (CNS) leukemia
Lead encephalopathy
CNS tuberculosis
Hypersensitivity to drugs (eg, trimethoprim-sulfamethoxazole, intravenous immune globulin, and antithymocyte globulin)
Disorders associated with vasculitis (eg, Kawasaki disease and collagen vascular disease)

Workup

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Media Gallery

Acute bacterial meningitis. This axial nonenhanced CT scan shows mild ventriculomegaly and sulcal effacement.
Acute bacterial meningitis. This axial T2-weighted MRI shows only mild ventriculomegaly.
Acute bacterial meningitis. This contrast-enhanced, axial T1-weighted MRI shows leptomeningeal enhancement (arrows).

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Table 1. Antibiotic Dosages for Neonatal Bacterial Meningitis, Adjusted by Weight and Age

Antibiotic	Route	Dosage
Antibiotic	Route	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
Penicillins
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
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

Table 2. Antibiotics for Neonatal Bacterial Meningitis That Must Be Dosed According to Serum levels

Antibiotic	Route	Desired Serum level, µg/mL	Dosage
Antibiotic	Route	Desired Serum level, µg/mL	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*
Aminoglycosides
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
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.

Table 3. Dosages and Dosing Intervals for Intravenous Antimicrobials in Infants and Children With Bacterial Meningitis

Antibiotic	IV Dosage	Maximum Daily Dose	Dosing Interval
Ampicillin	400 mg/kg/day	6-12 g	q6h
Vancomycin	60 mg/kg/day	2-4 g	q6h
Penicillin G	400,000 U/kg/day	24 million U	q6h
Cefotaxime	200-300 mg/kg/day	8-10 g	q6h
Ceftriaxone	100 mg/kg/day	4 g	q12h
Ceftazidime	150 mg/kg/day	6 g	q8h
Cefepime*	150 mg/kg/day	2-4 g	q8h
Imipenem†	60 mg/kg/day	2-4 g	q6h
Meropenem	120 mg/kg/day	4-6 g	q8h
Rifampin	20 mg/kg/day	600 mg	q12h
*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.

Table 4. Chemoprophylaxis for Bacterial Meningitis Caused by Haemophilus influenzae or Neisseria meningitidis

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
		< 1 month	>10 mg/kg PO qd for 4 days
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
	Ceftriaxone	>15 years	250 mg IM once
		=15 years	>125 mg IM once
	Ciprofloxacin	=18 years	>500 mg PO once

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Author

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics, Novavax, Regeneron, Diassess, Actelion<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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