Meningitis

Early diagnosis is essential for effective treatment. This section covers children
and infants over 2 months old. See section 3.8 (page 49) for diagnosis and
treatment of meningitis in young infants.
Diagnosis
Look for a history of:
■ vomiting
■ inability to drink or breastfeed
■ a headache or pain in back of neck
■ convulsions
■ irritability
■ a recent head injury.
On examination, look for:
■ a stiff neck
■ repeated convulsions
■ lethargy
■ irritability
■ bulging fontanelle
■ a petechial rash or purpura
■ evidence of head trauma suggesting
possibility of a recent skull fracture.
Also, look for any of the following signs
of raised intracranial pressure:
■ unequal pupils
■ rigid posture or posturing
■ focal paralysis in any of the limbs or trunk
■ irregular breathing.
MENINGITIS
Looking and feeling for stiff
neck in a child
Unequal pupil size—
a sign of raised
intracranial pressure
149
6. FEVER
Laboratory investigations
If possible, confirm the diagnosis with a lumbar puncture and examination of
the CSF. If the CSF is cloudy, assume meningitis and start treatment while
waiting for laboratory confirmation. Microscopy should indicate the presence
of meningitis in the majority of cases with the white cell (polymorph) count
above 100/mm3. Confirmatory information can be gained from the CSF glucose
(low: <1.5 mmol/litre), CSF protein (high: >0.4 g/litre), and Gram staining and
culture of the CSF, where possible. If there are signs of increased intracranial
pressure, the potential value of the information gained from a lumbar puncture
should be carefully weighed against the risk of the procedure. If in doubt, it
might be better to start treatment for suspected meningitis, and delay
performing a lumbar puncture (see p. 316).
Specific causes of meningitis
• During a confirmed epidemic of meningococcal meningitis it is not necessary
to perform a lumbar puncture on children who have petechial or purpuric
signs, which are characteristic of meningococcal infection. During such
epidemics, give oily chloramphenicol (100 mg/kg IM as a single dose up to
a maximum of 3 grams) for the treatment of meningococcal meningitis.
The oily suspension is thick and may be difficult to push through the needle.
If this problem is encountered, the dose can be divided into two parts and
an injection given into each buttock of the child. This simplified treatment
schedule is particularly useful in situations where there are limited resources
to deal with the epidemic.
MENINGITIS
Opisthotonus and rigid posture:
a sign of meningeal irritation and raised
intracranial pressure
150
6. FEVER
■ Consider tuberculous meningitis if:
— fever persists for 14 days
— fever persists for more than 7 days and there is a family member with
tuberculosis
— a chest X-ray suggests tuberculosis
— the patient remains unconscious
— CSF continues to have moderately high white blood cell counts (typically,
<500 white cells per ml, mostly lymphocytes), elevated protein levels
(0.8–4 g/l) and low glucose levels (<1.5 mmol/litre).
In children known or suspected to be HIV-positive, tuberculous or cryptococcal
meningitis should also be considered. For diagnosis of cryptococcus, do a
CSF stain with India ink.
Treatment
If the CSF is obviously cloudy, treat immediately with antibiotics before the
results of laboratory CSF examination are available. If the child has signs of
meningitis and a lumbar puncture is not possible, treat immediately.
Antibiotic treatment
➤Give antibiotic treatment as soon as possible. Choose one of the following
two regimens:
1. Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours
plus ampicillin: 50 mg/kg IM (or IV) every 6 hours
OR
2. Chloramphenicol: 25 mg/kg IM (or IV) every 6 hours
plus benzylpenicillin: 60 mg/kg (100 000 units/kg) every 6 hours IM
(or IV).
Where there is known significant drug resistance of common pathogens
(e.g. Haemophilus influenzae or Pneumococcus) to these antibiotics,
follow the national guidelines. In many circumstances, the most
appropriate treatment will be a third-generation cephalosporin such as:
— ceftriaxone: 50 mg/kg IM/IV, over 30–60 minutes every 12 hours; or
100 mg/kg IM/IV, over 30–60 minutes once daily; or
— cefotaxime: 50 mg/kg IM or IV, every 6 hours.
➤Review therapy when CSF results are available. If the diagnosis is confirmed,
give treatment parenterally for at least 5 days. Once the child has improved,
MENINGITIS
151
6. FEVER
give chloramphenicol orally unless there is concern about oral absorption
(e.g. in severely malnourished children or in those with diarrhoea), in which
cases the full treatment should be given parenterally. The total duration of
treatment is 10 days.
• If there is a poor response to treatment:
— Consider the presence of common complications, such as subdural
effusions (persistent fever plus focal neurological signs or reduced level
of consciousness) or a cerebral abscess. If these are suspected, refer
the child to a central hospital with specialized facilities for further
management (see a standard paediatrics textbook for details of
treatment).
— Look for other sites of infection which may be the cause of fever, such
as cellulitis at injection sites, arthritis, or osteomyelitis.
— Repeat the lumbar puncture after 3–5 days if the fever is still present
and the child’s overall condition is not improving, and look for evidence
of improvement (e.g. fall in leukocyte count and rise in glucose level).
• Consult a standard paediatrics textbook for further details if tuberculous
meningitis is suspected. Occasionally, when the diagnosis is not
clear, a trial of treatment for tuberculous meningitis is added to the treatment
for bacterial meningitis. Consult national tuberculosis programme guidelines.
The optimal treatment regimen, where there is no drug resistance,
comprises:
— isoniazid (10 mg/kg) for 6–9 months; and
— rifampicin (15–20 mg/kg) for 6–9 months; and
— pyrazinamide (35 mg/kg) for the first 2 months.
Steroid treatment
In some hospitals in industrially developed countries, parenteral dexamethasone
is used in the treatment of meningitis. There is not sufficient evidence to
recommend routine use of dexamethasone in all children with bacterial
meningitis in developing countries.
Do not use steroids in:
• newborns
• suspected cerebral malaria
• suspected viral encephalitis
• areas with a high prevalence of penicillin-resistant pneumococcal invasive
disease.
MENINGITIS
152
6. FEVER
Dexamethasone (0.6 mg/kg/day for 2–3 weeks, tailing the dose over a further
2–3 weeks) should be given to all cases of tuberculous meningitis.
Antimalarial treatment
In malarious areas, take a blood smear to check for malaria since cerebral
malaria should be considered as a differential diagnosis or co-existing condition.
Treat with an antimalarial if malaria is diagnosed. If for any reason a blood
smear is not possible, treat presumptively with an antimalarial.
Supportive care
Examine all children with convulsions for hyperpyrexia and hypoglycaemia.
Treat the hypoglycaemia (see page 143). Control high fever (≥39 °C or
≥102.2 °F) with paracetamol.
In an unconscious child:
• Maintain a clear airway.
• Nurse the child on the side to avoid aspiration of fluids.
• Turn the patient every 2 hours.
• Do not allow the child to lie in a wet bed.
• Pay attention to pressure points.
Oxygen treatment
Oxygen is not indicated unless the child has convulsions or associated severe
pneumonia with hypoxia (SaO2 <90%), or, if you cannot do pulse oximetry,
cyanosis, severe lower chest wall indrawing, respiratory rate of >70/minute.
If available, give oxygen to these children (see section 10.7, page 281).
High fever
➤If fever (≥39 °C or ≥102.2 °F) is causing distress or discomfort, give
paracetamol.
Fluid and nutritional management
There is no good evidence to support fluid restriction in children with bacterial
meningitis. Give them their daily fluid requirement, but not more (see page
273) because of the risk of cerebral oedema. Monitor IV fluids very carefully
and examine frequently for signs of fluid overload.
Give due attention to acute nutritional support and nutritional rehabilitation
(see page 261). Feed the child as soon as it is safe. Breastfeed every 3 hours,
if possible, or give milk feeds of 15 ml/kg if the child can swallow. If there is a
MENINGITIS
153
6. FEVER
risk of aspiration, give the sugar solution by nasogastric tube (see Chart 10,
page 15). Continue to monitor the blood glucose level and treat accordingly
(as above), if found to be <2.5 mmol/ litre or <45 mg/dl.
Monitoring
Nurses should monitor the child’s state of consciousness, respiratory rate and
pupil size every 3 hours during the first 24 hours (thereafter, every 6 hours),
and a doctor should monitor the child at least twice daily.
On discharge, assess all children for neurological problems, especially hearing
loss. Measure and record the head circumference of infants. If there is
neurological damage, refer the child for physiotherapy, if possible, and give
simple suggestions to the mother for passive exercises.
Complications
Convulsions
➤If convulsions occur, give anticonvulsant treatment with rectal diazepam or
paraldehyde (see Chart 9, page 14) or IM paraldehyde (see page 342).
Hypoglycaemia
➤Give 5 ml/kg of 10% glucose (dextrose) solution IV rapidly (see Chart 10,
page 15). Recheck the blood glucose in 30 minutes and if the level is low
(<2.5 mmol/litre or <45 mg/dl), repeat the glucose (5 ml/kg)
➤Prevent further hypoglycaemia by feeding, where possible (see above). If
you give IV fluids, prevent hypoglycaemia by adding 10 ml of 50% glucose
to 90 ml of Ringer's lactate or normal saline. Do not exceed maintenance
fluid requirements for the child’s weight (see section 10.2, page 273). If the
child develops signs of fluid overload, stop the infusion and repeat the 10%
glucose bolus (5 ml/kg) at regular intervals.
Follow-up
Sensorineural deafness is common after meningitis. Arrange a hearing assessment
on all children one month after discharge from hospital.
Public health measures
In meningococcal meningitis epidemics, advise families of the possibility of
secondary cases within the household so that they report for treatment
promptly.