Management

Early identification

  • Although rapid identification and treatment of this disease provides the best chance of recovery, it can be very difficult to recognise, because in the early stages it resembles less serious viral illnesses.

  • Paramedics should retain a high index of suspicion for meningococcal disease in unwell children.

  • Paramedics should take appropriate infection control precautions if meningitis is suspected.

Manage life-threatening conditions

  • Assess airway for patency and provide intervention if required, such as insertion of an appropriate adjunct or suctioning.

  • Assure adequate ventilation. If inadequate, provide positive-pressure ventilation, being aware of effects on preload and intrathoracic pressure in patients with shock.

Fluid resuscitation

  • Establish venous access through peripheral IV or IO if time-critical, administer crystalloid solution at 20ml/kg if in shock.

  • Ensure adequate cerberal perfusion by maintaining blood pressure at acceptable value (in setting of raised ICP)

  • Careful management of fluid and electrolyte balance is an important aspect of supportive therapy. Both over- and under-hydration are associated with adverse outcomes. (Maconochie and Bhaumik, 2014)

  • Children who are in shock should receive sufficient quantities of isotonic fluid to maintain blood pressure and cerebral perfusion (Kim, 2014)

Antibiotic therapy

  • Empirical antibiotic regimen should include coverage for penicillin-resistant S. pneumoniae and N. meningitidis, the two most common causes of bacterial meningitis in infants and children.

  • An appropriate empiric regimen includes high doses of a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and vancomycin (Arditi et al, 1998)

  • Third generation cephalosprins are recommended because of excellent CSF penetration and a broad spectrum of activity. 

Corticosteroids

  • Corticosteroids have been shown to significantly reduce hearing loss and neurological sequelae, but not reduce overall mortality (Brouwer et al, 2013)

  • Steroids should be administered concurrently with the first dose of antibiotics (Brouwer et al, 2013), and should not be given if more than 1 hour has elapsed (Tunkel et al, 2004)

  • The American Academy of Pediatrics (AAP) Committee on Infectious Diseases suggests that dexamethasone therapy may be beneficial in children with Hib meningitis if given before or at the same time as the first dose of antimicrobial therapy (AAP, 2015)

  • Dexamethasone is not indicated in the treatment of bacterial meningitis in infants younger than six weeks or in those with congenital or acquired abnormalities of the CNS.

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Created by Alan Batt, 2015. Site licenced under a CC BY-NC 4.0 licence (https://creativecommons.org/licenses/by-nc/4.0/)

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