Pediatric Bacterial Meningitis - Prevention

Pediatric Bacterial Meningitis Treatment

Prevention

Prevention is an important aspect of the management of pediatric bacterial meningitis because it has been shown to reduce mortality and morbidity. Preventive measures can be divided into 2 broad categories, chemoprophylaxis and immunization.

The use of rifampin, ceftriaxone, and ciprofloxacin has been effective chemoprophylaxis (see Table 4 below). Ciprofloxacin and ceftriaxone are more effective against resistant strains of N meningitidis up to 4 weeks after treatment. Routine childhood immunizations have been shown to effectively decrease the incidence of certain types of meningitis.

Table 4. Chemoprophylaxis for Bacterial Meningitis Caused by Haemophilus influenzae or Neisseria meningitidis (Open Table in a new window)

Haemophilus influenzae type b

The risk of invasive Hib disease is increased among unimmunized household contacts younger than 4 years. Rifampin eradicates the organism from the pharynx of approximately 95% of carriers. The efficacy of rifampin in preventing disease in childcare groups is not established.

Recommendations for rifampin chemoprophylaxis for contacts of index cases of invasive Hib disease include the following:

• All household contacts with at least one contact younger than 4 years who is unimmunized or partially immunized; those with a child younger than 12 months who has not received the primary series; and those with an immunocompromised child (even if older than 4 years), regardless of immunization status
• Nursery and childcare center contacts regardless of age, when 2 or more cases of invasive disease have occurred within 60 days
• The index case if younger than 2 years or with a susceptible household contact and treated with ampicillin or chloramphenicol

Immunizations should be administered in accordance with AAP guidelines.[29] Universal immunization against Hib infection has led to a dramatic decline in the incidence of invasive Hib meningitis.[30]

In June 2012, MenHibrix, a combination vaccine providing immunization against both Hib and meningococcal serogroups C and Y, was approved by the US Food and Drug Administration (FDA) for use in infants. This combination vaccine is indicated in children aged 6 weeks to 18 months for active immunity against invasive disease. It is given as a 4-dose series, usually at well-baby checkups.

The Advisory Committee on Immunization Practices (ACIP) recommends HibMenCY be given to infants at increased risk for meningococcal disease, in 4 doses at 2, 4, 6, and 12 through 15 months; at-risk infants are those with complement component deficiencies, those with known asplenia or sickle cell disease, and those exposed to community outbreaks of serogroup C or Y disease.[31, 32]

Neisseria meningitidis

Administration of antimicrobial agents to contacts is divided into high- and low-risk categories. Only contacts stratified as high-risk require prophylaxis. Candidates for chemoprophylaxis against meningococcal disease include the following:

• All household contacts
• Childcare or nursery school contacts during the 7 days before illness onset
• Contacts directly exposed to index case secretions through kissing, sharing toothbrushes or eating utensils, or other markers of close social contact during the 7 days before illness onset
• Persons who had mouth-to-mouth resuscitation or unprotected contact during endotracheal intubation in the 7 days before illness onset
• Contacts who frequently slept or ate in the same dwelling as the index patient during the 7 days before illness onset

Outbreaks or clusters must be managed as mandated by local public health authorities.

A quadrivalent (ie, A, C, Y, W-135) meningococcal conjugate vaccine is recommended for high-risk groups, including patients with immunodeficiency, patients with functional or anatomic asplenia, and patients with deficiencies of terminal components of complement. It has been given to high-risk children as young as 9 months (Menactra) or 2 months (Menveo). The vaccine is also valuable in controlling the epidemics of meningococcal disease.

The ACIP has recommended the quadrivalent meningococcal conjugate vaccine for all children aged 11-12 years, for first-year college students who will be living in a dormitory or a dormitorylike setting, and for other high-risk groups.[33, 34]

As noted above, a combination vaccine against both meningococcal serogroups C and Y conjugate and Hib has been approved by the FDA for use in infants. The HibMenCY is recommended by the ACIP for infants at increased risk for meningococcal disease, such as those: (1) with complement component deficiencies, (2) with known asplenia or sickle cell disease, and (3) exposed to community outbreaks of serogroup C or Y disease.[31, 32]

Streptococcus pneumoniae

Routine chemoprophylactic measures for invasive disease secondary to S pneumoniae are limited to people with specific medical conditions.

The heptavalent pneumococcal conjugate vaccine has been introduced into the primary childhood vaccination schedule. Immunizations should be administered according to AAP guidelines. The polysaccharide vaccine is generally used for those with specific medical conditions.