Rapid overview: Emergency management of infants (≥1 month) and children with suspected bacterial meningitis

Clinical findings

Infants – Fever, hypothermia, bulging fontanel, lethargy, irritability, seizures, respiratory distress, poor feeding, vomiting.

Older children – Fever, headache, photophobia, meningismus, nausea/vomiting, confusion, lethargy, irritability.

Evaluation

Laboratory testing – Initial laboratory testing should include (STAT):

Blood culture.
CBC with differential and platelet count.
Inflammatory markers (CRP, procalcitonin).
Serum electrolytes, BUN, creatinine, glucose.
PT, INR, and PTT.

Lumbar puncture (LP):

LP should be performed in all children with suspected meningitis, unless there is a specific contraindication to LP.
Contraindications to LP include: cardiopulmonary compromise, clinical signs of increased intracranial pressure, papilledema, focal neurologic signs, and skin infection over the site for LP. If there is a contraindication to or inability to perform an LP, or if the LP is delayed by the need for cranial imaging, antimicrobial therapy should not be delayed. Blood cultures should be obtained and empiric antibiotics administered as soon as is possible.
CSF should be sent for the following (STAT): cell count and differential, glucose and protein concentration, Gram stain, and culture.

Neuroimaging (eg, head CT):

In children who require neuroimaging before LP, blood cultures should be obtained and empiric antibiotics administered before imaging. LP should be performed as soon as possible after neuroimaging is completed, provided that the imaging has not revealed any contraindications.
Indications for neuroimaging before LP include: severely depressed mental status (coma), papilledema, focal neurologic deficit, history of hydrocephalus and/or presence of a CSF shunt, recent history of CNS trauma or neurosurgery.

Management

Supportive care:

Ensure adequate oxygenation, ventilation, and circulation.
Obtain venous access and initiate cardiorespiratory monitoring while obtaining laboratory studies.
Keep the head of bed elevated at 15 to 20°.
Treat hypoglycemia, acidosis, and coagulopathy, if present.

Antimicrobial therapy – Antibiotic therapy should be initiated immediately following the LP if the clinical suspicion for meningitis is high:

Administer first doses of empiric antibiotic therapy:
- Vancomycin (15 mg/kg IV), PLUS
- Ceftriaxone (50 mg/kg IV) or cefotaxime (100 mg/kg IV; where available).
Consider dexamethasone therapy* (0.15 mg/kg IV) in patients with certain risk factors (eg, unimmunized patients) or if there is known or suspected Haemophilus influenzae infection (eg, based on Gram stain results).
If dexamethasone is given, it should be administered before, or immediately after, the first dose of antibiotic therapy.

STAT: intervention should be performed emergently; CBC: complete blood count; CRP: C-reactive protein; BUN: blood urea nitrogen; PT: prothrombin time; INR: international normalized ratio; PTT: partial thromboplastin time; LP: lumbar puncture; CT: computed tomography; CSF: cerebrospinal fluid; CNS: central nervous system; IV: intravenous.

* The optimal use of dexamethasone in children with suspected meningitis is uncertain, and expert opinions varies. UpToDate's author would administer dexamethasone only to children who are known or highly suspected to have H. influenzae (Hib) at the time the LP is performed (a fairly uncommon scenario). Other experts would administer dexamethasone to all children with suspected community-acquired bacterial meningitis. In addition, it may be reasonable to use dexamethasone in older adolescent patients since dexamethasone is a recommended component of therapy for adult patients with suspected bacterial meningitis. The 2021 Red Book statement on dexamethasone use in pneumococcal meningitis also acknowledges that expert opinion differs on this issue. Evidence supporting the efficacy of dexamethasone in reducing the risk of hearing loss in children with meningitis is most clearly established for infections caused by Hib. For other bacterial pathogens (eg, pneumococcus, meningococcus), the efficacy of dexamethasone is uncertain. For further details, refer to UpToDate topics on bacterial meningitis in children and the use of dexamethasone and other measures to prevent neurologic complications of pediatric bacterial meningitis.

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Rapid overview: Emergency management of infants (≥1 month) and children with suspected bacterial meningitis