Meningitis (peds): Difference between revisions
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Revision as of 02:25, 14 July 2016
Background
- Meningismus is difficult to discern if <6mo, (esp if <2mo)
- <3months old
- 1% incidence of bacterial meningitis
- E. coli, Group B strep, listeria
- >3months old
Risk Factors
- Otitis Media
- Sinusitis
- Immunosuppression/splenectomy
- Alcoholism
- Pneumonia
- Diabetes Mellitus
- CSF leak
- Endocarditis
- Neurosurgical procedure / head injury
- Indwelling neurosurgical device / cochlear implant
- Malignancy
- Drug induced aseptic meningitis
- NSAIDs
- Antimicrobials, see above page for list
Clinical Features
Following features in the correct clinical context should raise suspicion
- Fever
- Headache
- Meningeal signs
- Poor feeding
- Irritability
- Apnea
- Lethargy
- Fever
- Hypothermia
- Seizures
- Bulging fontanelle
- Hypotonia
- Weak cry
- Hypoglycemia
Differential Diagnosis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Pediatric Rash
- Atopic dermatitis
- Bed bugs
- Contact dermatitis
- Drug rash
- Erythema infectiosum (Fifth disease)
- Hand-foot-and-mouth disease
- Henoch-schonlein purpura (HSP)
- Herpangina
- Herpes simplex virus (HSV)
- Infectious mononucleosis
- Meningitis
- Measles
- Molluscum contagiosum
- Roseola infantum
- Rubella (German measles)
- Scabies
- Scarlet fever
- Smallpox
- Varicella (Chickenpox)
Diagnosis
Work-Up
- CBC
- Chem
- Blood culture
- ?CT head: See CT Before Lumbar Puncture
- CXR (50% of patients with pneumoccocal meningitis have evidence of pneumonia on CXR)
- Lumbar Puncture
CSF interpretation by age
- In general neutrophils are abnormal in pediatric CSF and should increase the suspicion for bacterial meningitis. Meningitis can also occur in children with normal CSF microscopy.
| ' | Neutrophils | Lymphocytes | Protein | Glucose |
| (x 106 /L) | (x 106/L) | (g/L) | (CSF:blood ratio) | |
| Normal (>1 month of age) |
0 | ≤ 5 | < 0.4 | ≥ 0.6 (or ≥ 2.5 mmol/L) |
| Normal neonate (<1 month of age) |
0 | < 20 | <1.0 | ≥ 0.6 (or ≥ 2.5 mmol/L) |
CSF Interpretation by Diagnosis
- If the CSF is abnormal the safest course is to treat as if it is bacterial meningitis until cultures return negative growth.'[1]
- PCR is available for Neisseria meningitidis, Herpes Simplex and Enterovirus and will with inpatient diagnosis. PCR is most helpful for patients with encephalitis and has poor sensitivity and specificity for bacterial antigens.
| ' | Neutrophils | Lymphocytes | Protein | Glucose |
| (x 106 /L) | (x 106/L) | (g/L) | (CSF:blood ratio) | |
| Normal (>1 month of age) | 0 | ≤ 5 | < 0.4 | ≥ 0.6 (or ≥ 2.5 mmol/L) |
| Normal term neonate | 0* | < 20 | < 1.0 | ≥ 0.6 (or ≥ 2.5 mmol/L) |
| Bacterial meningitis | 100-10,000 | Usually < 100 | > 1.0 | < 0.4 |
| Viral meningitis | Usually <100 | 10-1000 | 0.4-1 | Usually normal |
| TB meningitis | Usually <100 | 50-1000 | 1-5 | < 0.3 |
Pediatric Bacterial Meningitis Score[2]
| Bacterial Meningitis Score | ' |
| Criteria | Point Score |
| Positive CSF Gram Stain | 2 |
| CSF protein > 80mg/dL | 1 |
| Blood Absolute neutrophil count > 10,000 cells/mm3 | 1 |
| Incidence of seizures with illness | 1 |
| CSF neutrophil count ≥ 1000 cells/mm3 | 1 |
- 0 points: Aseptic meningitis likely[3]
- 1 point: Aseptic meningitis less likely[4]
- ≥2 points: Bacterial Meningitis more likely[5]
Delay in LP
- CSF cultures are negative 2 hrs after parenteral antibiotics in meningococcal meningitis, and 6 hrs in pneumococcal meningitis[6][7]
- 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[8]
Management
"Steroids are unlikely to be beneficial for children with bacterial meningitis in the post-PCV7 era"[9]
<1 month old[10][11]
MRSA is uncommon in the neonate
- Ampicillin 75mg/kg IV q6hrs PLUS
- Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
- Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[12]
- If suspecting S. pneumoniae or MRSA, add Vancomycin
- Consider acyclovir for HSV
> 1 month old[13]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Children with Predisposing Factors[14]
| Risk Factor | Therapy |
| Basilar skull fracture | Vancomycin + third-generation cephalosporin |
| Penetrating trauma or recent neurosurgery | Vancomycin + cefepime, ceftazidime, or meropenem |
| Ventricular shunt | Vancomycin alone; if Gram stain reveals presence of gram-negative bacilli, then add cefepime, ceftazidime, or meropenem |
Disposition
- Admit despite negative meningitis score if:
- Age <2mo with any degree of pleocytosis
- Appear ill
- Infants with aseptic meningitis
See Also
References
- ↑ Brouwer MC et al. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet. 2012 Nov 10. 380(9854):1684-92.
- ↑ Chavanet P, Schaller C, Levy C, et al. Performance of a predictive rule to distinguish bacterial and viral meningitis. J Infect 2007;54: 328–36.
- ↑ Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60.
- ↑ Fine AM, Nigrovic LE, Reis BY, Cook EF, Mandl KD. Linking surveillance to action: incorporation of real-time regional data into a medical decision rule. J Am Med Inform Assoc 2007;14: 206–11.
- ↑ Dubos F, Korczowski B, Aygun DA, et al. Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules. Arch Dis Child 2010;95:963–7.
- ↑ Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74
- ↑ Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497
- ↑ Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794
- ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
- ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766