Overview
Pediatric Meningitis
Quick Reference
Critical Alerts
- Time-critical: Antibiotics within 60 minutes: Do NOT delay for LP
- LP is gold standard but don't delay treatment: Antibiotics first if unstable
- Dexamethasone before or with first antibiotics: For bacterial meningitis
- Petechial/purpuric rash = meningococcemia: Emergent management
- Age determines pathogens and empiric therapy: Different organisms by age
- Neonates and young infants are high-risk: Low threshold for full sepsis workup
Key Diagnostics
| Test | Finding | Significance |
|---|---|---|
| CSF WBC | >000 cells/μL (PMN predominant) | Bacterial meningitis |
| CSF Protein | >00 mg/dL | Elevated in bacterial |
| CSF Glucose | <40 mg/dL or <50% serum | Low in bacterial |
| CSF Gram stain | Organisms seen | Confirms bacterial, identifies pathogen |
| Blood cultures | Positive | Identifies organism |
| Procalcitonin | Elevated | Supports bacterial etiology |
Emergency Treatments (By Age)
| Age | Empiric Antibiotics | Additional |
|---|---|---|
| <1 month | Ampicillin + Cefotaxime (or Gentamicin) | HSV coverage: Acyclovir |
| 1-3 months | Ampicillin + Ceftriaxone | ± Vancomycin, ± Acyclovir |
| > months | Ceftriaxone + Vancomycin | Dexamethasone before/with 1st dose |
| All ages | Dexamethasone | 0.15 mg/kg IV q6h × 4 days (ideally before/with 1st abx) |
Definition
Overview
Meningitis is inflammation of the meninges (membranes surrounding the brain and spinal cord) and is a medical emergency in children. Bacterial meningitis can progress rapidly and has high morbidity and mortality without prompt treatment. Viral meningitis is more common and typically benign. Early recognition, empiric antibiotics, and lumbar puncture are essential.
Classification
By Etiology:
| Type | Characteristics |
|---|---|
| Bacterial | Most severe; rapid progression; requires urgent antibiotics |
| Viral (Aseptic) | Usually benign; enterovirus most common |
| Tuberculous | Chronic, subacute presentation |
| Fungal | Immunocompromised patients; chronic |
By Age Group:
| Age | Common Bacterial Pathogens |
|---|---|
| <1 month | Group B Strep (GBS), E. coli, Listeria, HSV |
| 1-3 months | GBS, E. coli, S. pneumoniae, H. influenzae, Listeria |
| 3 months-5 years | S. pneumoniae, N. meningitidis, H. influenzae type b |
| > years | S. pneumoniae, N. meningitidis |
Epidemiology
- Incidence of bacterial meningitis: ~0.5-1 per 100,000 children (post-vaccine era)
- Mortality: 5-10% with treatment; higher in neonates
- Morbidity: 10-30% have neurological sequelae
- Viral meningitis incidence: Much higher (~3-5× bacterial)
- Vaccination impact: Hib, pneumococcal, meningococcal vaccines dramatically reduced incidence
Etiology
Bacterial Causes (By Age):
| <1 Month | 1-3 Months | > Months |
|---|---|---|
| Group B Strep (35-40%) | Group B Strep | S. pneumoniae (most common) |
| E. coli (25-30%) | E. coli | N. meningitidis |
| Listeria monocytogenes | S. pneumoniae | H. influenzae type b (rarely now) |
| HSV (consider in neonates) | Listeria | |
| Other Gram negatives | N. meningitidis |
Viral Causes:
| Virus | Notes |
|---|---|
| Enteroviruses | Most common cause of aseptic meningitis |
| HSV | Neonates at high risk |
| Parechovirus | Young infants |
| Arboviruses | Geographic, seasonal |
| VZV, EBV, mumps | Less common |
Pathophysiology
Mechanism of Bacterial Meningitis
- Colonization: Nasopharyngeal colonization (S. pneumoniae, N. meningitidis) or vertical transmission (GBS, E. coli)
- Bacteremia: Organisms enter bloodstream
- CNS invasion: Cross blood-brain barrier
- Meningeal inflammation: Bacterial components trigger cytokine release
- Cerebral edema: Increased ICP
- Vascular injury: Vasculitis, thrombosis → infarcts
- Neuronal injury: Cell death, sequelae
Consequences
- Cerebral edema → Elevated ICP → Herniation risk
- Vasculitis → Stroke
- Subdural effusions/empyema
- Hydrocephalus
- Hearing loss (especially S. pneumoniae, H. influenzae)
- Seizures
Clinical Presentation
Symptoms
Classic Triad (Often absent in young children):
Symptoms by Age:
| Age | Symptoms |
|---|---|
| Neonates | Irritability, lethargy, poor feeding, temperature instability, bulging fontanelle |
| Infants | Fever, irritability, inconsolable crying, poor feeding, vomiting, lethargy |
| Older children | Fever, headache, neck stiffness, photophobia, nausea, vomiting, lethargy |
History
Key Questions:
Physical Examination
Vital Signs:
Neurological Examination:
| Finding | Significance |
|---|---|
| Neck stiffness | Classic; may be absent in young infants |
| Kernig sign | Pain with knee extension (hip flexed) |
| Brudzinski sign | Neck flexion causes hip/knee flexion |
| Altered mental status | Poor prognosis |
| Focal deficits | Concerning for stroke, abscess |
| Bulging fontanelle | Elevated ICP (infants) |
| Papilledema | Elevated ICP (rare acutely) |
Skin:
General:
Fever
Common presentation.
Headache
Common presentation.
Neck stiffness
Common presentation.
Red Flags
Life-Threatening Presentations
| Finding | Concern | Action |
|---|---|---|
| Petechial/purpuric rash | Meningococcemia | Emergent antibiotics; aggressive resuscitation |
| Shock (hypotension, poor perfusion) | Septic shock | IV fluids, vasopressors, antibiotics |
| Signs of herniation (posturing, blown pupil) | Elevated ICP | Osmotherapy, neurosurgery, delay LP |
| Seizures | Severe infection | Benzodiazepines, antibiotics, stabilize |
| Rapidly declining mental status | Severe disease | Airway, antibiotics, ICU |
| Coma | Very high mortality | ICU, aggressive management |
Contraindications to Immediate LP
| Finding | Action |
|---|---|
| Signs of herniation (unequal pupils, posturing) | CT first, defer LP |
| Severe cardiopulmonary compromise | Stabilize first |
| Skin infection over LP site | Avoid LP at that site |
| Coagulopathy | Correct first if possible |
ALWAYS: Start antibiotics first if LP will be delayed
Differential Diagnosis
Other Causes of Fever, Altered Mental Status, Meningismus
| Diagnosis | Key Features |
|---|---|
| Encephalitis | More altered mentation, seizures, behavioral changes |
| Brain abscess | Focal deficits, headache |
| Intracranial hemorrhage | Acute headache, focal signs |
| Sepsis without meningitis | May have similar presentation; LP negative |
| Febrile seizure | Post-ictal confusion, benign LP |
| Subarachnoid hemorrhage | Severe sudden headache, bloody CSF |
| Sinusitis with complication | Focal swelling, direct extension |
| Drug reaction (aseptic meningitis) | NSAIDs, IVIG, antibiotics |
Diagnostic Approach
Lumbar Puncture
Gold Standard for Diagnosis
CSF Analysis:
| Parameter | Normal | Bacterial | Viral |
|---|---|---|---|
| WBC (cells/μL) | <5 | >000, PMN predominant | 10-500, lymphocyte predominant |
| Protein (mg/dL) | <45 | >00 | 50-100 |
| Glucose (mg/dL) | >45 (or >0% serum) | <40 (or <40% serum) | Normal |
| Gram stain | Negative | Positive (60-90%) | Negative |
| Culture | Negative | Positive | Negative |
Additional CSF Testing:
| Test | Purpose |
|---|---|
| Bacterial PCR multiplex | Identifies common pathogens |
| HSV PCR | Neonates and encephalitis concern |
| Enterovirus PCR | Viral meningitis |
| Lactate | Elevated in bacterial (>5 mg/dL) |
When to Defer LP
CT Before LP if:
- Altered consciousness
- Focal neurological deficits
- Papilledema
- Recent seizure (some guidelines)
- Immunocompromised with new neurological sign
BUT: Do NOT delay antibiotics for CT or LP
Blood Tests
| Test | Purpose |
|---|---|
| Blood cultures | Identify organism |
| CBC | WBC elevation |
| CMP | Electrolytes, glucose (for CSF ratio) |
| CRP, Procalcitonin | Support bacterial vs viral |
| Coagulation | Pre-LP |
| Lactate | Sepsis severity |
Treatment
Principles of Management
- Stabilize: Airway, breathing, circulation
- Antibiotics within 60 minutes: Time to antibiotics = outcomes
- Dexamethasone before or with first antibiotics: If bacterial suspected
- LP when safe: Diagnostic but don't delay treatment
- Supportive care: Fluids, analgesia, ICU if needed
Empiric Antibiotic Therapy (By Age)
Age <1 Month (Neonates):
| Drug | Dose | Coverage |
|---|---|---|
| Ampicillin | 75-100 mg/kg IV q6h | GBS, Listeria, Enterococcus |
| + Cefotaxime | 50 mg/kg IV q6-8h | E. coli, Gram negatives |
| or + Gentamicin | 4-5 mg/kg IV q24h | Gram negatives (if cefotaxime unavailable) |
| + Acyclovir | 20 mg/kg IV q8h | HSV (always consider in neonates) |
Age 1-3 Months:
| Drug | Dose | Coverage |
|---|---|---|
| Ampicillin | 75-100 mg/kg IV q6h | Listeria, Enterococcus |
| + Ceftriaxone | 50 mg/kg IV q12h (or 100 mg/kg q24h) | S. pneumoniae, H. flu, Gram negatives |
| ± Vancomycin | 15 mg/kg IV q6h | Resistant S. pneumoniae |
| ± Acyclovir | 20 mg/kg IV q8h | If concern for HSV |
Age >3 Months:
| Drug | Dose | Coverage |
|---|---|---|
| Ceftriaxone | 50-100 mg/kg IV q12-24h (max 4g/day) | S. pneumoniae, N. meningitidis, H. flu |
| + Vancomycin | 15 mg/kg IV q6h (max 2g/dose) | Resistant S. pneumoniae |
Dexamethasone
Indication: Suspected or confirmed bacterial meningitis in children >6 weeks
Dosing: 0.15 mg/kg IV q6h × 4 days (or 0.4 mg/kg q12h × 2 days)
Timing: Give before or with first dose of antibiotics (ideally 30 min before)
Benefit: Reduces hearing loss (especially H. influenzae), may reduce neurological sequelae
Note: If diagnosis changes to viral, can discontinue
Supportive Care
| Intervention | Details |
|---|---|
| IV fluids | Isotonic; avoid over-hydration (SIADH risk) |
| Seizure management | Benzodiazepines → Levetiracetam/phenytoin |
| ICP management | Head of bed 30°, osmotherapy if needed |
| Analgesia | Acetaminophen, NSAIDs, opioids if needed |
| ICU care | If severe, unstable, or deteriorating |
Duration of Therapy
| Organism | Duration |
|---|---|
| N. meningitidis | 7 days |
| H. influenzae | 7-10 days |
| S. pneumoniae | 10-14 days |
| Group B Strep | 14-21 days |
| Listeria | 21 days |
| Gram-negative bacilli | 21 days |
Disposition
ICU Admission
- Altered mental status
- Hemodynamic instability
- Respiratory compromise
- Seizures
- Signs of elevated ICP
Floor Admission
- Confirmed or suspected bacterial meningitis (stable)
- Viral meningitis requiring observation/IV fluids
Discharge (Viral Meningitis)
- Older child, well-appearing, tolerating PO
- Confirmed viral etiology (positive enterovirus PCR)
- Reliable follow-up
Follow-Up
| Situation | Follow-Up |
|---|---|
| Bacterial meningitis | Audiology (hearing test) |
| Bacterial meningitis | Neurology/developmental follow-up |
| Viral meningitis | PCP in 1-2 weeks if discharged |
Patient Education
Condition Explanation (For Parents — Bacterial)
- "Your child has an infection of the membranes around the brain called meningitis."
- "This is very serious and requires strong antibiotics and hospital care."
- "We are treating quickly to prevent complications like hearing loss or brain damage."
Condition Explanation (Viral)
- "Your child has viral meningitis, which is much milder than bacterial."
- "It typically improves on its own with supportive care."
- "Your child should recover fully within 1-2 weeks."
Prevention (Contacts of Meningococcal Meningitis)
- Close contacts need prophylaxis (rifampin, cipro, or ceftriaxone)
- Public health notification
Special Populations
Neonates (<28 Days)
- High-risk for GBS, E. coli, Listeria, HSV
- Always add acyclovir if any concern for HSV
- Low threshold for full sepsis workup with LP
- Higher mortality and morbidity
Immunocompromised Children
- Broader differential (fungi, atypical organisms)
- May need CT before LP
- Broader empiric coverage
- Higher complications
VP Shunt Patients
- High risk for shunt infection
- Common organisms: Staph epidermidis, S. aureus
- May need shunt tap (by neurosurgery)
- Cover Staph: Vancomycin + Ceftazidime/Meropenem
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Antibiotics within 60 minutes | 100% | Reduces mortality |
| Dexamethasone given with/before abx | >0% | Reduces hearing loss |
| Blood cultures before abx (if possible) | >0% | Identify organism |
| LP performed (if no contraindication) | >5% | Diagnostic gold standard |
| Hearing test post-bacterial meningitis | 100% | Detect sequelae |
Documentation Requirements
- Time to antibiotics
- DexamethasonMicrosoftInternetExplorer4e given before/with antibiotics
- CSF results
- Clinical status and response
- Neurology/ID consultation if applicable
- Hearing referral
Key Clinical Pearls
Diagnostic Pearls
- Classic triad is often absent in young children: Low threshold for LP
- Irritability + fever in infant = meningitis until proven otherwise
- Petechial rash = meningococcemia: Treat immediately
- LP before antibiotics is ideal but never delay antibiotics: If LP delayed, cultures will still be positive >90% at 4 hours
- Normal WBC does not exclude meningitis: Early disease, immunocompromised
- Partially treated meningitis: CSF may be atypical; still treat empirically
Treatment Pearls
- Antibiotics within 60 minutes: Time = brain
- Dexamethasone before/with first antibiotics: For H. flu and pneumococcal especially
- Ampicillin covers Listeria: Required in neonates and <3 months
- Add Vancomycin >3 months: For resistant pneumococcus
- Acyclovir in neonates: Always consider HSV
- Restrict fluids cautiously: SIADH is common
Disposition Pearls
- All bacterial meningitis = ICU or close monitoring
- Viral meningitis can often be managed outpatient: If older child, well-appearing
- Audiology follow-up for all bacterial cases: Hearing loss is common
- Public health notification for meningococcal disease: Prophylaxis for contacts
References
- Tunkel AR, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis. 2004;39(9):1267-1284.
- van de Beek D, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004;351(18):1849-1859.
- Nigrovic LE, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297(1):52-60.
- Brouwer MC, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;(9):CD004405.
- American Academy of Pediatrics Committee on Infectious Diseases. Red Book: 2021-2024 Report of the Committee on Infectious Diseases.
- Kimberlin DW, et al. Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions. Pediatrics. 2013;131(2):e572-e579.
- Thigpen MC, et al. Bacterial Meningitis in the United States, 1998-2007. N Engl J Med. 2011;364(21):2016-2025.
- UpToDate. Bacterial meningitis in children older than one month: Treatment and prognosis. 2024.