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CLINICAL OVERVIEW

Bacterial meningitis in children

Elsevier Point of Care (ver detalles)
Actualizado November 8, 2018. Copyright Elsevier, Inc. Todos los derechos reservados.

Synopsis Urgent Action

Key Points Immediate administration of
Infants typically have nonspecific histories including fever supplemental oxygen and
and a bulging fontanelle; older children may present with airway management as
fever, headache, and stiff neck required

Cerebrospinal fluid culture is the gold standard for Correction of shock with fluid
diagnosis of bacterial meningitis; children with a resuscitation and vasopressor
ventriculoperitoneal shunt, known hydrocephalus, support
evidence of increased intracranial pressure, or focal
Administration of empiric
neurologic deficits should have a CT scan before lumbar
antibiotics as soon as possible
puncture

Most common organisms in infants younger than 30 days

are group B streptococcus, Listeria monocytogenes, and Escherichia coli; Streptococcus
pneumoniae is most common across all age groups

Administer empiric antibiotics as soon as possible, even before lumbar puncture, to critically
ill patients

Use of steroids is controversial

Significant morbidity and mortality is associated with bacterial meningitis

Majority of cases of bacterial meningitis can be prevented by vaccine administration or

intrapartum antibiotics

Pitfalls
Failure to diagnose and treat promptly has devastating consequences, including death or
significant morbidity 1

Administer empiric antibiotics as soon as possible, even before lumbar puncture, to a child
who is critically ill
 Failure to vaccinate a child at increased risk for bacterial meningitis

Terminology
Clinical Clarification
Bacterial meningitis is inflammation of the meninges secondary to bacterial infection

Diagnosis
Clinical Presentation
History

May be nonspecific and include:

Poor feeding

Irritability

Lethargy
Petechiae and purpural hemorrhages. -
Vomiting Petechiae and purpural hemorrhages
related to disseminated intravascular
Parent may report bulging fontanelle or stiff neck (8-
coagulation in meningococcemia.
fold increase in risk for meningitis) 2

Older children may complain of headache and/or stiff neck

Physical examination

Abnormal vital signs, including tachycardia and fever, may be present

Some features, when present alone or in combination, significantly increase the likelihood
of the diagnosis

Toxic appearance (sensitivity 49%, specificity 92%) 2

Lethargy/altered mental status (sensitivity 40%, specificity 79%) 2

Bulging fontanelle (sensitivity 14%, specificity 98%) 2

Nuchal rigidity (sensitivity 51%, specificity 89%) 2

Kernig sign (sensitivity 53%, specificity 85%) 2

In supine position, with hips and knees flexed, passive extension of the knees elicits
resistance or pain in back or thighs

Brudzinski sign (sensitivity 66%, specificity 74%) 2

 Passive neck flexion elicits flexion of hips and knees

Complex seizures (double the likelihood of meningitis) 2

Combination of seizures, lethargy or decreased consciousness, and stiff neck (sensitivity

98%, specificity 72%) 3

Petechiae or purpura may be present and are most commonly associated with Neisseria
meningitidis

Also observed in asplenic patients with pneumococcal meningitis

Causes and Risk Factors

Causes

For patients younger than 30 days

Group B streptococcus

77% of early-onset (patients aged 0-4 days) and 50% of late-onset cases (patients aged 5-
28 days) 4

Escherichia coli

7 times more frequent in preterm than term infants 5

Median patient age is 14 days 5

Majority are infants with 2 peaks of infection at age 0 to 3 days (mostly preterm
neonates) and 11 to 15 days (mostly term neonates) 5

Listeria monocytogenes

For patients aged 30 days to 23 months

Group B streptococcus

Escherichia coli

Less common in this age group than in younger infants, but about 10% of cases occur in
children aged 90 days and older 5

Streptococcus pneumoniae

Neisseria meningitides

For patients older than 23 months

 Streptococcus pneumoniae

Neisseria meningitides

Streptococcus pneumoniae and Neisseria meningitidis are responsible for 80% of cases in
the United States 6

Penetrating trauma or neurosurgery

Staphylococcal species

Streptococci

Aerobic gram-negative bacilli

Risk factors and/or associations

Age

Neonates and infants are at higher risk for meningitis than other age groups

Other risk factors/associations

Maternal colonization with group B streptococcus

Preterm birth, rupture of membranes more than 18 hours before delivery, and maternal
signs or symptoms of intra-amniotic infection are associated with an increased risk of
meningitis caused by group B streptococcus or Escherichia coli 7

Asplenia increases risk for meningitis due to Haemophilus influenzae, Streptococcus

pneumoniae, and Neisseria meningitidis

Hypogammaglobulinemia, Wiskott-Aldrich syndrome, thalassemia major, and diabetes

mellitus are also associated with an increased risk for pneumococcal meningitis 8

HIV infection is associated with meningitis due to Haemophilus influenzae and

Streptococcus pneumoniae, as well as various nonbacterial pathogens

Certain anatomic disruptions are associated with pneumococcal meningitis 8

Basilar skull or cribriform fracture with cerebrospinal fluid leak

Cochlear implants

30 times increased risk of developing pneumococcal meningitis 9

Diagnostic Procedures
  Primary diagnostic tools

History and physical examination are highly suggestive

Diagnosis is made by examining the cerebrospinal fluid, including cell count and
chemistries, Gram stain, cultures, and rapid antigen testing or polymerase chain
reaction; also obtain blood cultures in all children 2

Supportive blood work in all children includes CBC, coagulation studies, and chemistry;
inflammatory markers such as C-reactive protein and procalcitonin may help to
distinguish between aseptic and bacterial meningitis, but their use is not routinely
recommended 10

  Laboratory

CBC

Leukocytosis is usual in patients with bacterial meningitis

Leukopenia may be seen in neonates with bacterial meningitis

Coagulation studies

Results may be abnormal in meningococcal infection or in overwhelming sepsis of any

cause

Glucose and electrolytes

Essential baseline for fluid management and to provide a baseline against which to
compare cerebrospinal fluid glucose to assess for hypoglycorrhachia

Blood cultures

40% of children with meningococcal meningitis, 50% to 90% with Haemophilus

influenzae meningitis, and 75% with pneumococcal meningitis have positive blood
culture results 6

C-reactive protein

May be helpful in patients with cerebrospinal fluid findings consistent with meningitis
but with negative Gram stain result

A C-reactive protein result within the reference range has a high negative predictive
value in the diagnosis of bacterial meningitis 11
 An elevated level in the clinical context of suspected meningitis suggests a bacterial
etiology but does not establish the diagnosis 10

Procalcitonin

More sensitive and specific than C-reactive protein and WBC count for diagnosis of
bacterial meningitis 12

Procalcitonin level is 96% sensitive and 89% specific for distinguishing between
bacterial and aseptic meningitis 12

A level greater than 0.5 ng/mL has been found to correlate strongly with presence of
bacterial infection and suggests bacterial rather than aseptic cause in the clinical
setting of suspected meningitis 12

Cerebrospinal fluid analysis for WBCs, RBCs, glucose, protein, Gram stain, and culture

In meningitis, cerebrospinal fluid may be cloudy

WBC count is elevated, usually higher than 1000 cells/mm³ 11

Neutrophil predominance, typically between 80% and 95% 11

Cerebrospinal fluid glucose concentration is typically less than 40 mg/dL 11

Ratio of cerebrospinal fluid to serum glucose of 0.4 or less is 80% sensitive and 98%
specific for the diagnosis of bacterial meningitis in children older than 2 months 11

Ratio of cerebrospinal fluid to serum glucose is higher in term neonates 11

A ratio of 0.6 or less is considered abnormal

Elevated cerebrospinal fluid protein

Cerebrospinal fluid Gram stain results are positive in a majority of cases of untreated
bacterial meningitis

Cerebrospinal fluid culture results are positive in 70% to 85% of patients who have not
received prior antimicrobial therapy, but it may take up to 48 hours for organism
identification 11

Cerebrospinal fluid polymerase chain reaction testing 11

Role of polymerase chain reaction testing is evolving as the technology improves

 Current broad-based polymerase chain reaction tests have adequate sensitivity and
specificity for the most common etiologic agents, both bacterial and viral (eg, HSV,
enteroviruses)

Useful for excluding the diagnosis of bacterial meningitis and may play a role in
decisions to start or stop antimicrobial therapy

May also be used in patients with bacterial meningitis who have been pretreated
with antibiotics or have negative cerebrospinal fluid Gram stain results

Cerebrospinal fluid latex agglutination testing

Infectious Diseases Society of America Practice Guideline Committee does not

recommend routine use for rapid diagnosis, although some experts recommend it for
patients with a negative cerebrospinal fluid Gram stain result, especially if the patient
has been pretreated with antimicrobial therapy and has negative cerebrospinal fluid
culture results 11

Sensitivity is 78% to 100% for Haemophilus influenzae type b, 67% to 100% for
Streptococcus pneumoniae, 69% to 100% for Streptococcus agalactiae (group B
streptococcus), and 50% to 93% for Neisseria meningitides 11

Cerebrospinal fluid lactate

Measurement is not recommended for routine evaluation of suspected community-

acquired bacterial meningitis 11

However, a level of 4.0 mmol/L or higher may help to distinguish bacterial from viral
meningitis when other indicators are equivocal 13

In postoperative neurosurgical patients (in whom a cerebrospinal fluid pleocytosis is a

common finding for several weeks after surgery), lactate levels may provide adjunct
evidence of infection; consider initiating empiric antimicrobial therapy if
cerebrospinal fluid lactate concentrations are greater than 4.0 mmol/L 11

Repeated cerebrospinal fluid analysis

Perform for any patient who has not improved after 48 hours of appropriate
antimicrobial therapy 11

  Imaging

Noncontrast CT scan of brain before lumbar puncture for the following: 11

Focal neurologic findings

 Signs of increased intracranial pressure (including papilledema)

Deteriorating neurologic function

Immunocompromise or history of neurosurgical procedures

Shunt or hydrocephalus

  Procedures

Lumbar puncture

General explanation

Insertion of a hollow-bore needle between the vertebral bodies into the

subarachnoid space to obtain a specimen of cerebrospinal fluid

Indication

Suspected cerebrospinal fluid infection

Contraindications

Bleeding disorder

Patient at risk of brain herniation 14

Best predictors of precipitating herniation, even with a normal CT scan result,

include deteriorating level of consciousness (particularly to a Glasgow Coma Scale
score of 11 or less), brainstem signs (including pupillary changes, posturing, or
irregular respirations), and a very recent seizure

Interpretation of results

Characteristics of bacterial meningitis include: 11

High opening pressure (usually 200-500 mm H₂O, although may be lower or

unobtainable in infants and young children)

Cerebrospinal fluid WBC count (usually higher than 1000 cells/mm³)

Majority of WBCs polymorphonuclear

Elevated cerebrospinal fluid protein (100-200 mg/dL)

Low glucose (cerebrospinal fluid to serum ratio less than 0.4 in children aged 2
months or older, less than 0.6 in term neonates)
 Traumatic tap will yield blood-tinged fluid in which the RBC count, WBC count, and
differential are proportional to the peripheral blood count

For purposes of evaluating the possibility of meningitis, collect 3 or 4 tubes of

spinal fluid, and assess WBC count and differential on the last and clearest tube

Correct WBC count by subtracting 1 WBC for every 1000 RBCs per μL 15

Correct protein concentration by subtracting 1 mg/dL for every 1000 RBCs per μL 15

If patient has not received antibiotics:

Gram stain result may be positive at a rate that depends on the organism 6

50% to 65% for Haemophilus influenzae

69% to 93% for Streptococcus pneumoniae

49% to 73% for Neisseria meningitidis

Culture result is positive in a majority of cases 6

Polymerase chain reaction is the most sensitive 6

Pretreatment with antibiotics reduces the yield of Gram stain, culture, and
polymerase chain reaction, but do not delay administration of antibiotics to try to
optimize results of laboratory studies

Differential Diagnosis
Most common

Viral meningitis
Inflammation of the meninges by a virus, most commonly
nonpolio enterovirus

Clinical presentation similar to bacterial meningitis, but

degree of illness may be less severe

Infants with herpes simplex meningoencephalitis may

present with severe illness, including poor feeding,
lethargy, irritability, and seizures

Differentiated by:

Laboratory testing

Cerebrospinal fluid is usually clear, colorless

 WBC count less than 1000 cells/mm³, 15 predominantly
lymphocytes

Glucose level within reference range

Cerebrospinal fluid culture and viral testing (eg,

polymerase chain reaction) confirm the diagnosis

Encephalitis (Related:
Encephalitis is inflammation of the brain parenchyma,
Encephalitis in children)
manifested by neurologic dysfunction (eg, altered mental
status, behavior, or personality; motor or sensory deficits;
speech or movement disorders; seizure)

Differentiated by:

Laboratory testing

Isolation of the virus or viral antigen in tissue, blood,

cerebrospinal fluid, or other body fluid

Specific IgM antibody in serum or cerebrospinal fluid by

IgM-capture enzyme immunoassay

Brain abscess
Higher incidence in children with congenital heart disease,
recent penetrating head trauma, or neurosurgical procedure

Children present with fever, headache, altered mental status,

symptoms of increased intracranial pressure, and focal
neurologic deficits

Differentiated by:

Physical examination

Focal neurologic findings more common in brain abscess,

although may occur in bacterial meningitis

Imaging

Contrast CT scan or MRI of brain

Retropharyngeal
cellulitis/abscess Occurs most often in children younger than 10 years 16
 Children classically have a high fever, stiff neck, drooling,
and difficulty swallowing

Differentiated by:

Physical examination

No altered mental status

Negative Kernig and Brudzinski test results

Imaging

CT scan of neck

Results show soft tissue edema or collection

Treatment
Goals
Eradicate infection through administration of appropriate antibiotics as early as possible

Minimize sequelae from infection

Provide cardiorespiratory support and correct shock, if present

Disposition
Admission criteria

All patients require admission

Criteria for ICU admission

Oxygen requirement greater than 50% FiO₂ by face mask

Need for airway support

Cardiovascular instability characterized by hypotension, tachycardia, or arrhythmia

Altered mental status, including seizures

Recommendations for specialist referral

Pediatric infectious disease specialist for all patients with bacterial meningitis

Pediatric critical care specialist for all ICU patients

Pediatric neurologist for patients with seizures or altered mental status

Treatment Options
Administer dexamethasone before or concomitantly with first dose of antibiotics 11 17

Do not administer dexamethasone to children who have received antibiotics before

presentation

Associated with reduction in rates of hearing loss and neurologic sequelae, although not
mortality, in children older than 1 month in developed but not undeveloped countries 17 18

Steroids may reduce hearing loss and mortality in neonates with bacterial meningitis 19

Early administration of appropriate empiric antibiotic therapy 11 20

Administer empiric antibiotics as soon as possible, even before lumbar puncture, to a child
who is critically ill

Infants younger than 30 days

Ampicillin plus cefotaxime or ampicillin plus an aminoglycoside

Children aged 30 days to 23 months

Vancomycin plus a third-generation cephalosporin

Children older than 2 years

Vancomycin plus a third-generation cephalosporin

Targeted drug therapy is refined based on susceptibility testing, but general recommendations
include: 11

Streptococcus pneumoniae

Antibiotic selection is based on penicillin and cefotaxime sensitivity defined by minimum

inhibitory concentration

Penicillin minimum inhibitory concentration less than 0.1 mcg/mL: penicillin G or

ampicillin (alternatively, third-generation cephalosporin or chloramphenicol)

Penicillin minimum inhibitory concentration 0.1 to 1.0 mcg/mL: third-generation

cephalosporin (alternatively, cefepime or meropenem)

Penicillin minimum inhibitory concentration 2.0 mcg/mL or higher: vancomycin plus a

third-generation cephalosporin

Cefotaxime (or ceftriaxone) minimum inhibitory concentration 1.0 mcg/mL or higher:

vancomycin plus a third-generation cephalosporin
 Neisseria meningitidis

Antibiotic selection is based on penicillin minimum inhibitory concentration

Penicillin minimum inhibitory concentration less than 0.1 mcg/mL: penicillin or

ampicillin (alternatively, third-generation cephalosporin or chloramphenicol)

Penicillin minimum inhibitory concentration 0.1 to 1.0 mcg/mL: third-generation

cephalosporin (alternatively, chloramphenicol or meropenem)

Haemophilus influenzae

Antibiotic selection is based on production of β-lactamase

β-lactamase negative: ampicillin (alternatively, third-generation cephalosporin,

cefepime, or chloramphenicol)

β-lactamase positive: third-generation cephalosporin (alternatively, cefepime, or

chloramphenicol)

Listeria monocytogenes

Ampicillin or penicillin (alternatively, trimethoprim/sulfamethoxazole or meropenem)

Streptococcus agalactiae

Ampicillin or penicillin (alternatively, third-generation cephalosporin)

Escherichia coli

Third-generation cephalosporin (alternatively, aztreonam, meropenem,

trimethoprim/sulfamethoxazole, or ampicillin)

Drug therapy

Antibiotics

Ampicillin

Ampicillin Sodium Solution for injection; Neonates <= 7 days and <= 2000 g: 100
mg/kg/day IV/IM divided q12h has been recommended. The IDSA recommends 150
mg/kg/day IV divided q6—8h.

Ampicillin Sodium Solution for injection; Neonates > 7 days and < 2000 g: 150 mg/kg/day
IV/IM divided q8h has been recommended. The IDSA recommends 200 mg/kg/day IV
divided q6—8h.

Ampicillin Sodium Solution for injection; Neonates > 7 days and > 2000 g: 200 mg/kg/day
IV/IM divided q6h has been recommended. The IDSA recommends 200 mg/kg/day IV
 divided q6—8h.

Ampicillin Sodium Solution for injection; Infants and Children: 75 mg/kg/dose IV every 6
hours (Max: 12 g/day) per IDSA; FDA-approved dosage is 150 to 200 mg/kg/day IV/IM
divided every 3 to 4 hours.

Ampicillin Sodium Solution for injection; Adults and Adolescents: The manufacturer
recommends 150—200 mg/kg/day IV/IM divided q3—4h. The IDSA recommends 12 g/day
IV divided q4h.

Cefotaxime

Cefotaxime Sodium Solution for injection; Neonates 0 to 7 days: 50 mg/kg/dose IV every

8 to 12 hours is recommended by IDSA; FDA-approved dosage is 50 mg/kg/dose IV every
12 hours. Treat for 7 days for N. meningitidis and H. influenzae, 10 to 14 days for S.
pneumoniae, 14 to 21 days for S. agalactiae, 21 days for gram negative bacilli, and at
least 21 days for Listeria monocytogenes.

Cefotaxime Sodium Solution for injection; Neonates 7 to 29 days: 50 mg/kg/dose IV every

6 to 8 hours is recommended by IDSA; FDA-approved dosage is 50 mg/kg/dose IV every 8
hours. Treat for 7 days for N. meningitidis and H. influenzae, 10 to 14 days for S.
pneumoniae, 14 to 21 days for S. agalactiae, 21 days for gram negative bacilli, and at
least 21 days for Listeria monocytogenes.

Cefotaxime Sodium Solution for injection; Infants, Children, and Adolescents weighing
less than 50 kg: 225 to 300 mg/kg/day IV divided every 6 to 8 hours (Max: 2 g/dose)
recommended by IDSA; FDA-approved dosage is 180 mg/kg/day IV divided every 4 to 6
hours (Max: 2 g/dose). Treat 7 days for N. meningitidis and H. influenzae, 10 to 14 days
for S. pneumoniae, 14 to 21 days for S. agalactiae, and 21 days for gram negative bacilli.

Cefotaxime Sodium Solution for injection; Adults, Adolescents, and Children 50 kg or

more: 2 g IV every 4 to 6 hours. Treat 7 days for N. meningitidis and H. influenzae, 10 to
14 days for S. pneumoniae, 14 to 21 days for S. agalactiae, and 21 days for gram negative
bacilli.

Ceftriaxone

Ceftriaxone Sodium Solution for injection; Neonates: 100 mg/kg IV loading dose on day
1, followed by 100 mg/kg/day IV divided every 12 to 24 hours is FDA-approved dosage.
Cefotaxime recommended over ceftriaxone in neonates.

Ceftriaxone Sodium Solution for injection; Neonates, Infants, Children, and Adolescents:
100 mg/kg IV loading dose on day 1, followed by 100 mg/kg/day IV divided every 12 to 24
hours (Max: 4 g/day).

Vancomycin
 Vancomycin Hydrochloride Solution for injection; Neonates: IDSA recommends 20 to 30
mg/kg/day IV divided every 8 to 12 hours for neonates 0 to 7 days weighing 2 kg or more
or 30 to 45 mg/kg/day IV divided every 6 to 8 hours for neonates older than 7 days
weighing 2 kg or more. AAP recommends dosing based on serum creatinine (SCr)
concentration, which will take approximately 5 days from birth to reasonably reflect
neonatal renal function: SCr less than 0.7 mg/dL: 15 mg/kg/dose IV every 12 hours; SCr
0.7 to 0.9 mg/dL: 20 mg/kg/dose IV every 24 hours; SCr 1 to 1.2 mg/dL: 15 mg/kg/dose IV
every 24 hours; SCr 1.3 to 1.6 mg/dL: 10 mg/kg/dose IV every 24 hours; SCr more than 1.6
mg/dL: 15 mg/kg/dose IV every 48 hours. Dosing interval may need to be extended in
neonatal patients on ECMO; doses of 20 mg/kg/dose IV every 18 to 24 hours have been
suggested. Treat for 2 weeks for meningitis or for 4 to 6 weeks for brain abscess,
subdural empyema, spinal epidural abscess, and septic thrombosis of cavernous or
dural venous sinus.

Vancomycin Hydrochloride Solution for injection; Infants, Children, and Adolescents: 60

mg/kg/day IV divided every 6 hours is recommended by IDSA; for seriously-ill patients,
consider a loading dose of 20 to 25 mg/kg. Treat for 2 weeks for meningitis or for 4 to 6
weeks for brain abscess, subdural empyema, spinal epidural abscess, and septic
thrombosis of cavernous or dural venous sinus.

Corticosteroids (dexamethasone) 11 18

Initiate dexamethasone 10 to 20 minutes before or at least concomitantly with the first

antimicrobial dose 11

Do not give to patients who have already received antimicrobial therapy because
corticosteroids are unlikely to improve outcomes

As laboratory results become available, dexamethasone may be continued for 2 to 4 days

or discontinued

Available evidence supports use in infants and children with Haemophilus influenzae type
b meningitis

Reduces hearing loss and neurologic sequelae 18

Does not reduce overall mortality 18

In pneumococcal meningitis, the use of adjunctive dexamethasone therapy is

controversial because of inadequate and conflicting data 11 18

Dexamethasone Sodium Phosphate Solution for injection; Infants, Children, and

Adolescents: For the treatment of meningitis due to H. influenzae type B, the IDSA
recommends 0.15 mg/kg PO or IV every 6 hours for 2 to 4 days; the first dose should be
given 10 to 20 minutes before or concomitantly with the first dose of antimicrobial
 agent. Therapy may reduce hearing impairment and neuronal injury. Do not administer
to patients who have already received antimicrobial therapy as this is unlikely to
improve patient outcome. The IDSA and the AAP do not recommend routine use as
adjunctive therapy for other bacterial causes of meningitis in pediatric patients. The use
of dexamethasone in pneumococcal meningitis (S. pneumoniae) is controversial but
may be considered in those greater than 6 weeks of age. One study used dexamethasone
0.4 mg/kg IV twice daily for the first 2 days of antibiotic therapy in infants and children
2 months of age and older. NOTE: For the treatment of tuberculous meningitis, doses
used for adjunctive treatment of TB.

Nondrug and supportive care

Airway support

Supplemental oxygen

Consider early intubation and ventilation for any child with respiratory compromise,
septic shock, or elevated intracranial pressure

Cardiovascular support

Correct shock with fluid boluses/vasopressors

Whether maintenance fluids should be administered or restricted is an unresolved

management issue 21

Complications and Prognosis

Complications
Across all etiologies, risk of at least 1 major sequela is about 15% and 1 minor sequela is about
10% 22

Major sequelae include cognitive or motor deficit, seizures, visual or bilateral hearing
impairment, and hydrocephalus 22

Minor sequelae include learning or behavioral problems, unilateral hearing impairment,

diplopia, and hypotonia 22

Median risk of at least 1 major sequela is about 25% in pneumococcal meningitis, 10% in
Haemophilus influenzae type b, and less than 10% in meningococcal meningitis 22

About 20% of patients have multiple impairments 22

Most common major sequela is hearing loss 22

 Risk of a major sequela was twice as high in patients living in Africa and Southeast Asia as
compared with those living in Europe 22

Meningitis caused by Streptococcus pneumoniae is the most severe form of meningitis and has
the highest complication rate 23

Meningococcal meningitis is frequently complicated by arthritis, hearing loss, skin scarring,

amputation, renal dysfunction, and seizures

Late-onset group B streptococcal meningitis can be complicated by severe cerebrovascular

disease, including arterial ischemic stroke and cerebral sinovenous thrombosis 24

Cerebral herniation occurs in about 5% of patients 14

Seizures are the second most common sequelae 22

Subdural effusions 25

Usually bilateral over frontoparietal region

Most common with Haemophilus influenzae (45% of all effusions); less common with
Streptococcus pneumoniae (30% of all effusions) and Neisseria meningitidis (9% of all
effusions)

Symptoms are often subtle and include a bulging fontanel in infants and headache in older
children

Young age, rapid onset of illness, low peripheral WBC count, and high cerebrospinal fluid
levels of protein and bacteria increase the likelihood of developing effusion 25

Invasive treatment not necessary if child is improving 25

Hydrocephalus occurs in about 7% of patients 22

Prognosis
Failure to diagnose and treat promptly has devastating consequences, including death or
significant morbidity 1

Untreated, bacterial meningitis is uniformly fatal

30% of mortality from bacterial meningitis is secondary to cerebral herniation 14

Fatality rates for children with meningitis caused by Haemophilus influenzae, Streptococcus
pneumoniae, and Neisseria meningitidis are 0.0%, 9.2%, and 7.5%, respectively 26
 Overall mortality rate for neonates with meningitis is 13% but reaches 25% in preterm or
small-for-gestational-age infants 4

Screening and Prevention

Prevention
Prevention of Haemophilus influenzae meningitis

Haemophilus influenzae type b conjugate vaccine

94% reduction in the number of cases of Haemophilus influenzae meningitis 27

Current CDC recommendations for conjugate Haemophilus influenzae type b vaccine 28

2 or 3 doses, depending on vaccine product, for infants aged 2 through 6 months, and a
booster dose at ages 12 through 15 months

Children with early component complement deficiencies, immunoglobulin deficiency,

anatomic or functional asplenia, and HIV infection, as well as recipients of
hematopoietic stem cell transplant and chemotherapy or radiation therapy for
malignancies, are at high risk for invasive infection due to Haemophilus influenzae and
may need to receive doses outside of the standard schedule

The CDC provides a schedule of additional doses in Table 2 of Prevention and Control
of Haemophilus influenzae Type b Disease 28

Prevention of Streptococcus pneumoniae meningitis

13-valent pneumococcal conjugate vaccine

With institution of 13-valent vaccine, incidence of invasive pneumococcal disease in

children younger than 5 years declined by 64% compared to rate expected with continued
use of 7-valent vaccine; invasive pneumococcal disease caused by the 6 added serotypes
dropped by 93% 29

Current CDC recommendations 30

Vaccination of all children aged 2 to 59 months with a 4-dose series at 2, 4, 6, and 12 to

15 months 30

For information on catch-up vaccination with 13-valent pneumococcal conjugate

vaccine, specific details are available in the CDC Recommended Immunization Schedule
30
 For information on vaccination of persons with high-risk conditions, specific details are
available in the CDC Recommended Immunization Schedule 30

23-valent pneumococcal polysaccharide vaccine

Children aged 2 to 18 years with a variety of underlying medical conditions should receive
23-valent pneumococcal polysaccharide vaccine after all recommended doses of 13-valent
pneumococcal conjugate vaccine; specific details are available in the CDC Recommended
Immunization Schedule 30

Prevention of Neisseria meningitidis meningitis

Quadrivalent meningococcal polysaccharide-protein conjugate vaccine

Administer to:

All healthy adolescents aged 11 to 12 years with a booster at age 16 years 31

Infants aged 2 through 23 months at increased risk for meningococcal diseases

including persistent complement component deficiencies (C3, C5-C9, properdin, factor
D, and factor H), those with functional or anatomic asplenia (including sickle cell
disease), healthy infants in communities with a meningococcal disease outbreak for
which vaccination is recommended, and those traveling to or residing in areas where
meningococcal disease is hyperendemic or epidemic 32

2 MenB vaccines (serogroup B meningococcal vaccines) are currently licensed for use
among people aged 10 to 25 years in the United States: MenB-FHbp and MenB-4C 33

CDC Advisory Committee on Immunization Practices currently recommends routine use

of MenB vaccines among people aged 10 years or older who are at increased risk for
serogroup B meningococcal disease, including those with persistent complement
component deficiencies, those with anatomic or functional asplenia, microbiologists who
are routinely exposed to isolates of Neisseria meningitidis, and people identified as being
at increased risk because of a serogroup B meningococcal disease outbreak 33

Adolescents and young adults aged 16 to 23 years may also be vaccinated with MenB
vaccines to provide short-term protection against most strains of serogroup B
meningococcal disease 33

Either MenB vaccine can be used when indicated; however, they are not interchangeable
and the same product must be used for all doses 33

For people at increased risk for meningococcal disease and for use during serogroup B
meningococcal disease outbreaks, the Advisory Committee on Immunization Practices
 recommends that 3 doses of MenB-FHbp be administered at 0 months, 1 to 2 months, and
6 months 33

When vaccine is given to healthy adolescents who are not at increased risk for
meningococcal disease, the Advisory Committee on Immunization Practices recommends
that 2 doses of MenB-FHbp be administered at 0 and 6 months 33

MenB-4C is a 2-dose series, with doses administered at least 1 month apart 30

Prevention of group B streptococcal meningitis

Intrapartum antibiotic prophylaxis leads to a 30-fold reduction of early-onset neonatal

group B streptococcal disease 34

Indications include: 35

Group B streptococci recovered during prenatal screening from a urine culture or by

nucleic acid amplification testing during labor

Previous infant with invasive group B streptococcal infection

Preterm delivery, prolonged rupture of membranes, or fever during labor in woman with
unknown group B streptococcal status

REFERENCIAS
1: Carroll AE et al: Malpractice claims involving pediatricians: epidemiology and etiology.
Pediatrics. 120(1):10-7, 2007

| Referencia cruzada   (https://www.ncbi.nlm.nih.gov/pubmed/17606556)

2: Curtis S et al: Clinical features suggestive of meningitis in children: a systematic review of

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