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