Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age

Question 1

What are contraindications to doing a lumbar puncture?

Answer 1

1. Coagulopathy
2. Cutaneous lesions at the proposed puncture site
3. Signs of herniation (papilledema, focal neuro signs, ALOC –> imaging first)
4. Unstable clinical status (i.e. shock)

Question 2

What two bacteria are most likely to cause community-acquired meningitis in healthy, immunized children >1 month of age?

Answer 2

1. S pneumoniae
2. N meningitidis
   (+ E coli and GBS should be considered up to 3 months of age, + Hib occasionally in unimmunized patients)

Question 3

What empiric antibiotic therapy should you give for meningitis in children >1 month of age, and why?

Answer 3

1. Third-generation cephalosporin (cefotaxime or ceftriaxone, to cover penicillin-resistant S pneumoniae/Haemophilus/Neisseria)
   Ceftriaxone 100mg/kg/day div q12h
2. • vancomycin (because of the possibility of a cephalosporin-resistant S pneumoniae)
     60mg/kg/day div q6h, aim for trough 10-15.

(+ ampicillin to cover Listeria if patient is immuncompromised)
(meropenem if contraindication to cephalosporin, consult ID)

Question 4

What is the recommended duration of therapy for uncomplicated meningitis in children >1 month of age, by organism?

Answer 4

1. S pneumoniae: 10-14 days
2. Hib: 7-10 days
3. N meningitidis: 5-7 days
   (GBS: 14-21 days)
   (repeat CSF @ 24-48hrs for GBS and E coli to ensure sterilization, head imaging if not cleared)

Question 5

In what circumstance (and why) should you give steroids as adjuvant therapy for meningitis in children >1 month of age, and what would you order?

Answer 5

Evidence that steroids can reduce hearing loss in children with Hib if given before/with first dose of antibiotics, less certain data for S pneumoniae.
If no contraindications to steroids and suspect bacterial etiology (esp if Gram stain shows Gram+ diplococci or Gram- coccobacilli), give dexamethasone 0.6mg/kg/day IV div q6h x 48hrs (D/C if another etiology identified)