Management of Acute Bacterial Meningitis in Children

Figures & data

Table 1 Cerebrospinal Fluid Characteristics in Children with and without Meningitis (Viral, Bacterial) According to Age^18,89,90

	CSF WBC Count Cells/mm3	Neutrophils	CSF Protein Concentration mg/dL	CSF Glucose Concentration mg/dL
Term neonate 0–28 days^a	5.5(6.0)	20–60%	69.9 (25.7)	45.7 (8)
0–7 days	15.3(30.3)		80.3(30.8)	45.9(7.5)
8–14 days	5.4(4.4)		69.0(22.6)	54.3(17)
15–21 days	7.7(12.1)		59.8(23.4)	46.8(8.8)
22–28 days	4.8(3.4)		54.1(16.2)	54.1(16.2)
Young infant <60 days^b	3.6(4.3)	20–60%	53.2(21.2)	48.1 (8)
Healthy Children	<6	None	20–40	40–80
Bacterial	>1.000	85–90%	100–150	<1/2 serum to N
Viral	<1.000	20–50%	40- <100 g/dl	>1/2 serum

Note: ^a,bCSF WBC, Protein concentration and glucose values are provided as mean (standard deviation).

Table 2 The Most Common Organism Causing Acute Bacterial Meningitis per Age Group with the Recommended Standard Therapy Based on in vitro Susceptibility Testing^{18,21,30,69,70,91–95}

Age Group	Organisms	Treatment (Intravenously) Dose/kg/day	Length of Therapy (Uncomplicated Meningitis)
Term Neonates- early onset	GBS	Penicillin G (infant <7days) 250 000.0-450 000.0 U divided in 3 doses OR ampicillin (infant <7days) 200.0-300.0 mg divided in 3 doses	14 days
	L. monocytogenes	Penicillin G (infant <7days) 250 000.0-400 000.0 U divided in 4-6 doses OR ampicillin (infant <7days) 200.0-300.0 mg divided in 3 doses + gentamicin (infant <7days) neonate (weight < 2kg) 5.0mg/kg every 48 hours neonate (weight >2kg) 4.0 mg/kg every 24 hours	14-21 days
	E. coli (gentamicin should be added until CSF is sterile)		21 days
	- ampicillin-susceptible	ampicillin (infant <7days) 200.0-300.0 mg divided in 3 doses
	- ampicillin resistant, cefotaxime susceptible	Cefotaxime^a,b (infant <7days) neonate (weight > 2kg) 100.0-150.0 mg divided every 2-3 doses gentamicin (infant <7days) neonate (weight < 2kg) 5.0 mg/kg every 48 hours neonate (weight >2kg) 4.0 mg/kg every 24 hours
Term Neonates- Late onset	GBS	Penicillin G (infant >7days) 450 000.0-500 000.0 U divided in 4 doses OR ampicillin (infant >7days) 300.0 mg divided in 4 doses	14 days
	L. monocytogenes	Penicillin G (infant >7days) 250 000.0-400 000.0 U divided in 4-6 doses OR ampicillin (infant >7days) 300.0 mg divided in 4 doses + gentamicin (infant >7days) neonate (weight < 2kg) 5.0 mg/kg every 36 hours neonate (weight >2kg) 4.0-5.0 mg/kg every 24 hours	14-21 days
	E. coli (gentamicin should be added until CSF is sterile)		21 days
	- ampicillin-susceptible	ampicillin (infant >7days) 300.0 mg divided in 4 doses
	- ampicillin resistant, cefotaxime susceptible	cefotaxime^a,b (infant >7days) neonate (weight > 2kg) 150.0-200.0 mg divided in 3 to 4 doses gentamicin (infant >7days) neonate (weight < 2kg) 5.0 mg/kg every 36 hours neonate (weight >2kg) 4.0-5.0 mg/kg every 24 hours
Infants and Toddlers	GBS	Penicillin G 450 000.0-500 000.0 U divided in 4 doses OR ampicillin 300.0 mg divided in 4 doses	14 days
	E.coli (gentamicin should be added until CSF is sterile)		21 days
	- ampicillin-susceptible	ampicillin 300.0-400.0mg divided in 4 to 6 doses can substitute the cephalosporin
	- ampicillin resistant	Ceftriaxone 100.0 mg divided in 2 doses OR cefotaxime 200.0-300.0 mg divided in 4 doses PLUS gentamicin 7.5 mg divided in 3 doses
	L. monocytogenes	Penicillin G 250 000.0-400 000.0 U divided in 4-6 doses OR ampicillin 300.0 mg divided in 4 doses + gentamicin 7.5 mg divided in 3 doses	21 days
	S. pneumonia		10 to 14 days
	Penicillin MIC^c <0.06 µg/ml	Penicillin G 250 000.0-400 000.0 U divided in 4-6 doses(max 24 million U/day) OR ampicillin 300.0-400.0 mg divided in 4 to 6 doses (max 12g/day)OR Ceftriaxone 100.0 mg divided in 2 doses (max 2.0g/dose, 4.0g/day)OR cefotaxime 225.0-300.0mg divided in 3 to 4 doses (max 2.0g/dose)
	Penicillin MIC > 0.12µ g/ml AND cefotaxime/Ceftriaxone MIC <0.5 µg/ml	Ceftriaxone OR cefotaxime (dose as mentioned above)
	Penicillin MIC > 0.12µg/ml AND cefotaxime/Ceftriaxone MIC >1.0 µg/ml	Vancomycin 60.0 mg divided in 4 doses PLUS Ceftriaxone^d OR cefotaxime
	N. meningitides		5-7 days
	Penicillin MIC<0.1 µg/ml	Penicillin G 300 000 U divided in 4-6 doses (max 12 million /day)OR ampicillin OR cefotaxime OR Ceftriaxone (dose as in S. pneumonia)
	Penicillin MIC 0.1-1.0µg/ml	cefotaxime OR Ceftriaxone (dose as in S. pneumonia)
	H. influenzae		7 to 10 days
	β- Lactamase negative ^e	ampicillin (dose as in S. pneumonia)
	β- Lactamase positive	Ceftriaxone OR cefotaxime (dose as in S. pneumonia)
Children and Teenagers	N. meningitidis S. pneumoniae,  H. influenzae	Doses as mentioned above	Duration as mentioned above

Notes: ^aIf cefotaxime is not available or resistant, a carbapenem should be substituted for neonates and infants younger than 91 days and ceftriaxone or ceftazidime for older infants and children. ^bIf neonate <2 kg smaller doses and longer intervals should be used. ^cMIC = Minimum inhibitory concentrations. ^dConsider adding Rifampin if ceftriaxone MIC ≥2 µg/mL and organism is rifampin susceptible. ^eβ- Lactamase negative, ampicillin-resistant strains have been described, use ampicillin with caution if MIC is 1–2 µg/mL.

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