Acute Bacterial Meningitis in Children
- Acute bacterial meningitis is a serious and potentially life-threatening infection
- Infects the protective membranes surrounding the brain and spinal cord.
- In children, it can progress rapidly and requires prompt diagnosis and treatment.
Causes
- Streptococcus pneumoniae
- Neisseria meningitidis
- Haemophilus influenzae type b (Hib)
- Group B Streptococcus (especially in neonates, transmitted during labour and birth)
- Listeria monocytogenes
The Tumbler Test
Press a clear glass tumbler firmly against the rash. If you can see the marks clearly through the glass, seek urgent medical help immediately. Check the entire body for signs. Look out for tiny red or brown pinprick marks which can evolve into larger red or purple blotches and blood blisters. The darker the skin, the harder it is to see a septicaemic rash, so check lighter areas like the palms of the hands, soles of the feet, or inside the eyelids and the roof of the mouth.
Symptoms
- High fever (38°C or higher), Nausea and vomiting
- Moderate to severe headache, Neck stiffness
- A rash that does not blanch with a glass pressed against it
- Photophobia (sensitivity to light)
- Altered mental status or irritability, Seizures
- Aching muscles and joints, tachypnoea (rapid breathing)
- Cold hands and feet, suggesting sepsis
- In babies: refusal to feed, agitation, not wanting to be picked up, bulging soft spot on their head (fontanelle), being floppy or unresponsive, unusually high-pitched cry, stiff body
Don’t expect meningeal signs; septicaemic signs are more fatal. Any rash (or none) will do for the meningococcus. If you wait for purpura, you may be waiting too late until the disease is untreatable. Beware fever + lethargy + vomiting, even if no headache or photophobia.
Diagnosis
- FBC, U&E, culture blood, urine, nose swabs, stool virology. CRP
- Lumbar puncture to analyze cerebrospinal fluid (CSF): Catch 4 CSF drops in each of 3 bottles for: urgent Gram stain, culture, virology, glucose, protein (do blood glucose too). Polymerase chain reaction (PCR) tests
- Imaging studies (e.g., CT or MRI) when indicated
Treatment
Early treatment is critical to improve outcomes and prevent long-term complications. The primary treatment for bacterial meningitis is prompt administration of antibiotics and supportive care.
Pre Hospital admission Antibiotics
- You may need to defend non treatment
- Giving IM benzylpenicillin 300mg IM up to 1 year old.
- Giving IM benzylpenicillin 600mg if 1–9yrs.
- Giving IM benzylpenicillin 1.2g if >10yrs.
- If penicillin-allergic, cefotaxime may be used (50mg/kg IM stat; if >12yrs 1g)
Antibiotics (Check all doses with local guidelines AND WEIGHT)
- Ceftriaxone 50–80mg/kg/day (max2–4g) IV infusion if >3months–18yrs or Cefotaxime 50mg/kg—/12h if <7d; /8h if 7–21d; /6h if <21 days–3months) PLUS amoxicillin/ampicillin - Broad-spectrum cephalosporins that cover organisms such as Streptococcus pneumoniae and Neisseria meningitidis.
- Vancomycin - Added to provide coverage against resistant strains of Streptococcus pneumoniae (e.g., penicillin-resistant strains).
- Ampicillin - Used in cases involving Group B Streptococcus or Listeria monocytogenes, especially in neonates.
- Additional Antibiotics - In some cases, antibiotics targeted to specific pathogens (e.g., Haemophilus influenzae type b (Hib)) may be needed, based on initial diagnostic findings.
- HIV+ve Treat for cryptococcus
- Listeria monocytogenes soon after birth with meningitis or septicaemia (± pneumonia). It is rare unless immunocompromised. Microabscesses form in many organs (granulomatosis infantiseptica). IV ampicillin (above) + gentamicin
Acute Medical Care
- Along with antibiotic therapy, children with acute bacterial meningitis require intensive medical care
- Fluid and Electrolyte Management: Adequate hydration and electrolyte balance are important in maintaining circulatory volume and avoiding dehydration or shock.
- Monitoring Vital Signs: Close monitoring of temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation to assess the child's condition and detect signs of worsening or septic shock.
- Corticosteroids: Dexamethasone (0.15mg/kg/6h IV eg for 4 days) with 1st antibiotic dose if child >3months and not meningococcal septicaemia is sometimes used in combination with antibiotics to reduce inflammation and decrease the risk of neurological complications, particularly in cases caused by Haemophilus influenzae type b.
- Seizure Management: Seizures are common in children with meningitis and should be managed promptly with anticonvulsant medications if needed.
- Intensive Care Monitoring: In severe cases, children may need to be treated in a pediatric intensive care unit (PICU) for close monitoring, respiratory support, and other life-saving interventions.
- Inotropes may be needed: dopamine or dobutamine (same dose) e.g. at 10mcg/kg/min (put 15mg/kg in 50mL of 5% glucose and infuse at 2mL/h). 504 This is OK by peripheral vein, but if adrenaline is needed, use a central line (0.1mcg/kg/min, ie 300mcg/kg in 50mL of 0.9% saline at 1mL/h).
- Others: Extracorporeal membrane oxygenation; terminal fragment of human bactericidal/permeability-increasing protein (rBPI21) to reduce cytokines. Heparin with protein C concentrate to reverse coagulopathy; plasmapheresis to remove cytokines, and thrombolysis (rTPA) for limb reperfusion
Prevention
- Vaccination (e.g., Hib, pneumococcal, and meningococcal vaccines)
- Good hygiene practices
- Prophylactic antibiotics for close contacts when required
Prognosis and complications
- With early diagnosis and appropriate treatment, the prognosis for bacterial meningitis in children has improved significantly.
- However, some children may experience long-term complications such as hearing loss, neurological deficits, or learning disabilities.
- Complications such as Secondary abscesses, subdural effusion, hydrocephalus, ataxia, paralysis, deafness (steroids prevent this), IQ, epilepsy, brain abscess.