TABLE 94.3 ETIOLOGIES OF ACUTE BACTERIAL MENINGITIS CHILDREN OUTSIDE THE NEONATAL PERIOD Goals of Treatment The goal of treatment is the rapid recognition and treatment of bacterial meningitis to decrease a child’s risk of neurologic sequelae The clinical team should consider neuroimaging prior to LP in the immunocompromised child or the child with focal neurologic deficits Clinical outcomes include time to appropriate parenteral antibiotics, CSF sterility at 24 to 48 hours, and neurologic outcome Clinical Considerations Clinical recognition: The most common signs and symptoms of bacterial meningitis are listed in Table 94.4 Before months of age, the history is usually that of irritability, an altered sleep pattern, vomiting, and decreased oral intake In particular, paradoxical irritability points to the diagnosis of meningitis Irritability in the infant without inflammation of the meninges is generally alleviated by maternal fondling; however, in the child with meningitis, any handling, even directed toward soothing the infant, may increase irritability by its effect on the inflamed meninges The amount of time spent sleeping may either increase because of obtundation or decrease from irritability Bulging of the fontanelle, an almost certain sign of meningitis in the febrile, ill-appearing infant, is a late finding Vomiting is a sensitive but nonspecific feature of infantile meningitis As the child ages past months, the symptoms gradually become more specific for involvement of the central nervous system (CNS) A change in the level of activity is almost always noticeable However, it is only in the child older than years that meningitis manifests reliably with complaints of headache, neck stiffness, and photophobia TABLE 94.4 SIGNS AND SYMPTOMS OF MENINGITIS Signs Age Symptoms Early Late 0–3 mo Paradoxical irritability Lethargy Bulging fontanelle Altered sleep pattern Irritability Shock Vomiting Lethargy Fever Hypothermia (2 yrs Shock Headache Fever Coma Neck pain Nuchal rigidity Shock Lethargy Irritability The physical examination in the young infant rarely provides specific corroboration, even when the history suggests meningitis Fever may be absent in these children, despite the presence of bacterial infection Any child younger than months who is brought to the ED with a documented temperature of ≥100.4°F (38˚C) should be considered at risk for meningitis The physical signs are sufficiently elusive that many experts caution that one should not rely exclusively on the examination to rule out meningeal infection It is estimated that bacterial meningitis occurs in 1% to 2% of febrile young infants (Chapter 31 Fever ) After months of age, increasing, but not absolute, reliance can be placed on the physical findings; fever is typically noted Specific evidence of meningeal irritation is often present, including nuchal rigidity and, less often, Kernig (pain with extension of the leg on a flexed femur) and Brudzinski (involuntary lifting of the legs when the head is raised while the child is lying supine) signs When an LP fails to confirm the diagnosis of meningitis, despite the presence of meningeal signs, other conditions must be pursued that can mimic the findings on physical examination Conditions capable of producing the findings typical of meningismus (irritation of the meninges without pleocytosis in the CSF) include severe pharyngitis, retropharyngeal abscess (RTA), cervical adenitis, arthritis or osteomyelitis of the cervical spine, upper lobe pneumonia, subarachnoid hemorrhage, pyelonephritis, and tetanus Seizures are a presenting complaint for 20% of children with bacterial meningitis Many of these are focal, recurrent, or prolonged seizures Most clinicians advise that children younger than months with a first-time febrile seizure should routinely have LP performed to discern the presence of CNS infection, unless there are specific contraindications or an alternative diagnosis is readily apparent Febrile seizures are reviewed in Chapter 72 Seizures TABLE 94.5 IMMEDIATE MANAGEMENT STEPS FOR CHILDREN WITH SUSPECTED OR CONFIRMED BACTERIAL MENINGITIS Immediate evaluation Initiate hemodynamic monitoring and support Achieve venous access; use cardiorespiratory monitors Laboratory evaluation Ensure adequate ventilation and cardiac function CSF for cell count and differential; Gram stain and culture; glucose; protein Consider holding CSF in the laboratory for enteroviral or HSV PCR, AFB culture, cryptococcal, or arboviral studies CBC, blood culture, electrolytes, serum glucose, BUN and creatinine, prothrombin time and partial thromboplastin time Medications Fluid resuscitation for septic shock, if present If Mycobacterium tuberculosis or H influenzae type b is the suspected cause of meningitis, consider dexamethasone (0.15 mg/kg) before or with the first dose of antibiotics Antibiotics (see Table 94.7 ) Glucose (if serum glucose