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Which empiric antibiotics to use? — Pediatric Bacterial Meningitis November 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , trackback
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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Comments»

1. Zahra - November 7, 2018

Hi
Thanks for your case
According to signs and symptoms the infant is ill and also sepsis must be considered .
So,I start Cefitaxim plus vancomycin and do lumbar puncture in addition to blood culture ,CBC diff,CRP,PCT,and ESR,UA and UV

2. Chris - November 7, 2018

This could be a simple viral URTI, but several features of the history and physical are concerning- young age, prematurity, h/o PROM, and reported history of “pallor”. And although immunization status is reportedly up to date, maternal prenatal GBS carrier status is unknown in the vignette. Patient is tachycardic and tachypneic, but in the setting of fever. Blood pressure is not included in the vignette, but this is also important. More concerning to me is the patient’s altered mental status (doesn’t fix and follow, is fussy) and poor tone.

Differentials include URTI, viral syndrome, and more worrisome diagnoses such as sepsis, meningoencephalitis (both viral and bacterial), pneumonia (given h/o cough and fever). UTI a possibility but less likely.

ED workup should include: PIV, volume repletion with crystalloid, empiric parenteral antimicrobials (ceftriaxone + vancomycin given my concern for bacterial meningitis). I would defer antiviral such as acyclovir given lower suspicion for herpes CNS infection (lack of seizure, lack of historical risk factors for congenital HSV, and lack of skin or mucous membrane findings on exam that would raise concern for herpes infection). I would also obtain diagnostics- specifically biomarkers- CBC, BCx, UCx (cath’d specimen), UA, CSF (cell count, diff, gram stain, culture, protein, glucose, enterovirus PCR). I would not obtain CRP or pro-calcitonin as this would not change my management. If the above biomarkers are inconclusive or do not suggest an infectious source, then I would obtain a CXR looking for an infectious source. I would also give antipyresis for supportive measures.

Disposition- admission to pediatric hospitalist service, or if the patient shows clinical deterioration in the ED, then to Pediatric Critical Care Medcine service.

3. Cortes - November 7, 2018

I agree with above. Although I may attempt to find a source before LP.

4. Heidi B - November 8, 2018

Rocehin 100mm/kg

5. Ahmed moursi - November 8, 2018

The baby has dangerous finding:
1-History of pallor 2-sleepiness not interactive 3- baby wouldn’t feed at presentation(??? Blocked nose)4-hypotonic5-fussy on examination (??? Fever& blocked nose) in addition he had only one dose of PCV & HIB so ,I will admired & do full sepsis screen ( LP, blood culture, urine culture) ,CXR considering respiratory symptoms ( consider viral marker if there is influenza epidemic) & start empirical antibiotics ( ceftriaxone & vancomycin)

6. Ayaz Ali - November 9, 2018

I think emperically starts ceftriaxone + vancomysin(if suspected mrsa infection) check for meningeal sign raised icp,kernig,s sign

7. Zak - November 9, 2018

Sepsis should be R/O
Complete septic work up including L/P
Start empirical ampicillin and cefotaxim
Pending results
Thank you

8. Tesfu - November 9, 2018

I ( from the third world country, Ethiopia) will start with a high dose ceftriaxone, while investigating with CBC, blood culture, LP and urine analysis & culture simultaneously!

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Last Modified: 12-12-2018
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