Meningitis

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- Infants with meningitis often present with nonspecific findings of:

• fever, poor feeding, lethargy (or decreased interaction with caregivers), vomiting, irritability, +/- a rash
• inconsolable crying, prolonged or worsening irritability, or progressive lethargy are also important clinical features that may indicate a CNS infection such as meningitis
• nuchal rigidity is uncommon in infants

- Older children are more likely to have specific symptoms related to meningitis, such as:

• fever
• stiff neck
• altered mental status
• headache 

NB: Absence of stiff neck does not rule out meningitis in any age group, particularly those < 2 years old.

Management

- Blood culture recommended.

- Droplet/contact precautions recommended for 24 hours.

- Indications for CT before LP:

• focal neurological deficit
• papilledema
• GCS < 11 or decrease in score of 3 or more
• recent seizure without recovery to baseline mental status

- Lumbar puncture (LP) for cell count, glucose, protein, Gram stain and culture recommended prior to antibiotic therapy unless:

• uncorrected coagulopathy
• hemodynamically unstable
• extensive or spreading purpura

See Typical CSF findings

NB: Do not delay dexamethasone and antibiotics when clinical suspicion of meningitis is high if neuroimaging (CT/MRI) and/or LP cannot be performed expediently.

- Bacterial antigen test (latex agglutination) of CSF not recommended.

- Repeat LP should be considered if:

• patient not responding clinically after 48h of appropriate antibiotic therapy

• S. pneumoniae and patient received dexamethasone or has penicillin and/or cephalosporin intermediate/resistant S. pneumoniae, especially if clinical improvement has not occurred

- Consider CT/MRI of brain to rule out subdural empyema if slow to improve or focal neurologic signs or new or persistent fever as this will require a longer course of antibiotics +/- surgical drainage.

- For prophylaxis of H. influenzae and N. meningitidis in close contacts, see Prophylaxis for Contacts of Communicable Diseases. 

Dexamethasone Therapy in Meningitis

- Corticosteroids are not recommended in neonatal meningitis.

- Corticosteroids are an option in bacterial meningitis in infants and children ≥ 6 weeks of age.

- Dexamethasone 0.15mg/kg (maximum 10mg/dose) IV q6h. Give 15-20 minutes before, or with, the first dose of antibiotics.  Dexamethasone can be given up to 4 hours (UK guidelines up to 12h) after administration of antibiotics.

• if S. pneumoniae or H. influenzae or no pathogen identified, continue dexamethasone for 4 days.
• if pathogen not S. pneumoniae or H. influenzae, discontinue dexamethasone.
  • If Listeria monocytogenes, discontinue dexamethasone immediately as associated with increased mortality.

- Empiric vancomycin is not routinely indicated for:

• sepsis without meningitis
• viral meningitis
• neonatal meningitis 

NB: Vancomycin has slow distribution and poor CSF penetration. It should be given as soon as possible AFTER the first dose of cefotaxime/ceftriaxone, and continued ONLY if the C&S results indicate cefotaxime/ceftriaxone resistant S. pneumoniae. Maintain trough vancomycin serum concentration of 10-20mg/L.

Audiology Assessment

Formal audiology assessment should be performed prior to discharge to optimize management if hearing loss has occurred.