Peds Meningitis


  • Presentation:
    • -Displays meningeal irritation signs by18 mo old if meningitis.
    • -If > 2-3yo meningeal irritation absence (can kiss knees) suggests no meningitis
    • -Hypo/Hyperthermia
    • -irritability
    • -lethargy
    • -poor feeding
    • -Brudzinski’s sign-neck flexion causes hip flexion
    • -Kernig’s sign- cannot flex hips with thighs at 90 degrees
    • -bulging fontanelle
    • -rising sun sign (from hydrocephalus)
    • -coma/obtundation

Bacterial Meningitis

  • General
    • -Meningoencephalitis with vascular involvement > pure meningitis in kids.
    • -Most common entry into CNS is via bacteremia
    • -3 mo-8 mo age of peak incidence
  • Etiology
    • Neonate <28 days
    • -Foci of infection: gut, bladder, swallowing of vaginal/perineal flora intrapartum or in utero infection
    • -Pathogens: GBS, gram negatives (E.coli, Klebsiella, Pseudomonas), Listeria
    • Infant/Children 3 mo-5yrs
    • -Pathogens=pneumococcus, meningococcus, H. flu
    • -Children >3mo have decreased immunity, low nasopharyngeal IgA
    • -Bacteremia can seed CNS, joints, hea rt, lungs
    • -Most virulent meningitis but most easily treated
  • Labs(LP)
    • -Glucose <50, protein >50, WBC >10. -Opening pressure >140-180 mm /H2O in BM or in a small crying child.
    • -If bloody tap fluid does not decrease with flow, then has hemorrhagic CNS disease (HSV).
    • -Pus=100 PMN’s/ml.
    • -Protein cause turbidity
    • -Yellow csf indicates bilirubin
  • Sequelae of BM
    • -Deafness/hearing loss (mild or total)due to CN VIII swelling; etiology: pneumococcus > meningiococcus>H.flu. (pmh). More H.flu in prevaccine population.
    • -Seizures-tonic clonic sz can be presenting symptom of BM in 20-30% of pts. Leukocytes release cytokines which cause cerebral edema. Focal sz can be seen 3-4 days into MB due to localized dz (brain abscess, subdural effusion, empyema). Focal sz indicate poor prognosis.
    • -Cranial nerve palsies-mostly CN VI, the longest intracranial course
    • -increased ICP
    • -Cerebral Palsy/Mental Retardation
    • -Speech problems
    • -Focal neural loss
    • -Death- 5-10% even with abx (GM 20-25%, Strep 10-15%)
    • -Hydrocephalus- increased CSF production in lateral ventricles. Communicating or noncommunicating. Tx with VP shunt (complications: obstruction with no long term mental sequelae to infection with Staph epidermidis with mental sequelae).

Aseptic Meningitis

  • Presentation:
    • -Pathogens=80% Enteroviruses (Coxsackie, polio, echo), 7-8% Arbovirus
    • -Peaks in summer
    • -CSF- lympocytosis at 6-8 hours
    • -Herpes rarely causes meningitis, usually encephalitis

Antibiotics for Meningitis

  • Neonates <28 days
    • Pathogens
      1. GBS-Amp and Gent. Many are pen/gent resistant, but amp (cell wall inhibitor) helps.
      2. E. coli-Gent
      3. Gram (-) (Klebsiella)-Gent
      4. Listeria (tumbling gram (+) rod)-Amp
  • Infants 4-8 weeks
    • All pathogens for infants and kids should be considered and treated.
    • Abx=Amp and Cefotaxime
  • Infants >8 weeks
    • Encapsulated pathogens
      1. Strep pneumo
      2. Hib
      3. N. meningitides
    • Abx=Amp (enterococcus and listeria) and Cefotax; rifampin for HIB or N. meningitides to decrease carrier state.
    • Chloramphenicol is no longer used; can cause bone marrow suppression and gray baby syndrome (vascular collapse) in neonates always treat h. Flu or neisseria also with rifampin to decrease carrier state (treat contacts also)
    • If no improvement with abx think
    • -not enough or wrong drugs
    • -new pathogen (secondary infection)
    • -abx not penetrating (ie. Abscess)
    • -viral infection
    • Meningococcus: better prognosis if presenting as meningitis (pt survived seeding) rather than bacteremia; most rapidly fulminant but easiest treated.