GUIDELINE FOR THE MANAGEMENT OF MENINGITIS Reference: Mennigitis Version No: 1 Applicable to All children with suspected or confirmed meningitis Classification of document: Area for Circulation: Author: Group Consulted: Ratified by: Guideline Children s Hospital for Wales Dr J Stevens (SpR) Dr N MacDermott (ST3) Dr C Rossiter (GPST) Dr J Evans (Consultant) Practitioners within the CHfW Current literature Child Health Guideline Meeting February 2012 Date Published: June 2012 Version Number Date of Review Reviewer Name Completed Action Approved By Date Approved New Review Date 1 2014 Disclaimer These have been ratified at the Child Health Guideline Meeting, however clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of theindividual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Meningitis Guideline Introduction: Meningitis is an inflammatory process of the meninges, when this inflammation spreads to the brain parenchyma it is known as encephalitis. Meningitis may be caused by both viral and bacterial organisms. The most common bacterial organisms causing meningitis are strep pneumoniae and neisseria meningitidis. Haemophilus Influenzae type B used to be a significant cause but following the introduction of the HiB vaccine into the childhood vaccination schedule these numbers have significantly decreased, although in the last few years cases have started to reappear. In neonates and infants up to the age of approximately 3 months Group B streptococcus is also a common cause of meningitis and listeria monocytogenes and gram negative bacilli may also play a role. Viral meningitis is most commonly caused by enteroviruses (approx 85-95% of cases) and has a fairly indolent course. However, Herpes simplex viruses 1 and 2 are also a cause of viral meningo-encephalitis and cause significant mortality and morbidity (for further information please see Herpes encephalitis guideline). Symptoms & Signs Infants & toddlers Fever Poor feeding & vomiting Irritability Floppy/lethargic/unresponsive High pitched cry Bulging anterior fontanelle Seizures Non-blanching rash Children & Teenagers Fever Vomiting Headache/neck stiffness Photophobia Confusion/irritability/unresponsive Seizures Non-blanching rash
Management
Radiological investigations CT scanning: Does NOT reliably detect raised intracranial pressure, this should be a clinical diagnosis Is indicated if fluctuating or reduced conscious level or if focal neurological signs The purpose is to identify other possible intracranial pathology causing the above signs Do not delay treatment to undertake scan, stabilise patient and commence treatment first. Treatment 1. Antimicrobial treatment (all antibiotics should be intravenous) Age < 3months Age > 3 months Unconfirmed disease (ie. Cultures negative but raised CSF WCC / failed lumbar puncture) Cefotaxime and Amoxicllin or Ampicillin For minimum 14 days Ceftriaxone 80mg/Kg For minimum 10 days Confirmed disease (ie. Positive CSF cultures/pcr or positive blood cultures & raised CSF WCC) Group B Strep Cefotaxime for minimum 14 days Listeria monocytogenes Amoxicillin or Ampicillin for 21 days and Gentamicin for minimum 7 days Gram negative bacilli Cefotaxime for minimum 21 days Meningococcus Ceftriaxone for 7 days Haemophilus influenza Ceftriaxone for 10 days Strep Pneumoniae Ceftriaxone for 14 days Meningococcus Ceftriaxone for 7 days If sensitivities are available consider changing broad spectrum antibiotic to specific narrower spectrum antibiotic in a known sensitive organism ie. Group B streptococcus sensitive to benzylpenicillin.
2. Corticosteroids Do NOT use in children under 3 months of age Do NOT use in cases of meningococcal septicaemia unless under the guidance of a paediatric intensivist In bacterial meningitis: o DO administer dexamethasone 0.15mg/Kg (max 10mg) with 1 st dose of antibiotics or within 4 hours of 1 st dose provided there is: Strong clinical suspicion and one of the following (consider giving steroids irrelevant of other features if very strong clinical suspicion): Frankly purulent CSF CSF WCC >1000 Raised CSF WCC & protein >1 Bacteria on gram stain o Do NOT start dexamethasone more than 12 hours after first dose of antibiotics If dexamethasone started, discuss with consultant following first dose as to whether to proceed to 0.15mg/Kg QDS for 4 days If TB meningitis suspected, discuss use of steroids with consultant When is repeat LP & CT indicated? Consider performing repeat LP +/- repeat CT: In any child (especially neonates) with o Persistent or re-emergent fever o Deterioration in clinical condition o Persistently abnormal inflammatory markers o New clinical findings, especially neurological In children who have positive CSF cultures for either Group B streptococcus or gram negative organisms (such as E. Coli) on repeat LP at 14 days of antibiotic treatment, prior to stopping antibiotic treatment: o CT may confirm ongoing cerebritis, ventriculitis or abscess formation o If CSF shows polymorphs >30% of total cells or a protein level >2g/L this is indicative of cerebritis Continue antibiotics for a further 7 days Repeat lumbar puncture again prior to stopping antibiotics at day 21 It is rarely necessary to treat meningitis for longer than 3 weeks
Complications & follow up 1. Syndrome of inappropriate ADH if the child is not shocked then they should be fluid restricted to 60% maintenance fluids provided SIADH confirmed 2. Neurological sequelae All children should have a hearing test prior to discharge from hospital & outpatient follow up 4-6 weeks after discharge * Meningitis & meningococcal septicaemia are notifiable diseases and public health must be informed if high clinical suspicion or positive culture result *