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MarjoRenko

Meningitis in Children

Essentials

  • Suspect bacterial meningitis if a child is clearly ill and has severe symptoms.
  • Acute bacterial meningitis is a severe disease that, untreated, can lead to death in less than 24 hours. Early recognition is vital to avoid delaying treatment.
  • Symptoms of viral meningitis resemble those of bacterial meningitis at the early stage of disease, but viral meningitis is a less severe disease with good prognosis and usually only requires symptomatic treatment.

Aetiology and prevalence

  • The most common causative agents of bacterial meningitis
    • In children below the age of 3 months, Streptococcus agalactiae (also known as Group B Streptococcus or GBS), gram-negative rods and Listeria monocytogenes
    • In older children, Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus).
    • Borrelia and tuberculosis are rare causative agents, but should be kept in mind.
  • Viral meningitis is most often caused by enteroviruses.
  • Vaccines against meningococcus, pneumococcus and Haemophilus influenzae type b are available. Find out about local epidemiology and the vaccines included in the local national immunization programme. See also http://www.who.int/news-room/fact-sheets/detail/meningitis and e.g. http://journals.lww.com/pidj/Fulltext/2022/12000/Global_Epidemiology_of_Vaccine_preventable.24.aspx http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001510/.
    • In Finland, for example, after the inclusion of pneumococcal vaccine in the national immunization programme, the incidence of bacterial meningitis has clearly dropped.
  • Viral meningitis may occur in a considerable number of children per year, depending on the epidemic situation. It is not necessary to diagnose every case of viral meningitis.

Symptoms

  • A child with bacterial meningitis is clearly ill and is not comfortable in any position.
    • In older children, the symptoms include high fever, headache, vomiting, decreased level of consciousness and neck stiffness.
    • Small children may not have any neck stiffness but just a decreased level of consciousness and sensitivity to handling. They may present with abnormal crying, bulging fontanelle, hypotonia, unusual skin colour.
    • The appearance of haematomas on the skin suggest meningococcal sepsis which may be associated with meningitis.
  • Typical symptoms of viral meningitis are headache and neck stiffness, often in connection with flu. The patient's general condition is rarely reduced.

Diagnosis

  • It is important to recognize meningitis sufficiently early and to differentiate between bacterial and viral meningitis.
  • Diagnosis of meningitis is based on the examination of cerebrospinal fluid. Lumbar puncture Lumbar Puncture should be carried out without delay if the disease is suspected. Lumbar puncture is contraindicated if there is a suspicion of increased intracranial pressure due to e.g. a brain tumour.
  • In bacterial meningitis, findings are commonly suggestive of bacterial infection (CRP, blood leucocytes).
    • If an intravenous catheter has been placed, the sample for blood culture should be taken from the catheter.
  • In viral meningitis, the plasma CRP concentration is normal or only slightly increased, and the blood leucocyte count may be low or slightly increased.
  • Viral meningitis may coincide with inflammation of the brain tissue (meningoencephalitis).
  • Typical cerebrospinal fluid findings in bacterial and viral meningitis: see table T1

Typical cerebrospinal fluid findings in bacterial and viral meningitis

Bacterial meningitisViral meningitis
Hundreds (or even thousands) of inflammatory cells × 106 /lInflammatory cell count up to 200 × 106 /l
Nearly all inflammatory cells polymorphonuclearInflammatory cells mononuclear (at the beginning of the disease most of them may be polymorphonuclear)
Glucose concentration low (< 2.2 mmol/l or < half of blood glucose)Glucose concentration normal (> 2.2 mmol/l)
Protein concentration high (> 400 mg/l, typically > 1 000 mg/l)Protein concentration only slightly elevated
Gram-staining shows bacteriaGram-staining does not show bacteria
Lactate concentration high (> 2.7 mmol/l)Lactate concentration normal

Treatment

Bacterial meningitis Fluid Therapy for Acute Bacterial Meningitis, Antibiotics for Preventing Meningococcal Infections

  • Rapid start of antimicrobial therapy is very imporant and it must not be significantly delayed because of, for example, imaging studies or laboratory tests.
  • If the distance to a hospital is short, in most cases the patient can be, in practice, transported as quickly as possible, without taking samples or performing any therapeutic measures, to a facility where the diagnosis can be confirmed and treatment started. If it is not possible to acquire a CSF sample without delay, antimicrobial therapy can be started also after obtaining blood culture samples.
  • Treatment of bacterial meningitis in hospital
    • Antimicrobial therapy aimed against the suspected causative agent, using a drug that is known to penetrate well to the CSF. The penicillin sensitivity of S. pneumoniae, in particular, must be ensured. If the pneumococci in the area show high level penicillin resistance, vancomycin should be combined in the antimicrobial medication already from the start at a dose of 60 mg/kg/day in 4 divided doses (maximum dose 4 g/day).
    • In children below the age of 1 month, ampicillin 200 mg/kg/day (in 3 divided doses) and cefotaxime 200 mg/kg/day (in 2 divided doses)
    • In children over the age of 1 month, ceftriaxone, initial dose 150 mg/kg/day and then 100 mg/kg/day in 2 divided doses. If listeria is suspected as the causative agent, ampicillin should be added to the treatment.
    • In confirmed penicillin or cephalosporin allergy, meropenem 120 mg/day in 3 divided doses
    • Dexamethasone administered before the antimicrobial medication has been shown to be beneficial in children with meningitis caused by H. influenzae type b, which, depending on local epidemiology, may be nowadays very rare.
    • After confirming the causative bacteria, antimicrobial treatment can be changed, as necessary.
      • Bacterial staining of CSF sample will already provide some useful direction concerning the causative agent.
    • Close contacts (family members, other children at the day care place and the resuscitation team) should be treated if a gram-negative coccus (meningococcus) is defined as the causative agent. See also local policies concerning such cases.

Viral meningitis

  • The treatment of viral meningitis is symptomatic.
    • In the case of severe symptoms, if, for example, i.v. fluids are needed, initial treatment is given at a hospital.
    • If, based on rapid decline in level of consciousness and focal CNS symptoms, herpetic meningoencephalitis is suspected, aciclovir should be given intravenously.
      • For children below 12 years 60 mg/kg/day in 3 divided doses for 14-21 days. For children of 12 years and above the dosage is 30 mg/kg/day.

Prognosis

  • Bacterial meningitis may lead to permanent impairment of cerebrospinal fluid circulation, hearing loss and neurological disability.
  • The prognosis of other than herpetic viral meningitis is good.