meningitis%20-%20acute,%20bacterial%20(pediatric)
MENINGITIS - ACUTE, BACTERIAL (PEDIATRIC)
Acute meningitis is the bacterial infection of the subarachnoid space and cerebrospinal fluid that may cause local and systemic inflammatory response.
Common symptoms in newborns are lethargy, fever, seizures, irritability and bulging fontanelle. While in children the common symptoms are fever, nuchal rigidity (incidence increases with age) and altered consciousness.
Meningeal signs are stiff neck, Kernig's or Brudzinski's signs) are not reliably present in infants <6 months of age.
It may also observe the presence of persistent vomiting, changes in behavior or other psychological/neurologic signs.

Meningitis%20-%20acute,%20bacterial%20(pediatric) Management

Prevention

Precautions 
  • Use of mask, gloves, and gowns prevents spread of disease as meningitis is a droplet infection
Vaccination
  • Aside from giving antibiotic prophylaxis to susceptible at-risk contacts, vaccination also helps reduce the likelihood of bacterial meningitis
  • Meningococcal serogroup A, C, W, and Y conjugate vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) to be given in infants <1 year of age, and patients aged 11-12 years old with booster dose at age 16 while serogroup B meningococcal vaccine is recommended for patients aged ≥10 at increased risk for meningococcal disease, and to adolescents and young adults aged 16-23 years in need of short-term protection against serogroup B meningococcal disease
  • H influenzae type B conjugate vaccine is recommended by CDC to be given to all children starting at 2 months of age, to patients with anatomic or functional asplenia, and post-stem cell transplant patients
  • Pneumococcal vaccination for the prevention of pneumococcal meningitis should be considered, especially in patients with CSF leakage
    • ACIP recommends the administration of PCV13 to children ≥6 weeks of age and PPSV23 to children ≥2 years old at high risk for pneumococcal disease
Chemoprophylaxis of Contacts
H influenzae
  • Chemoprophylaxis eradicates nasopharyngeal colonization in 95% of carriers
  • Chemoprophylaxis is recommended for all household contacts with at least 1 unvaccinated or incompletely vaccinated child <48 months, or with an immunocompromised child (regardless of age and immunization status)
  • Recommended agent: Rifampicin, Ciprofloxacin or Ceftriaxone
N meningitidis
  • Recommended for all high-risk contacts:
    • All household contacts
    • Childcare or nursery school contact during 7 days before illness onset
  • Administer promptly, ideally within 24 hours after the index case is identified
  • Recommended agents: Rifampicin, Ciprofloxacin or Ceftriaxone
  • Alternative agent: Azithromycin
S pneumoniae
  • Chemoprophylaxis are limited to those with specific medical conditions


Follow Up

General Follow-up Principles

  • Magnetic resonance imaging (MRI) with contrast should be performed for neonates with uncomplicated meningitis 7-10 days after treatment initiation to ensure that no complicating pathology is present
  • All recovering patients, especially newborns, should have auditory evoked potential studies to screen for hearing impairment
  • Careful neurologic, visual and hearing tests should be done; results must be reviewed with parents so that they may be aware of any deficits

Outpatient Management

  • Since complications are exceedingly rare after 3-4 days of treatment, it may be appropriate for some patients
  • This may lead to less hospitalization costs, decreased risk for nosocomial infections and improved quality of life
  • Selection of qualified patients must be careful and close medical follow-up is essential

Maneuvers to Address Increased Intracranial Pressure (ICP)

Elevated ICP

  • Patients with signs of increased ICP (eg changes in level of consciousness, nonreactive or poorly reactive pupils, ocular movement disorders) and who are comatose or are stuporous may benefit from ICP monitoring
  • ICP >20 mmHg should be treated
  • Consider treating ICP >15 mmHg to avoid larger elevations that can lead to cerebral herniation and brain stem injury
Maneuvers to Decrease Elevated ICP
  • Elevation of head of the bed to maximize venous drainage with minimum compromise of cerebral perfusion
  • Hyperventilation to cause cerebral vasoconstriction and reduction in cerebral blood volume
    • Be cautious with this maneuver as it may exacerbate focal cerebral ischemia
  • An intraventricular shunt with CSF drainage may be needed when there is evidence of hydrocephalus
    • The need to perform this procedure depends on patient’s level of consciousness and degree of ventricular dilatation as seen on brain imaging
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