Meningitis (peds)
Background
- Meningismus is difficult to discern if <6mo, (esp if <2mo)
- <3months old
- 1% incidence of bacterial meningitis
- E. coli, Group B strep, listeria
- >3months old
Clinical Features
Differential Diagnosis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Juvenile rheumatoid arthritis
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Pediatric Rash
- Atopic dermatitis
- Bed bugs
- Contact dermatitis
- Drug rash
- Erythema infectiosum (Fifth disease)
- Hand-foot-and-mouth disease
- Henoch-schonlein purpura (HSP)
- Herpangina
- Herpes simplex virus (HSV)
- Infectious mononucleosis
- Meningitis
- Measles
- Molluscum contagiosum
- Roseola infantum
- Rubella (German measles)
- Scabies
- Scarlet fever
- Smallpox
- Varicella (Chickenpox)
Diagnosis
Bacterial Meningitis Score for >2mo and well-appearing
- Risk Factor
- Peripheral blood ANC >10K
- Seizure
- CSF
- CSF ANC >1000
- CSF protein >80
- CSF Gram stain (if + 61% Sn, 99% Sp)
- Any risk factor = high risk for bacterial meningitis
- Very low risk if infant lacks all risk factors
Work-Up
- CBC
- CSF
Pediatric Bacterial Meningitis Score[1]
| Bacterial Meningitis Score | ' |
| Criteria | Point Score |
| Positive CSF Gram Stain | 2 |
| CSF protein > 80mg/dL | 1 |
| Blood Absolute neutrophil count > 10,000 cells/mm3 | 1 |
| Incidence of seizures with illness | 1 |
| CSF neutrophil count ≥ 1000 cells/mm3 | 1 |
- 0 points: Aseptic meningitis likely[2]
- 1 point: Aseptic meningitis less likely[3]
- ≥2 points: Bacterial Meningitis more likely[4]
Treatment
Treatment guidelines based on van de Beek et al[5]
Neonates (up to 1 month of age)
MRSA is uncommon in the neonate
- Ampicillin 75mg/kg IV q6hrs PLUS
- Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
- Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[6]
- If suspecting S. pneumoniae or MRSA, add Vancomycin
- Consider acyclovir for HSV
> 1 month old
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Disposition
- Admit despite negative meningitis score if:
- Age <2mo with any degree of pleocytosis
- Appear ill
- Infants with aseptic meningitis
See Also
Source
- ↑ Chavanet P, Schaller C, Levy C, et al. Performance of a predictive rule to distinguish bacterial and viral meningitis. J Infect 2007;54: 328–36.
- ↑ Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60.
- ↑ Fine AM, Nigrovic LE, Reis BY, Cook EF, Mandl KD. Linking surveillance to action: incorporation of real-time regional data into a medical decision rule. J Am Med Inform Assoc 2007;14: 206–11.
- ↑ Dubos F, Korczowski B, Aygun DA, et al. Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules. Arch Dis Child 2010;95:963–7.
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1