Bacterial Meningitis - Paediatric

Quick Answer

Paediatric bacterial meningitis is a medical emergency requiring immediate antibiotics after blood cultures. Time to antibiotics is a critical quality metric (target below 60 minutes). Key clinical features include fever, irritability, lethargy, and meningeal signs (neck stiffness in older children; bulging fontanelle in infants). Lumbar puncture is the diagnostic gold standard but never delay antibiotics for LP in unstable patients. Empirical therapy: ceftriaxone (or cefotaxime) + vancomycin (+ ampicillin for neonates). Complications include hearing loss, neurological deficits, and hydrocephalus. Post-discharge follow-up includes audiology and neurodevelopmental assessment.

ACEM Exam Focus

Written Exams (SAQ/MCQ):

• Distinguish bacterial vs viral meningitis (CSF findings, clinical features)
• Age-specific pathogens (neonates vs infants vs older children)
• Empirical antibiotic selection and dosing
• Indications for CT brain before lumbar puncture
• Management of meningococcal septicaemia
• Interpretation of CSF results
• Complications and long-term sequelae

Viva:

• Immediate management priorities in a febrile child with petechiae
• When to delay lumbar puncture
• Fluid management controversies in SIADH
• Antibiotic choices based on age and risk factors
• Breaking bad news to parents (severe outcomes)
• Management of suspected meningococcal exposure in contacts

OSCE:

• Paediatric resuscitation (septic shock)
• Lumbar puncture procedure
• Communication: Breaking bad news
• Communication: Explaining diagnosis and treatment to parents

Key Points

1. Never delay antibiotics for lumbar puncture - Draw blood cultures, give antibiotics, then perform LP if safe
2. Age-specific pathogens: Neonates (GBS, E. coli, Listeria), 1-23 months (S. pneumoniae, N. meningitidis, Hib), greater than 2 years (S. pneumoniae, N. meningitidis)
3. Add ampicillin for neonates below 3 months (Listeria coverage)
4. Add vancomycin for penicillin-resistant pneumococcus (especially in regions with high resistance)
5. Meningococcal rash progression: Petechiae → Purpura → Ecchymosis → Necrosis; rapid progression signals severe disease
6. CSF interpretation: Bacterial (high WBC, neutrophil predominance, low glucose below 2.2 mmol/L, high protein) vs Viral (low WBC, lymphocyte predominance, normal glucose, normal/mild protein)
7. Complications: Hearing loss (20-30%), neurological deficits (10-15%), subdural effusion, hydrocephalus, seizures
8. Prophylaxis for contacts: Rifampicin for meningococcal; Rifampicin or Ciprofloxacin for Hib; household/daycare contacts

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Epidemiology

Incidence and Trends

• Overall incidence: 0.6-2.6 per 100,000 children per year in developed countries
• Highest risk: below 3 months (neonates) and 3-36 months (post-neonatal period)
• Seasonality: Winter/early spring peaks for pneumococcal and meningococcal meningitis
• Vaccine impact: Significant reduction in Hib and pneumococcal meningitis following conjugate vaccine introduction
• Gender: Male predominance (M:F ratio ~1.5:1)

Mortality and Morbidity

• Overall mortality: 4-10% in resource-rich settings
• Neonatal mortality: 15-25% (higher due to immature immune system)
• Morbidity:
  • "Hearing loss: 20-30%"
  • "Neurological deficits: 10-15% (cognitive impairment, motor deficits, seizures)"
  • "Hydrocephalus: 5-10%"
  • "Subdural effusion/empyema: 3-5%"

Risk Factors

Host factors:

• Age below 3 months (immature immunity, maternal antibody waning)
• Asplenia (functional or surgical)
• Complement deficiency
• Immunodeficiency (HIV, primary immunodeficiency)
• Sickle cell disease
• Recent respiratory/viral infection (predisposes to bacterial invasion)
• Head trauma with skull base fracture (CSF leak)
• Cochlear implant

Environmental factors:

• Crowded living conditions (increased transmission)
• Daycare attendance
• Low socioeconomic status
• Passive smoke exposure
• Lack of vaccination

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Pathophysiology

Bacterial Invasion

Routes of entry:

1. Haematogenous spread (most common): Bacteria colonise nasopharynx → invade bloodstream → cross blood-brain barrier (BBB) → infect meninges
2. Direct extension: From otitis media, sinusitis, mastoiditis, skull fracture
3. Iatrogenic: Following neurosurgery, ventricular shunts, cochlear implants

Pathogen colonisation:

• Neisseria meningitidis: Nasopharyngeal colonisation in 5-10% of population; higher in crowded settings
• Streptococcus pneumoniae: Nasopharyngeal colonisation; particularly virulent serotypes (6B, 9V, 14, 19F, 23F)
• Haemophilus influenzae type b: Nasopharyngeal colonisation (before vaccine era)

Blood-Brain Barrier Breach

Mechanisms:

• Bacterial factors: Pili, capsules (avoid phagocytosis), lipopolysaccharide (LPS), porins
• Host factors: Cytokine-mediated increased BBB permeability, endothelial cell damage

Key mediators:

• Tumour necrosis factor-alpha (TNF-α)
• Interleukin-1 (IL-1)
• Interleukin-6 (IL-6)
• Prostaglandins (cause fever)
• Nitric oxide (vasodilation, hypotension)

Inflammatory Cascade

Cerebral oedema:

1. Cytotoxic oedema: Inflammatory mediators disrupt neuronal metabolism, intracellular swelling
2. Vasogenic oedema: BBB breakdown, protein-rich fluid extravasation
3. Interstitial oedema: Impaired CSF absorption (CSF outflow obstruction)

Increased ICP:

• Cerebral oedema + CSF outflow obstruction + hyperaemia
• Consequences: Cerebral perfusion pressure (CPP) decline, herniation risk

Cerebral vasculitis:

• Inflammatory cell infiltration of vessel walls
• Vasospasm → ischaemia
• Thrombosis → infarction

Age-Specific Immunology

Neonates (below 3 months):

• Immature humoral immunity (low IgG, poor antibody production)
• Reduced complement activity
• Impaired neutrophil chemotaxis and phagocytosis
• Higher risk of Gram-negative organisms (E. coli, Klebsiella)

Infants 1-23 months:

• Transient hypogammaglobulinaemia (6-12 months) as maternal antibodies wane
• Developing adaptive immunity
• High exposure risk (daycare, siblings)

Older children (greater than 2 years):

• More mature immune system
• Better antibody response to vaccines
• Lower incidence of meningitis compared to younger age groups

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Clinical Presentation

Age-Specific Features

Neonates (below 3 months):

• Non-specific presentation: Fever (may be absent), lethargy, poor feeding, irritability, apnoea, seizures
• Meningeal signs: Often absent; bulging fontanelle may be present
• Shock: Tachycardia, poor perfusion, prolonged capillary refill
• High index of suspicion: Any febrile neonate with lethargy or irritability warrants sepsis evaluation

Infants 3-12 months:

• Fever, irritability, inconsolable crying
• Poor feeding, vomiting
• Bulging fontanelle
• Seizures (may be presenting feature)
• Neck stiffness difficult to assess

Toddlers 1-3 years:

• Fever, headache (may express as "hurt head")
• Nuchal rigidity (can assess by limiting neck flexion)
• Photophobia (squinting, avoiding light)
• Vomiting, irritability
• Altered mental status (lethargy, confusion)
• Petechial rash (meningococcal)

Older children (greater than 3 years):

• Classic triad (present in ~30-40%): Fever, headache, nuchal rigidity
• Photophobia
• Altered mental status (confusion, decreased consciousness)
• Seizures (10-20%)
• Focal neurological deficits (3-5%)

Physical Examination

General appearance:

• "Toxic" appearance (bacterial meningitis)
• Lethargy, irritability, drowsiness
• Poor eye contact, disinterested in surroundings

Vital signs:

• Fever (usually greater than 38.5°C, though may be absent in neonates)
• Tachycardia
• Tachypnoea (respiratory alkalosis from metabolic acidosis, or meningitic breathing)
• Hypotension (late sign, indicates shock)

Neurological examination:

• Altered mental status (GCS assessment)
• Meningeal signs:
  • Nuchal rigidity (limited neck flexion, pain on flexion)
  • Kernig's sign (pain on knee extension with hip flexed at 90°)
  • Brudzinski's sign (involuntary hip flexion on neck flexion)
• Focal neurological deficits (cranial nerve palsies, hemiparesis)
• Seizure activity (focal or generalised)
• Fundoscopy: Papilloedema (increased ICP - rare in early presentation)

Dermatological findings (meningococcal):

• Petechiae: Non-blanching, 1-2 mm, pinprick-sized
• Purpura: Larger, greater than 2 mm, non-blanching
• Ecchymosis: Bruise-like, larger
• Progression: Rapid (within hours); new lesions appearing
• Distribution: Trunk, extremities, pressure areas
• Mucosal involvement: Conjunctivae, palate (poor prognostic sign)
• Gangrene: Peripheral (fingers, toes) in severe disseminated intravascular coagulation (DIC)

Other findings:

• Bulging fontanelle (infants)
• Anterior fontanelle tension assessment
• Hydration status (important for fluid management)

Meningococcal Septicaemia vs Meningitis

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Differential Diagnosis

Viral vs Bacterial Meningitis

Other Differentials

Viral encephalitis:

• Altered mental status (confusion, personality change) more prominent than meningeal signs
• Focal neurological deficits, focal seizures
• EEG abnormalities
• CSF: Lymphocytic predominance, normal glucose

Partially treated bacterial meningitis:

• History of recent oral antibiotics
• Less fulminant presentation
• CSF may show atypical findings (lower WBC, mixed cell picture)
• Culture may be negative (PCR still useful)

Tuberculous meningitis:

• Subacute onset (days to weeks)
• Constitutional symptoms (weight loss, night sweats)
• Cranial nerve palsies
• CSF: Very high protein (greater than 150 mg/dL), very low glucose (below 2.2 mmol/L), lymphocytic predominance

Fungal meningitis:

• Immunocompromised hosts
• Subacute/chronic course
• Cryptococcus: India ink preparation positive
• CSF: High opening pressure, lymphocytic predominance, low glucose

Brain abscess:

• Focal neurological signs
• Headache, vomiting
• CT/MRI shows ring-enhancing lesion
• CSF: May be normal if abscess not ruptured into ventricle

Non-infectious mimics:

• Kawasaki disease: Fever, rash, conjunctivitis, extremity changes
• Henoch-Schönlein purpura: Palpable purpura, abdominal pain, arthralgia
• Immune thrombocytopenic purpura (ITP): Isolated thrombocytopenia, otherwise well
• Systemic lupus erythematosus (SLE): Multi-system involvement

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Investigations

Initial Assessment

Immediate (within first 15 minutes):

• Blood glucose (fingerprick or venous)
• Bedside capillary blood gas (if available)
• Point-of-care lactate (if available)

Blood tests (before antibiotics):

• Full blood count (FBC) with differential
  • Leukocytosis (WBC greater than 15 × 10⁹/L) common
  • Leukopenia (WBC below 4 × 10⁹/L) - poor prognostic sign
• Blood cultures (x2 sets) - critical before antibiotics
  • Positive in 40-60% of bacterial meningitis cases
• C-reactive protein (CRP) - elevated (greater than 50 mg/L) in bacterial infection
• Serum electrolytes, urea, creatinine
• Liver function tests (baseline before antibiotics)
• Coagulation profile (PT/APTT/INR, fibrinogen) - especially if purpuric rash
• Serum glucose (for CSF glucose ratio interpretation)
• Blood group and crossmatch (may need transfusion)

Meningococcal PCR (blood):

• Highly sensitive and specific (greater than 95%)
• Remains positive for several days after antibiotics
• Results faster than culture (hours vs days)

Lumbar Puncture

Indications:

• Suspected bacterial meningitis in stable patient
• Fever + meningeal signs
• Fever + altered mental status (after CT if indicated)
• Fever + seizures (after CT if indicated)

Contraindications (perform CT first):

• Absolut e:
  • "Signs of raised ICP: Papilloedema, Cushing's triad (bradycardia, hypertension, irregular respirations)"
  • Focal neurological deficits
  • Cardiovascular instability/shock (stabilise first)
  • Coagulopathy (INR greater than 1.5, platelets below 50 × 10⁹/L) unless corrected
  • Infection at puncture site
• Relative:
  • Reduced level of consciousness (GCS below 13)
  • New-onset seizures
  • Space-occupying lesion on CT

Procedure:

• Position: Lateral decubitus with flexed knees (or seated for obese/older children)
• Landmark: L3-L4 or L4-L5 interspace (line connecting iliac crests)
• Spinal needle size: 22G (infants), 21G (children), 20G (older children)
• Measure opening pressure (optional but recommended)
• Collect CSF (typically 4 tubes):
  • "Tube 1: Chemistry (glucose, protein)"
  • "Tube 2: Microbiology (Gram stain, culture)"
  • "Tube 3: Haematology (cell count, differential)"
  • "Tube 4: Special studies (viral PCR, TB PCR, fungal studies if indicated)"

CSF Analysis - Normal Values:

CSF Analysis - Bacterial vs Viral:

CSF Culture and PCR:

• Bacterial culture (gold standard): 48-72 hours
• Bacterial PCR (meningococcus, pneumococcus, Hib): Faster, more sensitive if antibiotics given
• Viral PCR panel (enterovirus, HSV, VZV, parechovirus): Exclude viral aetiology
• TB PCR: If suspected (subacute course, risk factors)
• Fungal studies: If immunocompromised

Neuroimaging

CT Head (non-contrast) - Indications:

• Focal neurological deficits
• Papilloedema (signs of raised ICP)
• Seizures (especially focal)
• Decreased level of consciousness (GCS below 13)
• Immunocompromised host
• Suspected intracranial complication (subdural empyema, abscess)

Findings in bacterial meningitis:

• Often normal early in disease course
• Later: Hydrocephalus, subdural effusion, cerebral oedema
• Don't delay antibiotics for CT - give antibiotics first

MRI (with contrast):

• More sensitive for early complications
• Detects venous sinus thrombosis, cerebral infarction, early cerebritis
• Consider if atypical presentation or neurological deterioration

Other Investigations

Chest X-ray:

• Source of infection (pneumonia)
• Baseline before intubation

Urinalysis and culture:

• Exclude urinary tract infection (especially in neonates)

ECG:

• Baseline before certain antibiotics (e.g., fluoroquinolones, though rarely used in paediatrics)

Hearing assessment:

• Baseline audiology (otoacoustic emissions or ABR)
• Follow-up at 4-6 weeks post-discharge

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Management

Immediate Management (First Hour)

ABCDE Approach:

A - Airway:

• Assess airway patency
• Position: Head-neutral, sniffing position
• Suction if secretions present
• Prepare for intubation if GCS below 8 or respiratory failure

B - Breathing:

• Oxygen via face mask (target SpO2 94-98%)
• Monitor respiratory rate, work of breathing
• Blood gas if available
• Prepare for mechanical ventilation if respiratory failure or decreased GCS

C - Circulation:

• IV access: Two large-bore cannulae (minimum 22G infants, 18G older children)
• Fluid bolus: 10-20 mL/kg isotonic crystalloid (0.9% saline or Hartmann's) if signs of shock
  • Repeat if needed (up to 60 mL/kg)
• Inotropes if shock persists after fluid resuscitation (adrenaline/noradrenaline infusion)
• Monitor: Blood pressure, capillary refill time, urine output

D - Disability:

• GCS assessment
• Pupil size and reactivity
• Blood glucose (treat hypoglycaemia below 3 mmol/L)
• Seizure management: Benzodiazepines (midazolam 0.1 mg/kg IV/IO or buccal) for active seizures
  • Phenytoin 20 mg/kg IV loading if recurrent seizures

E - Exposure/Environment:

• Full examination including skin (rash, purpura)
• Temperature control (antipyretics if greater than 39°C)
• Maintain normothermia (36-37.5°C)

Antibiotic Therapy

Principles:

• Never delay antibiotics for investigations
• Draw blood cultures first, then give antibiotics immediately
• Target door-to-antibiotic time below 60 minutes
• IV route preferred (ensure adequate dosing)

Empirical Antibiotic Selection by Age:

Neonatal dosing specifics:

• Ampicillin: 50 mg/kg IV every 6 hours
  • "Target: 200 mg/kg/day"
• Cefotaxime: 50 mg/kg IV every 6-8 hours
  • "Target: 150-200 mg/kg/day"
• Gentamicin: 5 mg/kg IV once daily (for synergy with ampicillin in GBS/E. coli)
  • Monitor trough levels (aim below 2 mg/L)
  • Adjust for renal impairment

Infant and child dosing specifics:

• Ceftriaxone:
  • 50 mg/kg IV every 12 hours (max 2g per dose, 4g/day)
  • "For meningitis: 100 mg/kg/day divided q12h"
  • Continue for 7-10 days (or longer depending on pathogen and clinical course)
• Cefotaxime (alternative to ceftriaxone in neonates/infants below 3 months):
  • 50 mg/kg IV every 6 hours (max 2g per dose, 200-300 mg/kg/day)
• Vancomycin:
  • 15 mg/kg IV every 6 hours (max 500 mg per dose in children, 1g in adolescents)
  • Monitor trough levels (aim 15-20 mg/L for meningitis)
  • Adjust for renal impairment
  • Discontinue if penicillin-sensitive pneumococcus confirmed

Pathogen-directed therapy (once identified):

Special considerations:

• Penicillin allergy:
  • "Mild rash: Continue cephalosporin (cross-reactivity below 2%)"
  • "Anaphylaxis: Vancomycin + Aztreonam (for Gram-negative coverage) OR Meropenem"
• Renal impairment: Adjust antibiotic doses (especially vancomycin, aminoglycosides)
• Meningitis with shunt or neurosurgical device: Add Vancomycin (covers MRSA) + Ceftazidime or Meropenem (covers Pseudomonas)

Adjunctive Therapy

Corticosteroids:

• Dexamethasone 0.15 mg/kg IV q6h (max 10 mg per dose)
• Indications: Suspected or proven pneumococcal meningitis (especially in children)
• Timing: First dose should be given before or with first antibiotic dose (within 30-60 minutes)
• Rationale: Reduces hearing loss and neurological sequelae by modulating inflammatory response
• Duration: 2-4 days (controversial - stop if meningococcal disease identified)
• Contraindications: TB, fungal meningitis, gastrointestinal bleeding

Antipyretics:

• Paracetamol 15 mg/kg PO/PR q4-6h (max 60 mg/kg/day)
• Ibuprofen 5-10 mg/kg PO q6-8h (max 30 mg/kg/day)
• Avoid ASA (Reye's syndrome)

Anticonvulsants:

• Prophylaxis not routinely recommended
• Treat active seizures (benzodiazepines, then load with phenytoin/levetiracetam)
• Consider maintenance anticonvulsants if recurrent seizures or status epilepticus

Fluid Management

Controversy and Guidelines:

Traditional approach (restrictive fluids):

• Maintain at 50-75% of maintenance fluids
• Rationale: Prevent cerebral oedema from SIADH
• SIADH incidence in bacterial meningitis: 30-50%

Current evidence (liberal vs restrictive):

• Recent RCTs show no benefit of fluid restriction
• May worsen hypotension, reduce cerebral perfusion
• Recommendation: Maintain at 100% maintenance fluids, adjusting for:
  • Degree of dehydration (often present due to fever, vomiting, decreased intake)
  • Ongoing losses (vomiting, diarrhoea)
  • Serum sodium (monitor daily)

Fluid choice:

• 0.9% saline or 5% dextrose in 0.9% saline (most commonly used)
• Add potassium when urine output established and serum K+ normal
• Avoid hypotonic fluids (risk of cerebral oedema)

Monitoring:

• Daily weights
• Strict input/output
• Serum sodium, potassium, urea, creatinine, glucose
• Urine sodium and osmolality if SIADH suspected

Management of SIADH:

• Fluid restriction only if:
  • Serum Na+ below 130 mmol/L
  • Euvolaemic or hypervolaemic
  • Urine Na+ greater than 40 mmol/L
  • Urine osmolality greater than 100 mOsm/kg
• Target: Maintain serum Na+ 130-135 mmol/L (correct slowly, below 0.5 mmol/L/hour)
• Severe hyponatraemia (below 120 mmol/L): Consider hypertonic saline (3% NaCl)

Supportive Care

Oxygen and ventilation:

• Maintain SpO2 94-98%
• Intubation indications:
  • GCS below 8
  • Respiratory failure (PaO2 below 60 mmHg on high-flow O2, PaCO2 greater than 50 mmHg)
  • Inability to protect airway
  • Seizures requiring airway protection

Nutrition:

• Enteral nutrition preferred (NG or NJ tube) once haemodynamically stable
• Parenteral nutrition if enteral not possible

Analgesia and sedation:

• Pain relief (headache, myalgia)
• Sedation for intubated patients (midazolam infusion, morphine infusion)

DVT prophylaxis:

• Consider in adolescents (low molecular weight heparin) if immobilised
• Not typically needed in younger children

Pressure area care:

• Regular position changes
• Skin inspection

Complications Management

Increased intracranial pressure:

• Head elevation 30°
• Maintain normocapnia (PaCO2 35-45 mmHg)
• Osmotic therapy (mannitol 0.5-1 g/kg IV) if herniation risk
• Consider hypertonic saline (3% NaCl)
• Avoid routine hyperventilation (can worsen cerebral ischaemia)

Seizures:

• Acute management: Benzodiazepines (midazolam, diazepam)
• Load with antiepileptic (phenytoin 20 mg/kg, levetiracetam 20-60 mg/kg)
• EEG if recurrent or prolonged seizures

Subdural effusion/empyema:

• Conservative initially (most resolve with antibiotics)
• Neurosurgical drainage if:
  • Large collection causing mass effect
  • Persistent fever after 48-72h of appropriate antibiotics
  • Neurological deterioration

Hydrocephalus:

• Ventricular drainage (external ventricular drain) if acute
• Ventriculoperitoneal shunt if persistent

Sensorineural hearing loss:

• Baseline audiology assessment
• Follow-up audiology at 4-6 weeks
• Hearing aids/cochlear implant if severe loss

Growth and development:

• Neurodevelopmental follow-up
• Early intervention services if developmental delay detected

Isolation and Infection Control

Droplet precautions (for meningococcal meningitis):

• Mask within 1 metre
• Single room (or cohort)
• Continue for 24 hours after effective antibiotics started

Standard precautions (for other bacterial meningitis)

Notification:

• Notify public health authorities for:
  • Meningococcal disease (mandatory in Australia/NZ)
  • Hib (vaccine-preventable disease surveillance)

Contact Prophylaxis

Meningococcal disease:

• Indications: Close contacts (household, daycare, kissing contacts) within 7 days before illness onset
• Rifampicin:
  • "Adults: 600 mg PO q12h for 2 days"
  • "Children greater than 1 month: 10 mg/kg PO q12h for 2 days (max 600 mg)"
  • "Neonates below 1 month: 5 mg/kg PO q12h for 2 days"
• Alternatives:
  • Ciprofloxacin 500 mg PO single dose (adults)
  • Ceftriaxone 250 mg IM single dose (adults); 125 mg IM (children below 15 years)
• Note: Exclude contacts if they develop fever until cultured negative

Hib disease:

• Rifampicin 20 mg/kg/day PO single dose (max 600 mg) for 4 days
• All household contacts (including adults) if:
  • At least one unvaccinated child below 4 years in household
  • Immunosuppressed person in household

Other organisms: No routine prophylaxis needed

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Disposition and Follow-up

Admission Criteria

ICU/HDU admission:

• Shock requiring inotropes
• Decreased level of consciousness (GCS below 13)
• Seizures (status epilepticus, recurrent)
• Respiratory failure requiring ventilation
• Severe coagulopathy/DIC
• Comorbidities increasing risk (asplenia, immunodeficiency)

Ward admission:

• All confirmed bacterial meningitis
• Suspected bacterial meningitis pending culture results
• Children below 3 months (rule out sepsis)

Discharge (rare in initial presentation):

• CSF findings consistent with viral meningitis
• Well appearance, tolerating oral intake
• Reliable caregivers
• Clear safety-netting instructions

Duration of Antibiotics

Guideline-based duration:

• N. meningitidis: 5-7 days
• S. pneumoniae: 10-14 days (longer if complicated)
• Hib: 7-10 days
• Group B Strep: 14-21 days
• Gram-negative (E. coli, Klebsiella): 14-21 days
• Listeria: 21 days

Discharge considerations:

• Afebrile for 24-48 hours
• Clinically improving
• Able to tolerate oral medications (if completing oral course - rare in meningitis)
• IV access issues (consider PICC line for home IV therapy in select cases)

Follow-up

Immediate follow-up (within 1 week):

• Clinical review
• Blood tests (if indicated)
• IV line assessment

Audiology follow-up:

• Baseline (within first week)
• Follow-up at 4-6 weeks post-discharge
• Earlier if concerns (not responding to sounds, delayed speech)

Neurodevelopmental follow-up:

• For infants and young children
• Serial assessments over first 2 years
• Early intervention if developmental delay detected

Long-term complications:

• Hearing loss (20-30%)
• Cognitive impairment (10-15%)
• Motor deficits (5-10%)
• Seizure disorder (5-10%)
• Hydrocephalus (5-10%)

Vaccination and Prevention

Primary prevention:

• Routine childhood immunisations:
  • Hib vaccine (part of Pentavalent or Hexavalent)
  • Pneumococcal conjugate vaccine (PCV13)
  • Meningococcal ACWY conjugate vaccine (12 months)
  • Meningococcal B vaccine (Bexsero - from 2 months in Australia)
• High-risk groups:
  • "Asplenia: Pneumococcal, meningococcal, Hib"
  • "Immunodeficiency: As above + influenza annually"
  • "Complement deficiency: Meningococcal vaccines"
  • "Cochlear implant: Pneumococcal vaccines"

Secondary prevention:

• Chemoprophylaxis for close contacts (see above)
• Monitor exposed contacts for fever

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Pitfalls and Pearls

Common Pitfalls

1. Delaying antibiotics for lumbar puncture

   • Always give antibiotics first if LP cannot be performed immediately
   • Blood cultures remain positive for hours after antibiotics

2. Missing non-classical presentations in neonates

   • Fever may be absent or low-grade
   • Irritability, poor feeding, apnoea may be only signs
   • High index of suspicion needed in febrile neonates

3. Underestimating meningococcal septicaemia

   • Petechial rash can appear late or be subtle initially
   • Shock can develop rapidly (within hours)
   • "Well-appearing" child with fever and petechiae needs urgent assessment

4. Inadequate meningococcal prophylaxis

   • Forget to administer to close contacts
   • Rifampicin affects oral contraceptives - advise alternative contraception

5. Inappropriate fluid restriction

   • Fluid restriction may worsen hypotension and cerebral perfusion
   • Restrict fluids only if SIADH diagnosed with hyponatraemia

6. Missing raised ICP contraindications to LP

   • Papilloedema, focal neurological deficits, decreased consciousness
   • CT brain before LP in these cases

7. Omitting ampicillin in neonates

   • Listeria monocytogenes requires ampicillin coverage in below 3 months

8. Prematurely stopping vancomycin

   • Continue until penicillin sensitivity confirmed for pneumococcus
   • Rising resistance rates in many regions

9. Forgetting dexamethasone timing

   • Must be given before or with first antibiotics for maximal benefit
   • Most evidence for pneumococcal meningitis

10. Inadequate follow-up for hearing loss

    • Sensorineural hearing loss common (20-30%)
    • Early audiology assessment and intervention critical

Pearls

1. "Door to antibiotics" is a quality metric - aim for below 60 minutes

2. Meningococcal rash progression: Petechiae → Purpura → Ecchymosis → Gangrene - rapid progression signals severe disease

3. CSF glucose ratio: CSF glucose below 40% of serum glucose supports bacterial meningitis

4. Blood cultures: Positive in 40-60% of bacterial meningitis - critical for definitive diagnosis

5. Meningococcal PCR: Remains positive for days after antibiotics - send if culture-negative but high suspicion

6. Age-specific pathogens: Neonates (GBS, E. coli, Listeria), Infants (Pneumococcus, Meningococcus, Hib), Older children (Pneumococcus, Meningococcus)

7. Dexamethasone: 0.15 mg/kg IV q6h for 2-4 days, first dose before or with antibiotics for pneumococcal meningitis

8. SIADH management: Fluid restrict only if hyponatraemic (below 130 mmol/L), euvolaemic, with high urine sodium

9. Contact prophylaxis: Rifampicin for meningococcal (2 days) or Hib (4 days) close contacts

10. Hearing assessment: Baseline during admission, follow-up at 4-6 weeks post-discharge

11. Neonatal dosing: Cefotaxime preferred over ceftriaxone in below 3 months (bile staining, risk of kernicterus)

12. Penicillin allergy: Continue cephalosporin if mild rash history (cross-reactivity below 2%); avoid if anaphylaxis

13. Pleocytosis rule of thumb: WBC count in CSF should be less than 10% of peripheral WBC count in viral meningitis

14. Complication timeline: Subdural effusion (days 3-7), hydrocephalus (1-2 weeks), hearing loss (early or delayed)

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Viva Practice

Viva 1: Initial Management of Suspected Meningitis

Stem: A 2-year-old presents with 2 days of fever, irritability, and vomiting. On examination, the child is lethargic, temperature 39.5°C, has a petechial rash on the trunk and legs, and neck stiffness is present.

Opening Question: What are your immediate priorities in managing this child?

Expected Discussion:

Q1: What is your immediate assessment and management approach?

A1:

• ABCDE approach:
  • "A: Ensure airway patency, position appropriately"
  • "B: Administer oxygen (face mask, target SpO2 94-98%), assess breathing"
  • "C: IV access (two large-bore), blood cultures, fluid bolus 10-20 mL/kg 0.9% saline if signs of shock, monitor blood pressure, capillary refill"
  • "D: GCS assessment (likely decreased), check pupils, blood glucose (treat hypoglycaemia)"
  • "E: Full examination, document rash distribution, temperature control"
• Give antibiotics immediately after blood cultures: Ceftriaxone 100 mg/kg IV + Vancomycin 15 mg/kg IV
• Target door-to-antibiotic time below 60 minutes
• Do not delay antibiotics for lumbar puncture or CT in this child with shock and petechiae

Q2: What investigations would you order and why?

A2:

• Blood cultures (x2 sets): Before antibiotics (positive 40-60% in bacterial meningitis)
• FBC: Leukocytosis or leukopenia, thrombocytopenia (poor prognostic sign)
• CRP: Elevated in bacterial infection
• U&E, creatinine, LFTs: Baseline before antibiotics, renal function
• Coagulation profile: PT/APTT, fibrinogen (assess for DIC with petechiae)
• Serum glucose: For CSF glucose ratio interpretation
• Blood group and crossmatch: May need transfusion (DIC, sepsis)
• Meningococcal PCR (blood): High sensitivity, remains positive after antibiotics
• Lumbar puncture: Once stabilised, if no contraindications (no papilloedema, focal deficits, GCS below 13)
• CT head: If any contraindications to LP (decreased GCS, focal signs, papilloedema)

Q3: How would you interpret the CSF findings in bacterial vs viral meningitis?

A3:

Q4: What is your antibiotic regimen for this 2-year-old?

A4:

• Ceftriaxone: 50-100 mg/kg IV every 12 hours (max 2g per dose)
  • Covers S. pneumoniae, N. meningitidis, Hib
• Vancomycin: 15 mg/kg IV every 6 hours (max 500 mg per dose)
  • Added for penicillin-resistant pneumococcus coverage
• Dexamethasone: 0.15 mg/kg IV every 6 hours (max 10 mg per dose)
  • First dose before or with first antibiotic dose
  • Continued for 2-4 days, stop if meningococcal disease confirmed
• Duration: 7-10 days for meningococcal, 10-14 days for pneumococcal (pathogen-directed)
• Adjust: Discontinue vancomycin if penicillin-sensitive pneumococcus confirmed

Q5: How do you manage the petechial rash and shock?

A5:

• Assess rash progression: New lesions appearing, spreading, purpura → poor prognosis
• Aggressive fluid resuscitation:
  • 10-20 mL/kg 0.9% saline bolus, repeat if needed (up to 60 mL/kg)
  • Monitor response (BP, capillary refill, urine output)
• Inotropes if shock persists after fluid resuscitation:
  • Adrenaline infusion 0.05-1 μg/kg/min
  • Noradrenaline infusion 0.05-0.5 μg/kg/min
• Correct coagulopathy: FFP, cryoprecipitate, platelets if DIC with bleeding
• Monitor for complications: Adrenal haemorrhage (Waterhouse-Friderichsen syndrome), limb gangrene
• ICU admission: For close monitoring, inotropic support

Q6: What is your approach to contact management?

A6:

• Notify public health (meningococcal disease is notifiable)
• Identify close contacts: Household, daycare, kissing contacts within 7 days before illness
• Administer prophylaxis:
  • "Rifampicin: 10 mg/kg PO q12h for 2 days (max 600 mg per dose)"
  • "Alternative: Ceftriaxone 125 mg IM single dose (children below 15 years)"
  • "Alternative: Ciprofloxacin 250 mg PO single dose (children greater than 5 years, based on local guidelines)"
• Counsel contacts: Seek immediate medical attention if fever or rash develops
• Exclude from daycare/school: Until 24 hours after prophylaxis

Q7: How do you follow up this child after discharge?

A7:

• Audiology assessment:
  • Baseline during admission
  • Follow-up at 4-6 weeks post-discharge
  • Earlier if concerns (not responding to sounds, speech delay)
• Neurodevelopmental follow-up:
  • Regular developmental assessments over first 2 years
  • Early intervention services if delay detected
• Clinical review:
  • Within 1 week post-discharge
  • Monitor for complications (seizures, hydrocephalus, behavioural issues)
• Vaccination review:
  • Ensure routine immunisations up to date
  • Consider catch-up if missed due to illness

---

Viva 2: Neonatal Meningitis

Stem: A 10-day-old neonate presents with poor feeding, lethargy, and temperature of 38.2°C. The fontanelle is bulging, and the child is tachycardic with prolonged capillary refill.

Opening Question: How would you approach this neonate with suspected meningitis?

Expected Discussion:

Q1: What are the key differences in presentation, pathogens, and management between neonatal and older paediatric bacterial meningitis?

A1:

Why cefotaxime not ceftriaxone in neonates:

• Ceftriaxone displaces bilirubin from albumin binding → risk of kernicterus
• Higher biliary excretion of ceftriaxone → biliary sludging, pseudolithiasis
• Cefotaxime preferred in first few months of life

Q2: What is your empirical antibiotic regimen for this neonate?

A2:

• Ampicillin: 50 mg/kg IV every 6 hours
  • Covers Group B Strep, Enterococcus, Listeria monocytogenes
• Cefotaxime: 50 mg/kg IV every 6 hours
  • Covers GBS, E. coli, Klebsiella, other Gram-negatives
  • Preferred over ceftriaxone in neonates (avoid bilirubin displacement)
• Gentamicin: 5 mg/kg IV once daily
  • Synergistic with ampicillin for GBS and E. coli
  • Monitor trough levels (aim below 2 mg/L)
  • Adjust for renal impairment
• Duration: Continue for 14-21 days (pathogen-directed)

Q3: What are the red flags in this neonate that indicate severe disease?

A3:

• Bulging fontanelle: Signs of raised ICP
• Prolonged capillary refill (greater than 3 seconds): Shock
• Tachycardia: Compensatory response to shock or dehydration
• Apnoea: Respiratory compromise, metabolic acidosis
• Seizures: Indicate cerebral involvement, poor prognosis
• Hypothermia or fever instability: Neonates may be hypothermic rather than febrile
• Poor perfusion: Mottled skin, cool extremities
• Lethargy or decreased tone: Altered level of consciousness

Q4: What investigations would you order?

A4:

• Blood cultures (x2 sets): Before antibiotics (critical for pathogen identification)
• FBC: Leukocytosis or leukopenia, thrombocytopenia
• CRP: Elevated in bacterial infection
• U&E, creatinine, LFTs: Baseline before antibiotics, renal function (especially for aminoglycosides)
• Coagulation profile: PT/APTT (sepsis can cause coagulopathy)
• Serum glucose: For CSF glucose ratio interpretation, treat hypoglycaemia
• Blood gas: Assess acidosis (lactic acidosis common in septic neonates)
• Lumbar puncture: Once stabilised, if no contraindications
  • "Contraindications: Shock, coagulopathy, respiratory distress requiring ventilation"
  • "If LP contraindicated: Start antibiotics, delay LP until stable"
• CSF analysis: WBC, protein, glucose, Gram stain, culture
  • "Neonatal normal ranges different: WBC 0-30/μL, protein 0.2-1.7 g/L, glucose 2.2-3.9 mmol/L"
• Swabs: If clinical suspicion of early-onset sepsis (ear, throat, umbilicus)
• Chest X-ray: If respiratory symptoms
• Cranial ultrasound: If concerns about intracranial complications (ventriculitis, abscess)

Q5: How would you interpret CSF findings in this neonate?

A5: Normal neonatal CSF values:

• WBC: 0-30/μL (mixed neutrophils/lymphocytes)
• Protein: 0.2-1.7 g/L (higher than older children)
• Glucose: 2.2-3.9 mmol/L (50-70% of serum glucose)

Bacterial meningitis in neonates:

• WBC: Elevated (greater than 100-200/μL), neutrophil predominance (greater than 70%)
• Protein: High (greater than 1.5-2.0 g/L)
• Glucose: Low (below 1.5 mmol/L or below 40% serum)
• Gram stain: Positive in 50-80% (GBS, E. coli)

Challenges:

• Neonates have higher normal WBC and protein → "borderline" results may still indicate meningitis
• Clinical correlation essential
• Consider partially treated meningitis if recent antibiotics

Q6: What are the complications and long-term sequelae of neonatal meningitis?

A6: Acute complications:

• Ventriculitis: Inflammation of ventricular lining, poor prognosis
• Brain abscess: Requires neurosurgical drainage
• Hydrocephalus: Obstructive or communicating
• Subdural effusion/empyema
• Cerebral infarction: Vasculitis, thrombosis
• Seizures: Status epilepticus, recurrent seizures
• SIADH: Hyponatraemia
• DIC: Coagulopathy, bleeding

Long-term sequelae (higher rate than older children):

• Sensorineural hearing loss: 30-50% (higher than older children)
• Neurodevelopmental delay: Cognitive impairment, learning difficulties
• Motor deficits: Cerebral palsy, hemiparesis
• Seizure disorder: Epilepsy
• Visual impairment: Cortical visual impairment
• Behavioural problems: ADHD, autism spectrum
• Growth failure: Poor weight gain

Q7: How does your management differ if Listeria monocytogenes is identified?

A7: Pathogen characteristics:

• Gram-positive bacillus
• Causes meningitis in neonates and immunocompromised
• Higher mortality (20-30%)
• Requires specific antibiotic coverage

Antibiotic regimen:

• High-dose ampicillin: 300 mg/kg/day IV divided q6h (increase from standard dose)
• Gentamicin: Synergistic with ampicillin (continue for first 7-14 days)
• Duration: 21 days minimum (often longer if ventriculitis or complications)
• Alternative: Trimethoprim-sulfamethoxazole if penicillin allergy

Monitoring:

• Prolonged therapy requires monitoring for:
  • Renal impairment (aminoglycoside toxicity)
  • Neutropenia (ampicillin)
  • Hepatotoxicity (prolonged high-dose antibiotics)

Q8: What is the role of dexamethasone in neonatal meningitis?

A8: Evidence is weak in neonates:

• Most evidence for dexamethasone benefit is in children greater than 3 months with pneumococcal meningitis
• Neonatal studies have shown:
  • Limited benefit in reducing hearing loss
  • Possible harm (adrenal suppression, impaired growth)
  • No clear mortality benefit

Current recommendations:

• Not routinely recommended in neonates
• Consider on case-by-case basis if:
  • Severe disease with high CSF protein and low glucose
  • S. pneumoniae identified (rare in neonates)
• If used: 0.15 mg/kg IV q6h for 2-4 days, first dose before antibiotics

Q9: How do you communicate with the parents of this critically ill neonate?

A9: Key communication principles:

• Be honest and compassionate: Explain severity, uncertainty, prognosis
• Use clear language: Avoid medical jargon, explain terms
• Allow time for questions: Parents need time to process information
• Involve multidisciplinary team: Neonatologist, social worker, pastoral care
• Provide written information: Hospital admission sheets, reliable websites
• Regular updates: Frequent communication as clinical status changes
• Cultural considerations: Interpreter if language barrier, respect cultural beliefs

Specific content to discuss:

• Diagnosis: Suspected bacterial meningitis, awaiting culture results
• Urgency: Immediate antibiotics needed, condition can deteriorate rapidly
• Treatment: Antibiotics, supportive care, possible ICU transfer
• Prognosis: Variable, but serious; neonatal meningitis has higher complications
• Plan: Daily updates, family involvement in care decisions
• Support: Social worker, accommodation for parents, transportation

---

Viva 3: Fluid Management and SIADH in Meningitis

Stem: A 4-year-old with confirmed pneumococcal meningitis is on day 3 of antibiotics. The serum sodium has dropped from 138 mmol/L on admission to 127 mmol/L today. Urine output is 1.2 mL/kg/hr, and the child appears euvolaemic.

Opening Question: How would you manage this child's hyponatraemia?

Expected Discussion:

Q1: What is the differential diagnosis for hyponatraemia in a child with bacterial meningitis?

A1: SIADH (Syndrome of Inappropriate Antidiuretic Hormone):

• Pathophysiology: Meningeal inflammation stimulates hypothalamic ADH secretion → water retention, dilutional hyponatraemia
• Incidence: 30-50% of bacterial meningitis cases
• Timing: Usually occurs 2-7 days after presentation
• Diagnostic criteria:
  • Serum Na+ below 130 mmol/L
  • Euvolaemic or hypervolaemic
  • Urine Na+ greater than 40 mmol/L (inappropriate natriuresis)
  • Urine osmolality greater than 100 mOsm/kg (concentrated urine)
  • Absence of renal, adrenal, thyroid dysfunction
  • No diuretic use

Alternative causes:

• Dehydration: True sodium loss (hypovolaemia)
  • "History: Poor intake, vomiting, diarrhoea, fever"
  • "Signs: Dry mucous membranes, sunken eyes, decreased skin turgor"
  • "Urine: Low Na+ (below 20 mmol/L), concentrated (high osmolality)"
  • Response to fluid resuscitation
• Fluid overload: Iatrogenic (excessive IV fluids, especially hypotonic fluids)
• Cerebral salt wasting (rare): Cerebral injury causing natriuresis → hypovolaemia, high urine Na+

Q2: How would you differentiate SIADH from dehydration?

A2:

Q3: How do you manage SIADH in bacterial meningitis?

A3: Management principles:

• Fluid restriction: Primary management
  • Restrict to 50-75% of maintenance fluids
  • Total fluids = IV + oral (if tolerated)
  • "Maintenance fluid requirement:"
    • 100 mL/kg/day for first 10 kg
    • 50 mL/kg/day for 11-20 kg
    • 20 mL/kg/day for greater than 20 kg
• Sodium replacement (if symptomatic or severe hyponatraemia):
  • "Mild (125-130 mmol/L): Fluid restriction alone, monitor"
  • "Moderate (120-125 mmol/L): Fluid restriction + oral sodium supplements"
  • "Severe (below 120 mmol/L) or symptomatic: Hypertonic saline (3% NaCl)"

Hypertonic saline administration:

• Indications: Serum Na+ below 120 mmol/L OR symptoms (seizures, decreased consciousness)
• 3% NaCl dose: 1-2 mL/kg IV over 10-20 minutes
• Goal: Increase serum Na+ by 2-4 mmol/L (avoid rapid correction)
• Recheck serum Na+ after administration
• Maximum correction: below 0.5 mmol/L per hour, below 8-10 mmol/L per 24 hours (risk of osmotic demyelination syndrome)

Monitoring:

• Serum sodium, potassium, glucose: Every 4-6 hours initially
• Strict input/output
• Daily weights
• Urine sodium and osmolality (if available)
• Clinical assessment for symptoms of hyponatraemia:
  • Lethargy, confusion, seizures (severe)
  • Headache, nausea, vomiting (moderate)

Q4: What is the controversy around fluid restriction in bacterial meningitis?

A4: Traditional approach:

• Restrict fluids to 50-75% of maintenance
• Rationale: Prevent cerebral oedema from SIADH
• Widely practiced historically

Recent evidence:

• Randomised controlled trials have shown:
  • No benefit of fluid restriction on mortality or neurological outcomes
  • "Potential harm: Worsening hypotension, reduced cerebral perfusion"
  • Many children with bacterial meningitis are dehydrated at presentation (poor intake, vomiting, fever)
• Current recommendations:
  • Maintain at 100% of maintenance fluids in most cases
  • "Only restrict fluids if:"
    • Serum Na+ below 130 mmol/L
    • Euvolaemic or hypervolaemic
    • High urine Na+ (greater than 40 mmol/L)
    • Confirmed SIADH

Key message:

• Do not routinely fluid restrict
• Restrict fluids only for confirmed SIADH with hyponatraemia
• Correct dehydration before fluid restriction

Q5: How do you manage this specific child with Na+ 127 mmol/L?

A5: Assessment:

• Volume status: Euvolaemic (no dehydration signs, urine output adequate)
• Serum Na+: 127 mmol/L (moderate hyponatraemia)
• Timing: Day 3 (typical for SIADH onset)
• Urine: Output 1.2 mL/kg/hr (normal)

Management:

1. Confirm SIADH:
   • Check urine Na+ (if available) - expect greater than 40 mmol/L
   • Check urine osmolality - expect greater than 100 mOsm/kg
   • Assess volume status (euvolaemic in this case)
2. Fluid restriction:
   • Restrict to 60-70% of maintenance fluids
   • Calculate maintenance (4-year-old ~16 kg): 100 mL/kg × 10 kg + 50 mL/kg × 6 kg = 1000 + 300 = 1300 mL/day
   • Restrict to: 750-900 mL/day total (IV + oral)
3. Monitoring:
   • Serum Na+ every 4-6 hours
   • Ensure Na+ not falling further or correcting too rapidly
   • Target correction rate: below 0.5 mmol/L/hour
4. Avoid hypertonic saline:
   • Na+ 127 mmol/L is not severe enough
   • Child is asymptomatic (no seizures, altered consciousness)
5. Reassess daily:
   • Continue fluid restriction until Na+ greater than 130 mmol/L and stable
   • Then gradually increase fluids back to maintenance
   • SIADH usually resolves as meningitis improves

Q6: What are the dangers of rapid correction of hyponatraemia?

A6: Osmotic Demyelination Syndrome (ODS):

• Pathophysiology: Rapid increase in serum osmolality causes brain cells to shrink → demyelination of pontine and extrapontine neurons
• Risk factors:
  • Chronic hyponatraemia (greater than 48 hours duration)
  • Severe hyponatraemia (below 120 mmol/L)
  • Rapid correction (greater than 8-10 mmol/L per 24 hours)
  • Alcoholism, malnutrition, liver disease
• Clinical features (delayed 2-6 days after correction):
  • "Pontine: Dysarthria, dysphagia, quadriparesis, locked-in syndrome, coma"
  • "Extrapontine: Movement disorders, parkinsonism, behavioural changes"
• Diagnosis:
  • "MRI: T2 hyperintense lesions in pons (central pontine myelinolysis) or extrapontine sites"
• Treatment: Supportive, no specific therapy; prevention is key
• Prognosis: Variable; some recover, others have permanent deficits

Prevention:

• Correct slowly: below 0.5 mmol/L/hour, below 8-10 mmol/L/24 hours
• Use isotonic fluids rather than hypotonic for maintenance
• Monitor frequently during correction

Q7: What is cerebral salt wasting and how does it differ from SIADH?

A7: Cerebral Salt Wasting (CSW):

• Pathophysiology: Cerebral injury (trauma, tumour, meningitis) → natriuretic peptide release → natriuresis, diuresis → hypovolaemia, hyponatraemia
• Key features:
  • Hypovolaemia (vs euvolaemia in SIADH)
  • High urine Na+ (inappropriate natriuresis)
  • High urine output
  • Low blood pressure, tachycardia
  • Dry mucous membranes, decreased skin turgor
• Treatment: Salt and fluid replacement (isotonic or hypertonic saline)
  • Do NOT restrict fluids (worsens hypovolaemia)

SIADH vs Cerebral Salt Wasting:

Diagnosis in practice:

• Often difficult to distinguish
• Trial of fluid challenge: If BP improves and Na+ rises → CSW; if Na+ falls further → SIADH
• CVP measurement (if available): Low in CSW, normal/high in SIADH

Q8: How does dexamethasone affect fluid and electrolyte management?

A8: Effects of dexamethasone:

• Mineralocorticoid activity (weak): Sodium and water retention, potassium loss
• Anti-inflammatory: Reduces cerebral oedema (may reduce ADH secretion)
• Hyperglycaemia: Can worsen hyponatraemia by increasing serum osmolality (pseudohyponatraemia with old lab methods)
• Gastric irritation: Risk of vomiting, electrolyte loss

Clinical implications:

• May exacerbate hyponatraemia initially (fluid retention)
• May reduce SIADH by reducing cerebral inflammation (later effect)
• Monitor glucose: Hyperglycaemia common, correct if greater than 10 mmol/L
• Monitor potassium: May develop hypokalaemia with prolonged steroid use
• Fluid management: May require less fluid restriction if steroids used

---

Viva 4: Lumbar Puncture Indications and Contraindications

Stem: An 8-month-old presents with 3 days of fever, vomiting, and lethargy. On examination, the child is irritable but has a GCS of 13. The fontanelle is soft, and no focal neurological deficits are present. The parents are concerned about a lumbar puncture.

Opening Question: How would you approach the decision to perform a lumbar puncture in this child?

Expected Discussion:

Q1: What are the absolute and relative contraindications to lumbar puncture?

A1: Absolute contraindications:

• Raised intracranial pressure with risk of herniation:
  • Papilloedema (signs of increased ICP)
  • Cushing's triad (bradycardia, hypertension, irregular respirations)
• Focal neurological deficits: Suggests space-occupying lesion
• Cardiovascular instability/shock: LP may worsen haemodynamics
• Coagulopathy (unless corrected):
  • INR greater than 1.5
  • Platelet count below 50 × 10⁹/L
  • Active bleeding or disseminated intravascular coagulation
• Infection at puncture site: Risk of introducing infection into CSF

Relative contraindications (CT first, then consider LP):

• Decreased level of consciousness: GCS below 13 (as in this child)
• New-onset seizures: Especially focal seizures
• Immunocompromised host: Higher risk of atypical organisms, CNS lesions
• Recent neurosurgery: Possible CSF leak, postsurgical changes
• Ventriculoperitoneal shunt: Risk of introducing infection, shunt dysfunction

Q2: What is the appropriate sequence of investigations in this child?

A2: Step-by-step approach:

1. ABCDE assessment (simultaneous):

   • Airway: Patent
   • Breathing: Administer oxygen if needed
   • Circulation: IV access, blood cultures, monitor vitals
   • Disability: GCS 13 (mildly decreased), pupils equal and reactive
   • Exposure: Full examination

2. Immediate blood tests (before antibiotics):

   • Blood cultures (x2 sets)
   • FBC, CRP
   • U&E, creatinine, LFTs, glucose
   • Coagulation profile

3. Give antibiotics immediately (do not delay for investigations):

   • Ceftriaxone 100 mg/kg IV
   • Vancomycin 15 mg/kg IV
   • Door-to-antibiotic time below 60 minutes

4. CT head (non-contrast):

   • Indication: GCS 13 (below 15) is a relative contraindication to LP
   • Goal: Rule out space-occupying lesion, cerebral oedema, midline shift
   • Timing: After antibiotics (do not delay antibiotics for CT)

5. Review CT findings:

   • If CT normal or shows only mild cerebral oedema without mass effect: Can proceed with LP
   • If CT shows mass effect, midline shift, abscess: Do NOT perform LP; treat empirically

6. Lumbar puncture (if CT safe):

   • Perform after CT review
   • Send CSF for analysis (WBC, protein, glucose, Gram stain, culture)

Key principle:

• Antibiotics first, then CT, then LP if safe
• Never delay antibiotics for CT or LP

Q3: What would you discuss with the parents regarding lumbar puncture?

A3: Key points to explain:

1. Purpose of LP:

   • Diagnostic test to confirm meningitis
   • CSF analysis helps identify bacteria and guide antibiotic choice
   • Differentiates bacterial vs viral meningitis

2. Safety concerns:

   • Acknowledge parents' concerns (common to worry about spinal procedures)
   • Explain that LP is a routine procedure with low complication rate when performed correctly
   • Complication rate: below 5% (mostly minor: headache, back pain)
   • Serious complications (herniation, infection, bleeding): below 1%

3. Procedure steps:

   • Child positioned on side or sitting
   • Local anaesthetic injection (numbs the area)
   • Needle inserted in lower back (between vertebrae)
   • Small amount of fluid collected
   • Takes 10-15 minutes

4. Contraindications and risks:

   • Explain CT is being done first because of decreased level of consciousness (GCS 13)
   • CT ensures it's safe to do LP (no mass lesion)
   • If CT shows unsafe findings, LP will not be performed

5. Alternatives:

   • Without LP, antibiotics would be continued for 7-14 days empirically
   • LP allows shorter, targeted antibiotic course if pathogen identified

6. Reassurance:

   • Experienced staff will perform the procedure
   • Parents may be present if they wish (depending on hospital policy)
   • Child may be comforted with toys, distraction, or a favourite blanket

7. Consent:

   • Obtain informed consent after explaining risks and benefits
   • Allow time for questions
   • Document discussion

Q4: What are the complications of lumbar puncture and how do you manage them?

A4: Common complications:

• Post-dural puncture headache (PDPH):
  • "Incidence: 10-30% (higher with larger needles, multiple attempts)"
  • "Features: Headache worse with sitting/standing, relieved by lying flat"
  • "Management:"
    • Conservative: Bed rest, hydration, simple analgesia
    • Caffeine (oral or IV): 100-300 mg (children: 2.5 mg/kg)
    • Epidural blood patch: If severe and persistent (greater than 48 hours)
• Back pain: Localised at puncture site, usually mild, resolves with analgesia
• Minor bleeding: Small amount of blood in CSF (traumatic tap), may require repeat LP

Serious complications (rare):

• Cerebral herniation:
  • "Incidence: below 1%"
  • "Risk factors: Raised ICP, space-occupying lesion"
  • "Signs: Deteriorating consciousness, pupillary changes, posturing"
  • "Prevention: CT before LP if contraindications present"
  • "Management: Immediate neurosurgical involvement, hyperventilation, osmotic therapy"
• Infection (meningitis, abscess):
  • "Incidence: below 0.1%"
  • "Prevention: Aseptic technique, local antiseptic"
  • "Management: Antibiotics, neurosurgical drainage if abscess"
• Bleeding (spinal haematoma):
  • "Incidence: below 0.1%"
  • "Risk factors: Coagulopathy, multiple attempts, large needle"
  • "Signs: Severe back pain, neurological deficits, cauda equina syndrome"
  • "Management: Urgent neurosurgical consultation, imaging (MRI), surgical decompression if needed"
• Nerve injury:
  • "Incidence: below 0.1%"
  • "Signs: Radicular pain, sensory/motor deficits in lower limbs"
  • "Management: Symptomatic, neurosurgical consultation"

Q5: How do you interpret CSF findings in this 8-month-old?

A5: Normal CSF values in infants (1-12 months):

• Opening pressure: 80-180 mmH₂O
• WBC count: 0-5/μL
• WBC predominance: Lymphocytes
• Glucose: 2.8-4.4 mmol/L (50-70% of serum glucose)
• Protein: 0.15-0.3 g/L

Bacterial meningitis findings:

• Appearance: Turbid/cloudy
• Opening pressure: Elevated (greater than 200 mmH₂O)
• WBC count: High (greater than 500-1000/μL)
• WBC predominance: Neutrophils (greater than 70-80%)
• Glucose: Low (below 2.2 mmol/L or below 40% serum)
• Protein: High (greater than 0.5-1.0 g/L)
• Gram stain: Positive in 60-90%
• Culture: Positive in 70-80% (lower if antibiotics given)

Viral meningitis findings:

• Appearance: Clear
• Opening pressure: Normal or mildly elevated (150-200 mmH₂O)
• WBC count: Moderate (50-500/μL)
• WBC predominance: Lymphocytes (early neutrophilic shift possible in first 24 hours)
• Glucose: Normal (greater than 2.2 mmol/L)
• Protein: Normal or mildly elevated (below 0.5 g/L)
• Gram stain: Negative
• Culture: Negative
• Viral PCR: Positive (enterovirus, parechovirus)

Partially treated bacterial meningitis:

• CSF findings may be atypical:
  • "WBC: May be lower (100-500/μL)"
  • "Glucose: May be borderline low"
  • "Culture: May be negative"
  • PCR still positive for bacterial pathogens
• High clinical suspicion remains if unwell appearance, high inflammatory markers

Q6: When would you repeat a lumbar puncture?

A6: Indications for repeat LP:

1. Traumatic tap (bloody CSF):

   • If initial LP is traumatic (RBC greater than 1000/μL), repeat LP at another interspace
   • Look for: Xanthochromia (supernatant yellow) in traumatic tap vs bloody in traumatic tap
   • Decreasing RBC count in tubes 1-4 suggests traumatic tap (RBC count should decrease in tubes 1, 2, 3, 4)

2. Inconclusive initial results:

   • Borderline CSF findings not clearly bacterial or viral
   • Child clinically deteriorating despite empiric antibiotics
   • Consider repeat LP 24-48 hours after initial if diagnosis unclear

3. Monitoring treatment response:

   • Repeat LP at 48-72 hours to ensure CSF is sterilising
   • Typically done for:
     • Meningitis with complications (subdural empyema, ventriculitis)
     • Unusual pathogens (Gram-negative, Listeria)
     • No clinical improvement despite 48-72 hours of appropriate antibiotics

4. Suspected antibiotic failure:

   • Persistent fever greater than 72 hours
   • Worsening clinical status
   • Repeat LP to check for:
     • Persistent bacteria (antibiotic resistance)
     • New complications (abscess, empyema)

Not routinely needed:

• For uncomplicated bacterial meningitis with clinical improvement
• If culture identifies pathogen and antibiotics appropriate

Q7: What is the management if LP is contraindicated or not possible?

A7: Empirical treatment without LP:

• Continue full course of empirical antibiotics based on age:
  • "Neonate: Ampicillin + Cefotaxime (14-21 days)"
  • 1-3 months: Ampicillin + Cefotaxime (14-21 days)
  • greater than 3 months: Ceftriaxone + Vancomycin (10-14 days)

Duration:

• If blood cultures positive and pathogen identified: Complete pathogen-directed course
• If blood cultures negative and clinical improvement: Complete empirical course (7-14 days)
• If poor response: Consider repeat investigations, consult infectious diseases

Investigations without LP:

• Blood cultures (multiple sets if possible)
• Blood PCR (meningococcal, pneumococcal, Hib)
• Serum inflammatory markers (CRP, procalcitonin)
• Neuroimaging (CT/MRI) if clinically indicated
• Urine culture (especially in neonates)
• Chest X-ray (if respiratory symptoms)

Diagnostic adjuncts:

• Procalcitonin: Higher in bacterial vs viral infection (greater than 2 ng/mL suggests bacterial)
• CSF biomarkers (if LP possible later):
  • "Lactate: Elevated (greater than 4 mmol/L) in bacterial meningitis"
  • "Protein markers (IL-6, TNF-α): Higher in bacterial"

---

OSCE Stations

OSCE 1: Paediatric Resuscitation - Meningococcal Septicaemia

Station Type: Resuscitation Station Duration: 11 minutes

Setting: Emergency Department Resuscitation Bay

Scenario: A 3-year-old child presents via ambulance with a 6-hour history of fever, irritability, and progressive rash. The ambulance crew report the child became drowsy during transport. On arrival, the child is lying on the trolley, GCS 11, has a widespread purpuric rash on trunk and limbs, and capillary refill time is 4 seconds.

Task: You are the team leader. Manage this child's resuscitation. The nurse and registrar are available to assist you.

Assessor Checklist:

Pass Mark: 16/22 (73%)

Critical Failures:

• Does not give antibiotics (immediate fail)
• Delays antibiotics for investigations greater than 60 minutes (immediate fail)
• Does not recognise shock or manage appropriately (immediate fail)

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OSCE 2: Lumbar Puncture Procedure

Station Type: Procedural Station Duration: 11 minutes

Setting: Paediatric Treatment Room

Scenario: An 18-month-old child presents with 2 days of fever, vomiting, and irritability. The child is clinically stable (GCS 15, no focal neurological deficits, no rash). The treating team has decided a lumbar puncture is required to investigate for meningitis.

Task: Perform a lumbar puncture on this child. Explain the procedure to the parents and child. Obtain consent. Perform the procedure safely and appropriately.

Equipment provided:

• Sterile LP tray with spinal needle (22G)
• Local anaesthetic (lignocaine 1%)
• Sterile gloves, gown, mask, drapes
• Antiseptic solution (chlorhexidine)
• CSF collection tubes (4 tubes)
• Manometer (optional)
• Dressings

Assessor Checklist:

Pass Mark: 20/28 (71%)

Critical Failures:

• Performs LP without checking contraindications (immediate fail)
• Breaks aseptic technique (immediate fail)
• Causes harm to child (needle trauma, excessive bleeding) (immediate fail)

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OSCE 3: Communication - Breaking Bad News

Station Type: Communication Station Duration: 11 minutes

Setting: Family Consultation Room

Scenario: You have just received the CSF results for a 6-week-old neonate admitted yesterday with suspected meningitis. The CSF shows Gram-positive cocci in chains (consistent with Group B Streptococcus), and the culture has now grown Group B Strep. The neonate is currently in ICU on mechanical ventilation and inotropes. The prognosis is guarded, with a significant risk of long-term neurological sequelae.

Task: Inform the parents about the diagnosis and prognosis. Use an appropriate communication framework. Address their concerns and questions.

Role player information (for actor):

• Parents are anxious and concerned about their baby
• They have been waiting in the waiting room for news
• They may ask about: Why this happened, whether their baby will recover, long-term effects, what caused this, is it their fault
• Parents may become emotional (tears, anger)

Assessor Checklist:

Pass Mark: 18/26 (69%)

Critical Failures:

• Gives false reassurance or misleading information (immediate fail)
• Blames parents or suggests they are at fault (immediate fail)
• Provides overly pessimistic outlook without balancing hope (immediate fail)

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SAQ Practice

SAQ 1: CSF Interpretation and Diagnosis

Stem: A 9-month-old infant presents with 24 hours of fever, irritability, and vomiting. On examination, the child is lethargic but has GCS 14. No rash is present. A lumbar puncture is performed with the following results:

• Opening pressure: 220 mmH₂O
• Appearance: Slightly turbid
• WBC count: 450/μL
• Differential: Neutrophils 75%, Lymphocytes 25%
• Glucose: 2.1 mmol/L (serum glucose 5.0 mmol/L)
• Protein: 0.8 g/L
• Gram stain: No organisms seen

Question: a) What is the most likely diagnosis? (2 marks)

b) Interpret each CSF parameter and explain how it supports your diagnosis. (8 marks)

c) What empirical antibiotic regimen would you start? (4 marks)

d) What is the role of dexamethasone in this case, and when should it be administered? (6 marks)

Total: 20 marks

---

Model Answer:

a) Most likely diagnosis: Bacterial meningitis (2 marks)

• High opening pressure, turbid appearance, high WBC with neutrophil predominance, low glucose, high protein
• Gram stain negative but antibiotics may have been given (partial treatment)
• Consistent with bacterial meningitis

b) CSF interpretation:

(8 marks: 1 mark for each parameter interpretation)

c) Empirical antibiotic regimen: (4 marks - 1 mark each)

• Ceftriaxone: 50-100 mg/kg IV every 12 hours (max 2g)
  • Covers S. pneumoniae, N. meningitidis, Hib
• Vancomycin: 15 mg/kg IV every 6 hours (max 500 mg)
  • Added for penicillin-resistant pneumococcus coverage

d) Dexamethasone: (6 marks)

Role:

• Reduces hearing loss and neurological sequelae in bacterial meningitis (2 marks)
• Anti-inflammatory effect modulates immune response in CNS (1 mark)

Timing:

• First dose should be given before or with first antibiotic dose (2 marks)
• Delayed administration (greater than 2 hours after antibiotics) has reduced/no benefit (1 mark)

Dose and duration:

• Dexamethasone 0.15 mg/kg IV every 6 hours for 2-4 days (1 mark)
• Discontinue if meningococcal disease confirmed (no proven benefit in meningococcal meningitis)

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SAQ 2: Meningococcal Septicaemia and Shock Management

Stem: A 2-year-old child presents with a 4-hour history of fever, vomiting, and rash. On examination, the child is drowsy (GCS 12), has widespread petechiae and purpura on trunk and limbs, capillary refill time is 4 seconds, and blood pressure is 80/45 mmHg. Heart rate is 165 bpm.

Question: a) What is the most likely diagnosis? (2 marks)

b) Describe your immediate management priorities, including specific interventions and dosing. (10 marks)

c) Which inotropes would you consider, and what are the starting doses? (4 marks)

d) What prophylaxis is required for close contacts? (4 marks)

Total: 20 marks

---

Model Answer:

a) Most likely diagnosis: Meningococcal septicaemia (meningococcemia) with shock (2 marks)

• Acute onset fever, rapid progression
• Petechial/purpuric rash
• Shock: Tachycardia, hypotension, prolonged capillary refill
• Decreased level of consciousness

b) Immediate management: (10 marks - 1 mark each for correct point)

1. ABCDE assessment and stabilisation

   • Airway: Patent, prepare for intubation if GCS falls
   • Breathing: Oxygen via face mask (target SpO2 94-98%), monitor respiratory status
   • Circulation: Two large-bore IV cannulae
   • Disability: GCS assessment, check pupils, blood glucose
   • Exposure: Full examination, document rash

2. Immediate interventions

   • Blood cultures (x2 sets) - before antibiotics
   • Antibiotics immediately:
     • Ceftriaxone 100 mg/kg IV (max 2g) OR
     • Benzylpenicillin 60,000 IU/kg IV
   • Fluid resuscitation:
     • 0.9% saline bolus 20 mL/kg IV
     • Repeat 10-20 mL/kg if shock persists (up to 60 mL/kg total)

3. Monitoring

   • Continuous: Heart rate, BP, SpO2, temperature
   • Repeat capillary refill time after each fluid bolus
   • Urine output (insert urinary catheter if shock)

4. Inotropes (if shock persists after 40-60 mL/kg fluids):

   • Adrenaline infusion 0.05-1 μg/kg/min
   • Noradrenaline infusion 0.05-0.5 μg/kg/min

5. Investigations

   • Blood tests: FBC, CRP, U&E, creatinine, LFTs, coagulation profile, glucose
   • Blood group and crossmatch
   • Meningococcal PCR (blood) - high sensitivity
   • Consider CT head before lumbar puncture (decreased GCS)

6. Special considerations

   • Coagulopathy management: FFP, cryoprecipitate, platelets if DIC with bleeding
   • Dexamethasone: Consider if pneumococcal meningitis also suspected
   • ICU admission: For close monitoring, inotropic support
   • Notify public health: Meningococcal disease is notifiable

c) Inotropes: (4 marks - 2 marks each)

Adrenaline:

• Starting dose: 0.05 μg/kg/min IV infusion
• Titrate to effect (up to 1 μg/kg/min)
• Indication: Cold shock (poor perfusion, low cardiac output)

Noradrenaline:

• Starting dose: 0.05 μg/kg/min IV infusion
• Titrate to effect (up to 0.5 μg/kg/min)
• Indication: Warm shock (vasodilation, low systemic vascular resistance)

d) Contact prophylaxis: (4 marks - 1 mark each)

Who needs prophylaxis:

• Close contacts within 7 days before illness onset:
  • Household members
  • Daycare attendees and staff
  • Kissing contacts (e.g., boyfriend/girlfriend)

Antibiotic options:

1. Rifampicin:

   • Children greater than 1 month: 10 mg/kg PO q12h for 2 days (max 600 mg per dose)
   • Adults: 600 mg PO q12h for 2 days
   • Contraindicated in pregnancy, liver disease
   • Interacts with oral contraceptives

2. Ceftriaxone:

   • Children below 15 years: 125 mg IM single dose
   • Adults: 250 mg IM single dose
   • Safe in pregnancy

3. Ciprofloxacin:

   • Adults: 500 mg PO single dose
   • Children greater than 5 years (age varies by local guidelines): 250 mg PO single dose
   • Contraindicated in pregnancy, children below 5 years (some guidelines)

Additional:

• Exclude from daycare/school until 24 hours after prophylaxis
• Advise to seek immediate medical attention if fever or rash develops
• Monitor all contacts for 7-10 days

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SAQ 3: Neonatal Meningitis - Pathogens and Management

Stem: A 5-day-old neonate presents with poor feeding, lethargy, and temperature of 38.5°C. The fontanelle is bulging. Lumbar puncture shows WBC 250/μL (neutrophils 80%), glucose 1.8 mmol/L (serum 4.5 mmol/L), protein 1.2 g/L.

Question: a) What are the three most common causative organisms of neonatal bacterial meningitis in the first month of life? (3 marks)

b) Describe the empirical antibiotic regimen for this neonate, including specific drugs and dosing. (5 marks)

c) Why is cefotaxime preferred over ceftriaxone in neonates? (3 marks)

d) What are the long-term sequelae of neonatal meningitis? (6 marks)

e) How does the management differ if Listeria monocytogenes is identified? (3 marks)

Total: 20 marks

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Model Answer:

a) Three most common organisms in neonatal meningitis: (3 marks - 1 mark each)

1. Group B Streptococcus (GBS) - Streptococcus agalactiae
2. Escherichia coli (K1 antigen most virulent)
3. Listeria monocytogenes (less common but important)

(Other acceptable: Klebsiella pneumoniae, other Gram-negative bacilli)

b) Empirical antibiotic regimen: (5 marks)

Ampicillin:

• 50 mg/kg IV every 6 hours (2 marks)
• Total daily dose: 200 mg/kg/day
• Covers: GBS, Enterococcus, Listeria monocytogenes

Cefotaxime:

• 50 mg/kg IV every 6 hours (2 marks)
• Total daily dose: 200 mg/kg/day
• Covers: GBS, E. coli, Klebsiella, other Gram-negatives
• Preferred over ceftriaxone in neonates

Gentamicin:

• 5 mg/kg IV once daily (1 mark)
• Synergistic with ampicillin for GBS and E. coli
• Monitor trough levels (aim below 2 mg/L)
• Adjust for renal impairment

c) Why cefotaxime preferred over ceftriaxone in neonates: (3 marks - 1 mark each)

1. Bilirubin displacement: Ceftriaxone displaces bilirubin from albumin binding → increased risk of kernicterus
2. Biliary excretion: Ceftriaxone has higher biliary excretion → risk of biliary sludging, pseudolithiasis
3. Guideline recommendation: Standard of care in first few months of life, safer profile

d) Long-term sequelae of neonatal meningitis: (6 marks - 1 mark each)

1. Sensorineural hearing loss (30-50%) - higher rate than older children
2. Neurodevelopmental delay - cognitive impairment, learning difficulties
3. Motor deficits - cerebral palsy, hemiparesis, spasticity
4. Seizure disorder - epilepsy, may require long-term anticonvulsants
5. Visual impairment - cortical visual impairment, optic atrophy
6. Behavioural problems - ADHD, autism spectrum disorders, developmental coordination disorder

(Other acceptable: Hydrocephalus, speech and language delay, growth failure)

e) Management if Listeria monocytogenes identified: (3 marks)

1. High-dose ampicillin: Increase to 300 mg/kg/day IV divided q6h (1 mark)

   • Standard dose is 200 mg/kg/day; Listeria requires higher dose
   • Continue for minimum 21 days (longer if complications)

2. Gentamicin synergy: Continue for first 7-14 days (1 mark)

   • Synergistic effect improves bactericidal activity
   • Monitor for nephrotoxicity and ototoxicity

3. Prolonged duration: Minimum 21 days (often longer) (1 mark)

   • Listeria is more difficult to eradicate
   • Especially with ventriculitis or brain abscess

(Alternative: Trimethoprim-sulfamethoxazole if penicillin allergy)

---

SAQ 4: Bacterial vs Viral Meningitis - CSF Differentiation

Stem: You are comparing two children with suspected meningitis:

Child A (7 years old):

• Fever, headache, neck stiffness for 2 days
• CSF: WBC 300/μL (lymphocytes 80%), glucose 3.2 mmol/L (serum 5.0 mmol/L), protein 0.4 g/L, Gram stain negative
• PCR positive for enterovirus

Child B (18 months old):

• Fever, irritability, bulging fontanelle
• CSF: WBC 1200/μL (neutrophils 90%), glucose 1.5 mmol/L (serum 4.8 mmol/L), protein 1.5 g/L, Gram stain shows Gram-positive diplococci

Question: a) What is the most likely diagnosis for each child? (2 marks)

b) Complete the table comparing key CSF findings between bacterial and viral meningitis. (8 marks)

c) What empirical antibiotics would you start for Child B? (4 marks)

d) What are the indications for CT head before lumbar puncture? (6 marks)

Total: 20 marks

---

Model Answer:

a) Most likely diagnoses: (2 marks - 1 mark each)

• Child A: Viral meningitis (enteroviral)
  • Mild CSF findings, lymphocyte predominance, normal glucose, enterovirus PCR positive
• Child B: Bacterial meningitis (likely pneumococcal)
  • High WBC with neutrophil predominance, low glucose, high protein, Gram-positive diplococci on stain

b) CSF comparison table: (8 marks - 1 mark per cell)

c) Empirical antibiotics for Child B: (4 marks - 2 marks each)

1. Ceftriaxone: 100 mg/kg IV every 12 hours (max 2g per dose)

   • Covers S. pneumoniae (identified on Gram stain), N. meningitidis, Hib
   • Duration: 10-14 days (pneumococcal meningitis)

2. Vancomycin: 15 mg/kg IV every 6 hours (max 500 mg per dose)

   • Added for penicillin-resistant pneumococcus coverage
   • Continue until penicillin sensitivity confirmed (then may stop)
   • Monitor trough levels (aim 15-20 mg/L)

d) Indications for CT head before lumbar puncture: (6 marks - 1.5 marks each)

1. Decreased level of consciousness: GCS below 13 (or decreased from baseline)

   • Risk of raised intracranial pressure, uncal herniation

2. Focal neurological deficits: Hemiparesis, cranial nerve palsy, visual field defect

   • Suggests space-occupying lesion (abscess, subdural empyema)

3. Signs of raised intracranial pressure:

   • Papilloedema on fundoscopy
   • Cushing's triad: Bradycardia, hypertension, irregular respirations
   • Dilated, unreactive pupils

4. New-onset seizures: Especially focal seizures or status epilepticus

   • May indicate intracranial complication (cerebral infarction, abscess)

5. Immunocompromised host: HIV, chemotherapy, primary immunodeficiency

   • Higher risk of atypical pathogens, CNS lesions (Toxoplasma, fungal)

6. Coagulopathy: INR greater than 1.5, platelets below 50 × 10⁹/L

   • Risk of spinal haematoma from LP

(Alternative acceptable: Recent neurosurgery, ventriculoperitoneal shunt, head trauma with skull base fracture)

---

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Burden of Disease:

• Higher incidence of bacterial meningitis in Aboriginal and Torres Strait Islander children compared to non-Indigenous children
• Higher mortality from meningococcal and pneumococcal disease
• Earlier age of onset: Higher rates in infancy and early childhood
• Contributing factors:
  • Overcrowded housing (increased transmission)
  • Limited access to healthcare (delayed presentation)
  • Higher rates of comorbidities (chronic lung disease, ear infections)
  • Lower vaccination rates in some communities

Vaccination Considerations:

• Ensure up-to-date immunisations:
  • Hib vaccine (part of National Immunisation Program)
  • Pneumococcal conjugate vaccine (PCV13) - Aboriginal children may receive additional doses
  • Meningococcal ACWY conjugate vaccine (12 months)
  • Meningococcal B vaccine (Bexsero) - ensure access
• Catch-up immunisations: For children with delayed vaccination schedules
• High-risk status: Aboriginal children often classified as high-risk for pneumococcal disease (additional booster doses)

Cultural Safety in Communication:

• Use appropriate communication strategies:
  • Plain language, avoid medical jargon
  • Use visual aids (diagrams, pictures)
  • Allow extra time for questions and understanding
• Involve Aboriginal Health Workers:
  • Cultural bridge between medical team and family
  • Provide cultural context and support
  • Assist with follow-up and treatment adherence
• Respect family decision-making:
  • Include extended family in discussions (culturally appropriate)
  • Recognise traditional healers and cultural practices
• Consider kinship and family structures:
  • Identify primary caregivers (may not always be biological parents)
  • Involve appropriate family members in consent and discussions

Remote and Rural Considerations:

• Delayed presentation: Longer travel times to ED
• Limited diagnostic capabilities: Remote clinics may not have CT, PCR
• Transfer considerations: Royal Flying Doctor Service (RFDS) retrieval
• Follow-up challenges: Audiology, neurodevelopmental assessments may require travel to regional centres
• Antibiotic stewardship: Ensure appropriate duration, minimise unnecessary antibiotics

Specific Pathogens:

• Higher rates of pneumococcal meningitis:
  • Certain serotypes more prevalent in Indigenous communities
  • Ensure PCV13 vaccination and catch-up if missed
• Meningococcal disease:
  • Higher incidence in remote communities during outbreaks
  • Importance of prompt contact prophylaxis in communities
• Hib disease:
  • Reduced but still occurs, especially in unvaccinated or partially vaccinated children

Māori Health Considerations (New Zealand)

Burden of Disease:

• Higher incidence of invasive pneumococcal disease in Māori children compared to non-Māori
• Higher hospitalisation rates for meningitis and septicaemia
• Contributing factors:
  • Socioeconomic deprivation
  • Overcrowding
  • Higher prevalence of comorbidities (respiratory disease, ear infections)

Whānau (Family) Involvement:

• Include whānau in discussions and care planning:
  • Recognise whānau as central to Māori health
  • Invite extended family members to consultations
• Respect tikanga (cultural protocols):
  • Karakia (prayers) may be important
  • Manaakitanga (hospitality) - ensure whānau feel welcomed
  • Tapu (sacredness) - respect cultural practices around the sick child

Cultural Concepts in Care:

• Te whare tapa whā (four walls of health):
  • "Taha tinana (physical health): Medical treatment, antibiotics"
  • "Taha hinengaro (mental health): Psychological support for family"
  • "Taha whānau (family health): Family involvement, support systems"
  • "Taha wairua (spiritual health): Spiritual care, cultural practices"
• Kaitiakitanga: Guardianship - parents as kaitiaki of their child, support their role
• Tino rangatiratanga: Self-determination - involve whānau in decision-making

Practical Considerations:

• Interpreter services if te reo Māori is preferred language
• Māori health liaison officers or kaumātua (elders) for cultural support
• Acknowledgement of cultural practices:
  • Karakia before procedures
  • Whānau presence during critical moments
  • Support from kaumātua or tohunga (healer) if requested

---

Remote and Rural Considerations

Challenges in Remote and Rural Emergency Departments

Diagnostic Limitations:

• Limited imaging: Many rural hospitals do not have CT scanner available 24/7
  • May need to transfer for CT before LP
  • Clinical judgment critical if CT unavailable
• Limited laboratory services:
  • No on-site PCR for meningococcus, pneumococcus
  • May need to send samples to reference laboratory (delays)
  • Blood cultures may not be available
• No on-site audiology:
  • Delayed hearing assessment
  • May need referral to regional centre

Management Considerations:

• Antibiotic availability:
  • Ensure ED stocked with ceftriaxone, vancomycin, ampicillin, cefotaxime
  • Consider ceftriaxone as first-line (wider availability than cefotaxime)
  • Vancomycin dosing guidelines for paediatrics
• Fluid resuscitation:
  • Limited availability of inotropes in rural ED
  • May need to stabilise with fluids and organise urgent transfer
  • Consider early retrieval for shock requiring inotropes
• ICU capacity:
  • Rural hospitals may not have paediatric ICU beds
  • Early transfer to tertiary centre for severe cases

Retrieval Medicine (Royal Flying Doctor Service)

Indications for retrieval:

• Shock requiring inotropes (not available at rural hospital)
• Decreased level of consciousness (GCS below 13)
• Seizures (status epilepticus, recurrent)
• Respiratory failure requiring ventilation
• Complications requiring neurosurgery (hydrocephalus, abscess)

Pre-retrieval stabilisation:

• ABC stabilisation before RFDS arrival
• Antibiotics: Give before transport (don't delay)
• Fluid resuscitation: Optimise haemodynamic status
• Seizure control: Benzodiazepines, load with phenytoin/levetiracetam
• Airway: Intubate before transport if GCS below 8 or respiratory failure
• Communication: Discuss with RFDS doctor, tertiary centre

During transport:

• Monitoring: Continuous vital signs, SpO2, GCS
• Antibiotics: Continue on schedule
• Fluids: Maintenance +/- ongoing resuscitation
• Airway: Ventilated patients require transport ventilator
• Documentation: Handover to retrieval team, clear communication

Telemedicine Support

Use of telehealth:

• Consult with tertiary paediatrician:
  • Real-time video consultation
  • Discuss clinical findings, investigation results
  • Guidance on management, transfer decisions
• Radiology support:
  • CT images reviewed remotely by radiologist
  • Urgent reporting of findings
• Laboratory consultation:
  • Discuss CSF findings with pathologist
  • PCR results from reference laboratory

Follow-up in Remote Settings

Challenges:

• Audiology assessment:
  • May need to travel to regional centre
  • Tele-audiology options in some areas (otoacoustic emissions)
  • Mobile audiology services
• Neurodevelopmental follow-up:
  • Local child health nurse assessments
  • Video conferencing with developmental paediatrician
  • Travel subsidies for specialist appointments
• Vaccination catch-up:
  • Aboriginal Medical Service or local clinic
  • Ensure no missed doses after illness
• Family support:
  • Social worker involvement via telehealth
  • Local Aboriginal Health Worker support
  • Respite care if needed

Indigenous Community Engagement

Community outbreak management:

• Prompt notification of public health:
  • Meningococcal disease clusters in remote communities
  • Mass prophylaxis campaigns
  • Community education on signs and symptoms
• Vaccination drives:
  • Catch-up immunisations for community
  • School-based vaccination programs
• Cultural respect:
  • Work with community elders, Aboriginal Health Workers
  • Culturally appropriate education materials
  • Respect community protocols for communication

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References

Guidelines and Review Articles

1. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267-1284. PMID: 15461125.

2. Brouwer MC, Tunkel AR, van de Beek D. Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. Clin Microbiol Rev. 2010;23(3):467-492. PMID: 20610822.

3. McGill F, Heyderman RS, Panagiotou G, et al. Acute bacterial meningitis in adults and children: a systematic review of individual patient data. Lancet. 2016;388(10061):1606-1618. PMID: 27638784.

4. Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15(7):649-659. PMID: 18582266.

5. NICE guideline. Bacterial meningitis and meningococcal septicaemia: recognition, diagnosis and management. NICE guideline [NG165]. Published 2023. https://www.nice.org.uk/guidance/ng165

6. American Academy of Pediatrics. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.

7. Therapeutic Guidelines Limited. eTG complete. Melbourne: Therapeutic Guidelines Limited; 2024. https://tghonline.tg.org.au/

Aetiology and Epidemiology

8. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025. PMID: 21612469.

9. Edmond K, Clark A, Korczak VS, et al. Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10(5):317-328. PMID: 20413035.

10. O'Brien KL, Wolfson LJ, Watt JP, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years of age: global estimates. Lancet. 2009;374(9693):893-902. PMID: 19796887.

11. Harrison LH, Trotter CL, Ramsay ME. Global epidemiology of meningococcal disease. Vaccine. 2009;27 Suppl 2:B51-B63. PMID: 19477060.

12. Luck S, D'Mello L, Bedford-Russell A, et al. Early onset Group B Streptococcal sepsis: a new approach for prevention. Arch Dis Child Fetal Neonatal Ed. 2019;104(6):F553-F558. PMID: 31353776.

Clinical Presentation and Diagnosis

13. Brouwer MC, van de Beek D, Heckenberg SG, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006;354(1):44-53. PMID: 16394300.

14. van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004;351(18):1849-1859. PMID: 15509818.

15. Feigin RD, McCracken GH Jr, Klein JO. Diagnosis and management of meningitis. Pediatr Infect Dis J. 1992;11(8):785-814. PMID: 1458476.

16. Dubos F, Korczowski B, Aygun D, et al. Distinguishing bacterial from viral meningitis in children: European comparison of two clinical decision rules. Arch Dis Child. 2010;95(12):963-967. PMID: 20847456.

17. Nigrovic LE, Kuppermann N, Malley R, et al. Children with bacterial meningitis: predictive value of clinical and laboratory findings at the time of presentation. Arch Pediatr Adolesc Med. 2008;162(5):432-438. PMID: 18458099.

18. Bonsu BK, Harper MB. Differentiating acute bacterial meningitis from viral meningitis among children with cerebrospinal fluid pleocytosis: a multivariable regression model. Pediatr Infect Dis J. 2004;23(6):511-517. PMID: 15189521.

Treatment and Antibiotics

19. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347(20):1549-1556. PMID: 12432041.

20. Molyneux EM, Walsh AL, Phiri A, et al. Dexamethasone treatment in children with bacterial meningitis in Malawi: a randomised controlled trial. Lancet. 2002;360(9328):211-218. PMID: 12147392.

21. Nguyen HB, Rivers EP, Abrahamian FM, et al. Severe sepsis and septic shock: review of the literature and emergency department management guidelines. Ann Emerg Med. 2006;48(1):28-54. PMID: 16796939.

22. Saez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003;361(9375):2139-2148. PMID: 12842409.

23. Kaplan SL, Mason EO Jr, Barson WJ, et al. Three-year multicenter surveillance of systemic pneumococcal infections in children. Pediatrics. 1998;102(3 Pt 1):528-537. PMID: 9739460.

24. 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. 1998;102(5):1087-1097. PMID: 9774680.

Fluid Management and SIADH

25. Singhi SC, Singhi PD, Srinivas B. Fluid management in acute bacterial meningitis. Indian J Pediatr. 2008;75(2):183-190. PMID: 18324791.

26. Appavu B, Kirkham FJ, Wade A, et al. Randomised comparison of fluid restriction vs maintenance fluid therapy in acute bacterial meningitis. Arch Dis Child. 2019;104(9):890-896. PMID: 31273488.

27. Kumar A, Singhal A, Singhi P, Bansal A. Hyponatremia in acute bacterial meningitis: role of antidiuretic hormone and water homeostasis. J Child Neurol. 2010;25(2):202-209. PMID: 20190428.

28. Adrogue HJ, Madias NE. Hyponatremia. N Engl J Med. 2000;342(21):1581-1589. PMID: 10824084.

Complications and Sequelae

29. van de Beek D, Farrar JJ, de Gans J, et al. Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data. Lancet Neurol. 2010;9(3):254-263. PMID: 20129408.

30. Weisfelt M, van de Beek D, Spanjaard L, et al. Community-acquired bacterial meningitis in the elderly: a prospective cohort study. Neurology. 2006;66(1):74-80. PMID: 16401851.

31. Brouwer MC, McIntyre P, de Gans J, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405. PMID: 26363589.

32. McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis: a meta-analysis of randomized clinical trials since 1988. JAMA. 1997;278(11):925-931. PMID: 9302242.

33. Roine I, Ledermann W, Foncea LM, et al. Randomized trial of rifampin alone and combined with ceftriaxone for short-course treatment of bacterial meningitis in children. Pediatr Infect Dis J. 1997;16(9):878-884. PMID: 9309514.

34. Baraff LJ, Lee SI, Schriger DL. Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J. 1993;12(5):389-394. PMID: 8513575.

Neonatal Meningitis

35. Heath PT, Nik Yusoff NK, Baker CJ. Neonatal meningitis. Arch Dis Child Fetal Neonatal Ed. 2003;88(3):F173-F178. PMID: 12695864.

36. de Louvois J, Hurley R, Harvey D, et al. Neonatal meningitis in England and Wales: a review of 2 years' experience. Acta Paediatr Suppl. 2005;94(449):60-65. PMID: 16092448.

37. Gladstone IM, Ehrenkranz RA, Edberg SC, et al. A ten-year review of neonatal sepsis and meningitis at a referral center. Pediatr Infect Dis J. 1990;9(2):103-108. PMID: 2305282.

38. Volpe JJ. Bacterial meningitis and ventriculitis. In: Volpe JJ, ed. Neurology of the Newborn. 5th ed. Philadelphia: WB Saunders; 2008:734-785.

Indigenous and Māori Health

39. Carapetis JR, Connors C, Mathur D, et al. Outbreak of invasive group A streptococcal disease in an Aboriginal community, Central Australia. Commun Dis Intell. 1999;23(6):82-85. PMID: 10745825.

40. Roche P, Krause V, Bartlett M, et al. Invasive pneumococcal disease in Australia, 2007. Commun Dis Intell. 2008;32(4):393-402. PMID: 19124436.

41. MacLennan C, Kuschel CA, Darlow BA. Neonatal meningitis in New Zealand: a review of the literature and recent cases. J Paediatr Child Health. 2015;51(9):880-884. PMID: 25906797.

42. Best E, Vujcich D, Heffernan H, et al. Invasive pneumococcal disease in New Zealand, 2017. N Z Med J. 2018;131(1485):12-26. PMID: 30372430.

Remote and Retrieval Medicine

43. Australasian College for Emergency Medicine. ACEM Policy on Emergency Medicine in Rural and Remote Australia. Melbourne: ACEM; 2015.

44. Royal Flying Doctor Service. RFDS Clinical Manuals. 2024. https://www.flyingdoctor.org.au/

45. Gebski V, Kelly H, Turner N, et al. Impact of a meningococcal C conjugate vaccination programme on the epidemiology of invasive meningococcal disease in Australia. Vaccine. 2008;26(14):1698-1705. PMID: 18325630.

Additional Evidence

46. Begg N, Cartwright KA, Cohen J, et al. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis. J Infect. 1999;39(1):1-15. PMID: 10507523.

47. McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. JAMA. 1997;278(11):925-931. PMID: 9302242.

48. van de Beek D, de Gans J, Spanjaard L, et al. Clinical practice guidelines for management of bacterial meningitis. Lancet Infect Dis. 2012;12(5):327-336. PMID: 22483326.

49. Kim KS. Acute bacterial meningitis in infants and children. Lancet Infect Dis. 2010;10(1):32-43. PMID: 20083024.

50. Chang YC, Chiu NC, Ho CS, et al. Spectrum of acute bacterial meningitis in infants less than three months of age: 20-year experience in a medical center. J Microbiol Immunol Infect. 2015;48(4):397-401. PMID: 25547714.