Pediatric Bacterial Meningitis - Initial Supportive Measures

Neonates

Initiate treatment as soon as bacterial meningitis is suspected. Ideally, blood and CSF cultures should be obtained before antibiotics are administered. If a newborn is on a ventilator and clinical judgment dictates that a lumbar puncture may be hazardous, it can be deferred until the infant is stable. A lumbar puncture performed a few days after initial treatment still reveals cellular and chemical abnormalities, but culture results may be negative.

Establish IV access, and meticulously monitor fluid administration. Neonates with meningitis are prone to develop hyponatremia as a consequence of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). These electrolyte changes also contribute to the development of seizures, especially during the first 72 hours of disease.

Increased ICP secondary to cerebral edema is rarely a management problem in infants. Monitor blood gas levels closely to ensure adequate oxygenation and metabolic stability.

Magnetic resonance imaging (MRI) with gadoteridol, ultrasonography, or computed tomography (CT) with contrast is needed to delineate intracranial pathology. Certainly, some instances warrant automatic CNS imaging (eg, meningitis caused by gram-negative enterics, a complicated course). However, the efforts of a Pediatric Academic Societies meeting resulted in the suggested recommendation that contrast MRI should be performed for neonates with uncomplicated meningitis 7-10 days after treatment initiation to ensure that no complicating pathology is present. All newborns recovering from meningitis should undergo auditory evoked potential studies to screen for hearing impairment.

Infants and children

Management of acute bacterial meningitis in infants and older children involves both supportive measures and appropriate antimicrobial therapy. All patients should have an audiologic evaluation upon completion of therapy.

Closely monitor patients’ fluid and electrolyte status. Check vital signs and neurologic status, and ensure that an accurate record of intake and output is maintained.

By prescribing the correct type and volume of fluid, the risk of brain edema can be minimized. The child should receive sufficient amounts of fluid to maintain systolic blood pressure at around 80 mm Hg, urinary output at 500 mL/m2/day, and adequate tissue perfusion. Although it is important to avoid SIADH, it is equally important to avoiding underhydration of the patient and the risk of decreased cerebral perfusion.

Dopamine and other inotropic agents may be necessary to maintain blood pressure and adequate circulation.