Risk Management Pitfalls in the Management of Pediatric Patients With Bacterial Meningitis
March 19, 2020
Posted by Andy Jagoda, MD in: Risk Management Pitfalls , trackback
The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Inflammatory markers, such as procalcitonin, in the serum and cerebrospinal fluid may help distinguish between bacterial meningitis and viral meningitis. Appropriate early antibiotic treatment and management for bacterial meningitis is critical for optimal outcomes. Although debated, corticosteroids should be considered in certain cases.
These risk management pitfalls will help you avoid unwanted outcomes when identifying and managing bacterial meningitis in pediatric patients in the ED.
1. “The patient is sleeping. I don’t want to wake her up to perform a neurological examination.”
The neurologic assessment of the young child can be difficult, even under optimal circumstances. If you are performing this evaluation when a child is fearful or when they should be sleeping, it can be even more challenging and requires patience and, frequently, a dedicated period of observation for reassessment. Efforts should also be made to provide distraction to reduce the amount of fear or inhibition caused by the hospital environment to allow the most accurate examination possible. This distraction can be provided by family interaction with the child or by having the child play independently with a toy.
2. “The patient has inflamed tympanic membranes. The fever and irritability are likely due to otitis media. It’s not meningitis.”
Many young children with bacterial meningitis can have concomitant inflammation in other areas on physical examination or diagnostic study. Otitis media and upper respiratory tract infections are common enough conditions that their presence can lead the emergency clinician to “explain away” the child’s more serious symptoms as being due to those pathophysiologic findings. Anchoring on a simpler, less severe diagnosis can result in missing or delaying the correct diagnosis.
3. “The patient likely had a febrile seizure. I can’t get a neurological examination in his postictal state.”
Delay during decision-making can result in harmful diagnostic or therapeutic delay. A high-risk scenario can develop while waiting for a postictal child to awaken from a febrile seizure to perform a thorough neurologic examination and determining the need for a lumbar puncture or empiric antibiotics. The large majority of patients with simple febrile seizure are going to awaken to a baseline neurologic state within 1 to 2 hours after the seizure. Is the patient who is still “sleeping” 2 to 3 hours after a febrile seizure postictal, or is the patient progressing to a state of unresponsiveness? Patients who behave in this manner after a complex febrile seizure can be particularly concerning, and a lower threshold of lumbar puncture should be considered.
4. “This patient’s neck stiffness or meningismus is likely due to pharyngitis or ‘flu-like’ symptoms.”
Pharyngitis and other viral illnesses can also give a clinical presentation of neck stiffness. Meningismus is not specific to meningitis. Emergency clinicians can be inundated with patients presenting with neck stiffness during the winter months, and it is important to be vigilant for any other clues that seem disproportionate to a normal viral illness.
5. “The patient has a normal WBC count, so I don’t need to be worried about meningitis.”
In isolation, the absence of leukocytosis or leukopenia is an inadequate tool by which to make clinical management decisions. The peripheral blood absolute neutrophil count can be used in combination with other elements of the bacterial meningitis score to guide initial decision-making while awaiting results of CSF culture.
6. “The patient likely has viral meningitis, so we don't need to get a lumbar puncture.”
The notion that emergency clinicians can distinguish the difference between viral and bacterial meningitis based on the history and physical examination is not supported by the available evidence. The clinical overlap of these conditions is substantial, particularly early in the course of illness. Diagnosis should not be made based on the history and physical examination alone.
7. “I did not consider group B Strep in my differential for this perinatal infant.”
GBS infection must be considered in any febrile infant in the first 2 months of life, even after maternal treatment of colonization.
8. “We need to wait for a CT scan and lumbar puncture before we can give antibiotics, as they can cause sterilization of CSF.”
When caring for a patient with a presumptive diagnosis of bacterial meningitis, do not delay administration of appropriate antibiotics for the completion of a CT scan or lumbar puncture or for the results of these studies. Although antibiotics may obscure the ultimate bacteriologic diagnosis, this is a small clinical price to pay to prevent further bacterial proliferation and inflammation within the CNS.
9. “We don’t need to consider tuberculosis or fungal meningitis.”
Meningitis due to atypical pathogens such as Mycobacterium tuberculosis can be notoriously insidious and indolent in presentation. Consider these pathogens, particularly in patients with immunodeficiency, patients traveling from high-risk parts of the world, or, in the case of tuberculosis, those with prolonged contact with an infected individual.
10. “My patient has a positive urinalysis. This is clearly just a UTI. I don’t need to consider any other diagnoses.”
While concomitant UTIs are rare, they do occur. In a recent study involving 1737 infants aged 29 to 60 days, concomitant UTI with bacterial meningitis occurred 0.2% of the time, and was more prevalent in infants aged 0 to 28 days.
Need more information? Click here to review the course on Pediatric Bacterial Meningitis: An Update on Early Identification and Management (Pharmacology CME).