Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age Flashcards
What are common pathogens for community-acquired bacterial meningitis in healthy immunized children >1mo?
- Streptococcus pneumonia
- Neisseria meningitidis
- Streptococcus agalactiae (i.e. GBS) - consider in infants up to 3mo
- E coli - consider in infants up to 3mo
- Hemophilus influenza - non typable, and occasionally Hib in non-immunized children
What is the criteria for penicillin susceptibility in S. pneumoniae?
- Penicillin susceptible = MIC <0.06ug/mL penicillin
2. Penicillin resistant if MIC >0.12ug/mL
What are Canadian susceptibility patterns?
- S. pneumoniae ~20% resistant to penicillin and ~2% resistant to ceftriaxone
- N meningitidis
- 6% resistant to penicillin
- Hib
4-42% resistant to ampicillin
What are signs and symptoms of meningitis?
Infant 1. Fever 2. Poor feeding 3. Lethargy esp. progressive 4. Emesis 5. Irritability esp. prolonged or worsening 6. Rash 7. Inconsolable crying Older child 1. Nuchal rigidity 2. Headache 3. Impaired consciousness
What should be done to diagnose meningitis?
LP for CSF analysis (cell count, glucose, protein, microbiology culture, viral studies, bacterial DNA testing)
What are contraindications to a LP?
- Coagulopathy
- Cutaneous lesions at the proposed puncture site
- Signs of herniation
- Unstable clinical status such as shock
When should an LP be deferred until imaging (contrast CT or MRI head) can be performed?
- Papilledema
- Focal neurological signs
- Decreased LOC
- Coma
When should empirical antimicrobial therapy be given?
Do not delay for imaging or LP if will take awhile
Blood culture prior to antimicrobial therapy start
What is the minimum blood volume required for a blood culture?
2 mL for a child weighing 1.5 kg to <4 kg;
4 mL for a child weighing 4 kg to <8 kg;
6 mL for a child weighing 8 kg to <14 kg;
10 mL for a child weighing 14 kg to <19 kg;
16 mL for a child weighing 19 kg to <26 kg; and
20 mL for a child weighing >26 kg
When should a urine culture, pharyngeal culture or CXR be done?
As clinically indicated
What are poor prognostic factors?
- Delay in start of antimicrobial therapy
- Severity of clinical state at presentation
- Isolation of non-penicllin susceptible S pneumoniae
When should Listeria coverage (ampicillin) be added?
Underlying immunodeficiency
What is the recommended empirical treatment pending blood and CSF culture?
Ceftriaxone OR cefotaxime AND vancomycin ADD ampicillin to cover Listeria if patients are at risk because they are immunocompromised
What is the recommended empirical treatment if blood and CSF cultures are negative or not performed but a diagnosis of bacterial meningitis is supported by clinical course and laboratory investigations?
Ceftriaxone OR cefotaxime, without vancomycin* *Vancomycin could be continued if there is local epidemiological evidence of third-generation cephalosporin resistance of Streptococcus pneumoniae
What is the recommended treatment for penicillin susceptible S pneumoniae?
- Penicillin G or ampicillin
2. Alternative: cefotaxime OR ceftriaxone
