CPS Statement: Management of bacterial meningitis

CPS Statement: Management of bacterial meningitis

The following was adapted from the Canadian Paediatric Society’s statement on "Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age." Please see the full statement for the full recommendations from the Canadian Paediatric Society.

Background:

These guidelines apply to children older than one month of age with suspected and confirmed bacterial meningitis.  They do not apply to children in the neonatal period, meningitis associated with cerebrospinal fluid shunts, or meningitis caused b gram-negative bacteria or viruses.

Etiology:

There are three major pathogens to consider that cause bacterial meningitis in children.  All three of these bacteria now have vaccines in the routine immunization schedule that cover most common serotypes.

  • Haemophilus influenzae (H. influenzae) - Vaccine covers H. influenzae type B (Hib).
  • Streptococcus pneumonia (S. pneumoniaie) - The PCV13 vaccine covers 13 serotypes.
  • Neisseria meningitidis (N. meningitidis) - The MCV4 vaccine covers serogroup A, C, Y, and W. A vaccine for serogroup B is now available but is not included in routine immunization schedules.

Other possible etiologies are rare in this age group but may include:

  • Group B streptococcus (GBS or Streptococcus agalactiae) and Escherichia coli (E. coli) - Rare beyond the neonatal period.
  • Listeria monocytogene - Rare beyond the neonatal period, but may be seen in children who are immunocompromised.

The epidemiology of bacterial meningitis has changed considerably since the introduction of vaccination.  For example, Hib meningitis is now almost only seen in children who are immunocompromised or unimmunized.  There has also been a relative and absolute increase in the prevalence of disease caused by serotypes of bacteria that are not covered by vaccines.  New trends in antimicrobial resistance have led to changes in the recommended empiric therapy for meningitis.

Diagnosis:

Diagnosis of meningitis is based on both the clinical presentation and investigations.

Presentation: Infants have very non-specific symptoms including fever, poor feeding, lethargy, vomiting and irritability. Older children are more likely to have specific symptoms including headache, neck pain and nuchal rigidity in addition to the non-specific symptoms. All children should be assessed for respiratory distress, focal neurologic signs and level of consciousness

Lumbar Puncture (LP): Because the presentation of meningitis is so non-specific, clinicians should perform a LP whenever meningitis is suspected. CSF should be analyzed for cell count, glucose and protein levels, bacterial culture and viruses when appropriate. Contraindications include active infection at the proposed puncture site, unstable clinical status, coagulopathies and signs of increased intracranial pressure.  If increased intracranial pressure is suspected, an LP should be deferred until imaging can rule out the risk of herniation.

Investigations: Blood cultures should be drawn before starting antibiotic therapy.  Other investigations including a urine culture, pharyngeal culture or chest X-ray may be indicated in some cases.

Management:

Antimicrobials: Therapy with IV antibiotics should begin as soon as possible when meningitis is suspected for the best possible prognosis.  Ideally an LP and blood culture should be collected before starting therapy, however if it is not possible to perform an LP right away, the antibiotics should not be delayed.

  • Empiric Therapy: Ceftriaxone OR Cefotaxime AND Vancomycin.
  • Specific Treatment: Tailor antibiotics to the specific etiology once culture results come back. 

Please see the complete guideline for recommendations for specific bacteria, or consult local resources that include local resistance patterns.

Steroids: The use of IV steroids such as dexamethasone in bacterial meningitis is controversial. Studies have shown that steroids may reduce the risk of hearing loss in meningitis caused by Hib or S. pneumoniae, but there is no evidence to support their use in other bacteria at this time.  The CPS recommends starting steroids in patients, and then discontinuing them if the etiology is not Hib or S. pneumoniae.

Last updated by Pedscases: March 14, 2015

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