Meningitis

Most cases of childhood meningitis are caused by an enterovirus. Bacterial meningitis is less common, with 90% of cases occurring in children less than 5 years of age. Bacterial meningitis has a mortality rate of 20% in infants and 2% in children; neurologic sequalae occur in approximately one-third of children who survive their infection. Early diagnosis and treatment of bacterial meningitis is associated with better outcomes. Viral meningitis is a diagnosis of exclusion.

• If vaccinations are incomplete, children are at higher risk of N. meningitidis, S. pneumoniae and H. influenzae.
• Consider Lyme meningitis (in an endemic area) if there is a history of tick exposure, erythema migrans or a facial palsy, though these symptoms are not always present.
• Parechovirus, herpes simplex, varicella-zoster and arboviruses are more frequently associated with encephalitis.

• Infants: Fever or hypothermia may be the only symptoms in neonates, progressive lethargy, irritability (often worse with handling), inconsolable crying, bulging fontanelle, poor feeding, hyper/hypotonia, vomiting, diarrhea, and/or seizures.
• Children/Adolescents: The classic triad of fever, neck stiffness and headache is found in less than half of meningitis cases in children/adolescents.
  • Non-specific symptoms as in infants (above), headache, altered LOC, photophobia, and/or nausea.
  • Signs include neck stiffness (likelihood ratio (LR) for confirmed meningitis 4.00 [2.6–6.3]), Kernig’s sign (LR 3.50 [2.1–5.7]) and Brudzinski’s sign (LR 2.50 [1.8 –3.6]).² The absence of meningeal signs does not exclude meningitis.
  • The presentation of bacterial meningitis may occur over hours or may be insidious over a few days. Lyme meningitis often has a more indolent course.
  • A spreading petechial rash or purpura is associated with meningococcal or pneumococcal meningitis but is not reliably present.
  • Concurrent oral antibiotic or steroid administration may alter presentation.^2,3,4

• Assess ABCDs. If concern for hemodynamic compromise, refer to TREKK Pediatric Severe Sepsis Algorithm.
• Assess neurological status. If concern for raised ICP:
  • Elevate head of bed to 30o, keep head midline.
  • Monitor BP and perfusion closely to avoid hypotension and maintain cerebral perfusion pressure.
  • Administer 3% NaCl 5 mL/kg (MAX 250 mL) IV over 10 min OR mannitol 0.5-1 g/kg (MAX 100 g) IV over 15 min.
  • If seizure activity, refer to TREKK Pediatric Status Epilepticus Algorithm.
• Administer antibiotics within 60 min of concern for meningitis.
• Contact Pediatrics/Pediatric Referral Centre/Transport Team.

• Investigations: CBC with differential, blood culture, CRP, glucose, electrolytes, urea, creatinine, blood gas, lactate, PTT, INR and procalcitonin (if available). Urinalysis and urine culture via clean catch, catheter, or suprapubic aspirate in infants4. Serology for Lyme only if high index of suspicion in consultation with Pediatrics/Pediatric Infectious Disease/Pediatric Referral Centre.
• Neuroimaging: Never delay antibiotics while waiting for head CT. Head CT required if:

1. 1. suspicion of space occupying lesion (focal seizure, focal neurological deficit, underlying immunodeficiency predisposing to opportunistic infections) OR
   2. raised intracranial pressure (Cushing’s triad, focal seizures, focal neurological deficit, irregular breathing, papilledema, persistently reduced level of consciousness, refractory seizures).

• Cerebral Spinal Fluid (CSF): CSF cell count, Gram stain, culture, protein, glucose, PCR for enterovirus, pneumococcus, meningococcus, or other bacteria (if available), and parechovirus in infants less than 3 months,⁴ PCR for HSV-1/2 in infants less than 6 weeks with compatible CSF cell count. Local anesthesia doubles the chance of a successful LP. Refer to TREKK Recommendations for Procedural Pain and/or Procedural Sedation in stable patients older than 1 year.
• Contraindications to Lumbar Puncture: respiratory or cardiovascular compromise, skin infection at LP site or coagulopathy/severe thrombocytopenia.

• Practical Interpretation of the CSF Cell Count: Interpretation varies by age. Neutrophils are not normal in the CSF in any age group. If there is a traumatic tap, the safest option is to count the total number of white cells and disregard the red cell count or accept one more WBC to the total for each 1000 RBC.

• Monitor closely for signs of potential complications important to identify and treat early:
  • Sepsis, shock, hypoglycemia, anemia, raised ICP, SIADH, seizures.

• All patients with suspected or proven meningitis are admitted to hospital.
• Contact PICU/Transport Team if hemodynamic instability, altered LOC, airway compromise needing critical care.

Thank you to the following content experts who led the development of the Meningitis Bottom Line Recommendations:

Shannon MacPhee, MD, FRCPC Medical Director, Patient Safety Program, IWK Health Atlantic Nodal Leader, TREKK, Associate Professor, Department of Emergency Medicine, Dalhousie University

Christian Renaud, MD MSc FRCPC Medical Microbiology & Pediatric ID CHU Sainte-Justine, Associate professor of clinic Department of Microbiology, Infectiology and Immunology & Pediatrics, Université de Montréal

Thank you to the TREKK Editorial Committee and editor Dr. Sarah Reid (CHEO) who provided editorial support and expertise in the development of this resource and Mary Anne Nurmi, MA, MSc, TREKK Knowledge Broker (University of Manitoba) who coordinated the development process.

To see our resource development process please visit our website here.

1. Ouchenir L, Renaud C, Khan S, Bitnun A, et al. The Epidemiology, Management, and Outcomes of Bacterial Meningitis in Infants. Pediatrics. 2017 Jul;140(1):e20170476.
2. Curtis S, Stobart K, Vandermeer, B. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010;126(5):952-960.
3. Le Saux N, Canadian Paediatric Society Infectious Diseases and Immunization Committee. Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age. Paediatr Child Health. 2014;19(3):141-152.
4. Children’s Health Queensland Hospital and Health Service. Meningitis: Emergency Management in Children. 2019.
5. Tracy A, Waterfield T. How to use clinical signs of meningitis. Arch Dis Child Educ Pract Ed. 2020;105(1):46-49.
6. Baxter AL, Fisher RG, Burke BL, et al. Local anesthetic and stylet styles: factors associated with reisdent lumbar puncture success [published correction appears in Pediatrics. 2006 May;117(5):1870]. Pediatrics. 2006;117(3):876-881.
7. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment [published correction appears in Pediatrics 2002 Sep;110(3):651]. Pediatrics. 2001;108(5):1169-1174.
8. Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst
   Rev. 2015;2015(9):CD004405.

For a complete list of the evidence that informed the creation of the Meningitis Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use