Meningitis bacterial, neonatal

G01

DESCRIPTION

A bacterial infection of the meninges in the first month of life.

Consider meningitis in any neonate being evaluated for sepsis or infection, as most organisms implicated in neonatal sepsis also cause neonatal meningitis. The most common causative organisms are Group B ß-haemolytic streptococcus type III and Gram-negative organisms such as E. coli with K[1] antigen. Consider S. epidermidis and S. aureus as causative organisms with central nervous system anomalies such as open defects or with indwelling devices such as VP shunts.

Consider HIV infection in neonates with meningitis.

DIAGNOSTIC CRITERIA

Clinical

  • Clinical presentation is usually with one or more non-specific signs such as:
    • temperature disturbances,
    • altered level of consciousness,
    • lethargy,
    • blood glucose disturbances,
    • irritability,
    • bulging/full fontanel,
    • vomiting,
    • convulsions,
    • feeding problems,
    • apnoea, and
    • vasomotor changes.
  • Complications include:
    • cerebral oedema,
    • convulsions,
    • raised intracranial pressure,
    • hydrocephalus,
    • vasculitis, with haemorrhage,
    • subdural effusion,
    • ventriculitis,
    • brain abscess,
    • ischaemia and infarctions of the brain,
    • inappropriate antidiuretic hormone (ADH) secretion.
  • Late complications include:
    • neurological sequelae,
    • blindness,
    • deafness, and
    • intellectual disabilities.

Special Investigations

  • Lumbar puncture:
    • CSF appears turbid to purulent.
    • Protein concentration is increased (> 1.0 g/L).
    • Leucocyte count is increased with a predominance of polymorphonuclear leucocytes (> 6 cells/mm³).
    • Glucose concentration is low, < ⅔ of blood glucose.
  • Gram stain, microscopy, culture and sensitivity of CSF.
  • Blood cultures for microscopy, culture and sensitivity.

GENERAL AND SUPPORTIVE MEASURES

  • Admit to high or intensive care unit, if available.
  • Maintain a neutral thermal environment.
  • Monitor, where indicated:
    • neurological status, > calcium and magnesium,
    • vital signs, > acid-base status,
    • electrolytes, > blood glucose,
    • haematocrit, > serum and urine osmolality,
    • fluid balance (hydration), > blood gases.
  • Ensure adequate nutrition:
    • Enteral feeding where possible, use nasogastric tube, if necessary.
    • If enteral feeding is not possible, IV fluids, e.g. neonatal maintenance solution and parenteral nutrition under supervision by paediatrician.
  • Limit total daily fluid intake, IV and oral:
    • Do not exceed the daily requirements for age.
    • Prevent fluid overload.

MEDICINE TREATMENT

Antibiotics, empirical

  • Cefotaxime, IV, 50 mg/kg over 30 minutes, for 21 days.
    • If < 7 days of age: 50 mg/kg 12 hourly.
    • If 7 days – 3 weeks of age: 50 mg/kg 8 hourly.
    • If > 3 weeks of age: 50 mg/kg 6 hourly.
      PLUS
  • Ampicillin, IV, for 14 days.
    • If < 7 days of age: 50mg/kg 12 hourly.
    • If > 7 days – 3 weeks of age: 50 mg/kg 8 hourly.
    • If > 3 weeks of age: 50 mg/kg 6 hourly.

During the course of treatment, a cranial ultrasound should be done.
Repeat CSF examination after 48–72 hours to ensure there is a response to therapy.
Reconsider choice of antibiotic when the results of blood and CSF cultures become available or the child does not improve within 72–96 hours.

No response or intolerant to cephalosporins or ampicillin
For patients not responding to adequate antibiotic therapy where no organisms were identified or cultured, consider viruses, fungi and bacteria not usually causing meningitis.

Convulsions
See Seizure, neonate .

Raised intracranial pressure or cerebral oedema
Avoid fluid overload.
Limit total daily intake, IV and oral.
Do not exceed the total fluid maintenance requirements for age.

REFERRAL

  • Meningitis not responding to adequate treatment.
  • Meningitis with complications.
  • Follow up is essential for assessing neurodevelopment, hearing and vision.