Meningitis, newborn/infant
- Workup for ill infant: consider lytes, ammonia, CXR, urine, cultures
- neonatal pathogens: GBS, E.
coli, enterics (i.e salmonella), Listeria
- Transition to childhood pathogens
occurs at about 6 weeks: S. pneumoniae, N. menigitides. H. flu has
virtually disappeared as a pathogen.
- GBS
can be early onset (within 1st week, tends to cause PNA or overwhelming
sepsis) or late (typically 2 to
6 weeks, causing meningitis)
- For GBS,
ampicillin
and an aminoglycoside
are used. It has become conventional to treat with dbl abx for 5-7 days of GBS
meningitis, then complete a 14-21 day course with penicillin alone. Note:
aminoglycosides don't penetrate the BBB, but in the presence of inflammation
this barrier is not intact.
- If early results don't point to a specific organism, make sure that
coverage includes ampicillin
for Listeria (a
contaminant in soft cheeses from Mexico).
- If childhood pathogens are being considered i.e. around age 6 weeks, cover
with 3-rd
gen
cephalosporin + vancomycin
(to cover 3rd-gen-ceph-resistant-pneumococcus)
- ABX
prior to LP? Median time from presentation to ED to LP was 2 hours.
Currently, there are no data that withholding therapy for a short time
influences the ultimate outcome of meningitis. Particularly in meningococcus,
the CSF and blood can be sterilized within 1 hour.
- Hydrocortisone? has been
given to children in shock, 50-100 mg/m2/day. There is currently a study
looking at a dose of 30. Sideffects: HTN and hyperglycemia (adult literature
advocates tight control of sugar 80-120 with insulin)
- GCSF,
GM-csf?
GCSF increases neutrophil # in vivo, and increases function in
vitro. No RCT's to show decreased mortality in septic neonates, but some
subgroup analyses suggest use in neutropenic neonates.
- SIADH:
watch for in first 48 hours of meningitis: decreased plasma osmolality,
inappropriately elevated urine osmolality, euvolemia and absence of
hypothyroid, adrenal insufficiency, kidney disease. Clinically, see decreased
UOP, incr urine SG, hyponatremia, which may cause seizures.
- Sterile
subdural
effusions are common sequelae of bacterial meningitis and generally
require no intervention.
- Prophylaxis for close
contacts: see Rifampin
Pediatric Annals 33(9), Sept 2004