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

Question 1

What are common pathogens for community-acquired bacterial meningitis in healthy immunized children >1mo?

Answer 1

1. Streptococcus pneumonia
2. Neisseria meningitidis
3. Streptococcus agalactiae (i.e. GBS) - consider in infants up to 3mo
4. E coli - consider in infants up to 3mo
5. Hemophilus influenza - non typable, and occasionally Hib in non-immunized children

Question 2

What is the criteria for penicillin susceptibility in S. pneumoniae?

Answer 2

1. Penicillin susceptible = MIC <0.06ug/mL penicillin

2. Penicillin resistant if MIC >0.12ug/mL

Question 3

What are Canadian susceptibility patterns?

Answer 3

1. S. pneumoniae ~20% resistant to penicillin and ~2% resistant to ceftriaxone
2. N meningitidis
3. 6% resistant to penicillin
4. Hib
   4-42% resistant to ampicillin

Question 4

What are signs and symptoms of meningitis?

Answer 4

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

Question 5

What should be done to diagnose meningitis?

Answer 5

LP for CSF analysis (cell count, glucose, protein, microbiology culture, viral studies, bacterial DNA testing)

Question 6

What are contraindications to a LP?

Answer 6

1. Coagulopathy
2. Cutaneous lesions at the proposed puncture site
3. Signs of herniation
4. Unstable clinical status such as shock

Question 7

When should an LP be deferred until imaging (contrast CT or MRI head) can be performed?

Answer 7

1. Papilledema
2. Focal neurological signs
3. Decreased LOC
4. Coma

Question 8

When should empirical antimicrobial therapy be given?

Answer 8

Do not delay for imaging or LP if will take awhile

Blood culture prior to antimicrobial therapy start

Question 9

What is the minimum blood volume required for a blood culture?

Answer 9

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

Question 10

When should a urine culture, pharyngeal culture or CXR be done?

Answer 10

As clinically indicated

Question 11

What are poor prognostic factors?

Answer 11

1. Delay in start of antimicrobial therapy
2. Severity of clinical state at presentation
3. Isolation of non-penicllin susceptible S pneumoniae

Question 12

When should Listeria coverage (ampicillin) be added?

Answer 12

Underlying immunodeficiency

Question 13

What is the recommended empirical treatment pending blood and CSF culture?

Answer 13

Ceftriaxone OR cefotaxime AND vancomycin ADD ampicillin to cover Listeria if patients are at risk because they are immunocompromised

Question 14

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?

Answer 14

Ceftriaxone OR cefotaxime, without vancomycin* *Vancomycin could be continued if there is local epidemiological evidence of third-generation cephalosporin resistance of Streptococcus pneumoniae

Question 15

What is the recommended treatment for penicillin susceptible S pneumoniae?

Answer 15

1. Penicillin G or ampicillin

2. Alternative: cefotaxime OR ceftriaxone

Question 16

What is the recommended treatment for penicillin resistant AND ceftriaxone or cefotaxime susceptible S pneumoniae?

Answer 16

1. Ceftriaxone OR cefotaxime

2. Alternative: Meropenem

Question 17

What is the recommended treatment for penicillin resistant AND ceftriaxone or cefotaxime intermediate or fully resistant (MIC >1ug/mL) S pneumoniae?

Answer 17

1. Ceftriaxone OR cefotaxime AND vancomycin and consult an ID expert
2. Alternative: Meropenem

Question 18

What is the recommended treatment for penicillin susceptible Neisseria meningitidis?

Answer 18

1. Penicillin G or ampicillin

2. Alternative: cefotaxime OR ceftriaxone

Question 19

What is the recommended treatment for penicillin resistant Neisseria meningitidis?

Answer 19

Ceftriaxone OR cefotaxime

Question 20

What is the recommended treatment for ampicillin susceptible Haemophilus influenzae?

Answer 20

Ampicillin

Question 21

What is the recommended treatment for ampicillin resistant Haemophilus influenzae?

Answer 21

Ceftriaxone or cefotaxime

Question 22

What is the recommended treatment for Streptococcus agalactiae (GBS)?

Answer 22

Penicillin G or ampicillin; ADD gentamicin for the first 5 to 7 days or until cerebrospinal fluid sterility confirmed

Question 23

What is the recommended treatment for other organisms?

Answer 23

Consult an ID expert

Question 24

What is the recommendations re: steroids?

Answer 24

Give dexamethasone 0.6mg/kg/day IV QID administered with or within 30min of the first dose of antimicrobials
If S. pneumoniae or Hib continue for total of 48h, otherwise d/c

Question 25

What do steroids do?

Answer 25

prevent hearing loss in children with acute bacterial meningitis caused by Hib

Question 26

What are the recommendations re: repeat CSF sampling?

Answer 26

Not recommended usually
GBS meningitis consider at 24-48h post initiation of therapy
E coli (gram negative enteric pathogens) repeat CSF culture at 24-48h

Question 27

What is the recommended duration of therapy with IV antibiotic therapy?

Answer 27

1. S pneumoniae 10-14d
2. Hib 7-10d
3. N meningitidis 5-7d
4. GBS 14-21d

Question 28

When should routine formal audiology assessment occur in children with diagnosis of bacterial meningitis?

Answer 28

Before discharge or within one month of discharge