Pediatric Bacterial Meningitis (IDSA/NICE)

Algorithm Steps

1. ▶

   Start

   Suspected Pediatric Bacterial Meningitis

   Child with fever, altered mental status, meningeal signs

   1. ●

      Action

      Recognition & Initial Stabilization

      Clinical features and immediate actions

      • CLINICAL FEATURES:
      • • Fever, headache, photophobia
      • • Neck stiffness (may be absent in infants)
      • • Altered mental status, lethargy, irritability
      • • Bulging fontanelle (infants)
      • • Petechial/purpuric rash (meningococcal)
      • STABILIZE: ABCs, IV access, vitals
      1. ◆

         Decision

         LP Contraindicated?

         Can lumbar puncture be done safely?

         • CONTRAINDICATIONS to LP:
         • • Signs of raised ICP (papilledema, posturing)
         • • GCS <10 or rapidly deteriorating
         • • Focal neurologic signs
         • • Coagulopathy (platelets <50K, INR >1.5)
         • • Hemodynamic instability/shock
         • • Skin infection at LP site
         1. ●

            Action

            Perform Lumbar Puncture

            CSF analysis essential for diagnosis

            • CSF STUDIES:
            • • Cell count and differential
            • • Glucose and protein
            • • Gram stain and culture
            • • Consider: PCR (bacterial, viral), latex agglutination
            • BACTERIAL CSF typical:
            • • WBC >1000 (neutrophil predominant)
            • • Protein >100 mg/dL
            • • Glucose <40 mg/dL or CSF:serum ratio <0.4
            1. ●

               Action

               Empiric Antibiotic Therapy

               Age-based empiric coverage

               • AGE >1 MONTH:
               • • Ceftriaxone 100 mg/kg/day IV divided q12h (max 4g/day)
               • • + Vancomycin 60 mg/kg/day IV divided q6h (for resistant S. pneumoniae)
               • NEONATES (<1 month):
               • • Ampicillin 200-300 mg/kg/day + Cefotaxime (or gentamicin)
               • • Covers GBS, E. coli, Listeria
               • Duration: 7-21 days depending on organism
               1. ●

                  Action

                  Dexamethasone

                  Give with or before first antibiotic dose

                  • DEXAMETHASONE 0.15 mg/kg IV q6h x 2-4 days
                  • Give BEFORE or WITH first antibiotic dose
                  • Most beneficial for H. influenzae and S. pneumoniae
                  • May reduce neurologic sequelae
                  • Contraindicated in neonates (debated)
                  1. ●

                     Action

                     Supportive Care & Monitoring

                     ICU-level care often needed

                     • Monitor for complications:
                     • • Seizures (treat with lorazepam/levetiracetam)
                     • • Cerebral edema (consider mannitol/hypertonic saline)
                     • • SIADH (fluid restrict if hyponatremic)
                     • • DIC (if meningococcal)
                     • • Subdural effusion/empyema
                     • Serial neuro exams
                     • Repeat LP if not improving by 48-72 hours
                     1. ✓

                        Outcome

                        Follow-Up

                        Post-treatment care

                        • Hearing evaluation before discharge
                        • Neurodevelopmental follow-up
                        • Vaccination review
                        • Contact prophylaxis for N. meningitidis exposure
         2. ●

            Action

            Empiric Antibiotics IMMEDIATELY

            Do NOT delay antibiotics for LP or imaging

            • DO NOT DELAY ANTIBIOTICS!
            • If LP contraindicated → give antibiotics first
            • Get blood cultures before antibiotics if possible
            • (but do not delay abx for cultures)