Pediatric Bacterial Meningitis: An Update on Early Identification and Management (Pharmacology CME) -
Publication Date: November 2018 (Volume 15, Number 11)
CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 11/1/2021
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 2 Pharmacology CME credits, subject to your state and institutional approval.
Emerson Posadas, MD, MBA
Department of Emergency Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, NV
Jay Fisher, MD, FAAP, FACEP
Clinical Professor of Emergency Medicine and Pediatrics, University of Nevada, Las Vegas School of Medicine; Medical Director, Pediatric Emergency Services, Children’s Hospital of Nevada at University Medical Center, Las Vegas, NV
Sheldon L. Kaplan, MD
Professor and Executive Vice Chair, Head, Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine; Chief, Infectious Disease Service, Texas Children’s Hospital, Houston, TX
Lise Nigrovic, MD, MPH
Associate Professor, Pediatrics and Emergency Medicine, Harvard Medical School; Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
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. This issue provides evidence-based recommendations for the early identification and appropriate management of bacterial meningitis in pediatric patients.
Excerpt From This Issue
On a warm day in June, an unvaccinated 9-year-old girl is sent to your ED. Earlier that day, she was seen at her primary care physician’s office by a physician assistant who reported that the child had headache and fever intermittently for 3 to 4 days. The PA was concerned that she might have meningitis. The patient arrives, ambulatory and alert, complaining of a bitemporal headache. Her fever at home was 38.3°C (101°F). There has been no photophobia or rash, and there are no ill contacts. The child took acetaminophen 2 hours prior to arrival. On physical examination, the child is tired but not toxic-appearing. She had an episode of vomiting in triage. Her vital signs are: temperature, 38.7°C (101.6°F); heart rate, 142 beats/min; respiratory rate, 22 breaths/min; blood pressure, 119/77 mm Hg; and oxygen saturation, 95% on room air. Her pain score is 8/10. Her physical examination is notable for head and neck discomfort when moving from sitting to the supine position. Her neck has full range of motion and she is negative for Kernig sign and Brudzinski sign. The remainder of her examination is normal. The patient is given a 20 mL/kg normal saline bolus IV, 6 mg ondansetron IV, and 10 mg/kg ibuprofen orally. An hour later, her vital signs are: temperature, 37.2°C (99°F); heart rate, 126 beats/min; respiratory rate, 20 breaths/min; and blood pressure 111/67 mm Hg. Her pain score is now 4/10. Her peripheral white blood cell count is 16,000 with a left shift, and her chemistry is notable only for a glucose level of 146 mg/dL. Given the girl’s lack of frank meningismus and improvement with ibuprofen, is a lumbar puncture indicated? What are the most common causes of meningitis in this age group? Should antibiotics be given?
Dr. Posadas and Dr. Fisher - 04/01/2019 This was a very thorough review with good clinical application.
Dr. Posadas and Dr. Fisher - 03/29/2019 As usual, an excellent presentation on a very broad topic. You have outdone yourselves again! As always, many thanks!
Dr. Posadas and Dr. Fisher - 03/22/2019 Great article discussing the physiology of meningitis as well as the diagnosis and treatment.
Dr. Posadas and Dr. Fisher - 03/21/2019 Good information on antimicrobial coverage; I have previously given ceftriaxone and ampicillin in neonates, so good to learn this update.
Dr. Posadas and Dr. Fisher - 03/19/2019 Excellent points in the management of pediatric meningitis.
Dr. Posadas and Dr. Fisher - 03/16/2019 I will continue to emphasize early appropriate antibiotic administration based on age and risk factors to optimize empiric choices.
Dr. Posadas and Dr. Fisher - 03/13/2019 I will run through red flag symptoms of somnolence, fever, neck stiffness, meningismus, ill appearance, severe headache more routinely. I will also add the bacterial meningitis score to my practice.
Dr. Posadas and Dr. Fisher - 03/08/2019 This course helped improved decision making based on the strongest clinical evidence, improved diagnosis of bacterial meningitis, improved treatment, and management of meningitis.
Dr. Posadas and Dr. Fisher - 03/06/2019 I was not aware of the bacterial meningitis score for children and feel this will greatly impact the way I approach bacterial meningitis. Also, the procalcitonin as an adjunct in the differential between viral bacterial meningitis was also enlightening.
Dr. Posadas and Dr. Fisher - 03/04/2019 Better evaluation and treatment of pediatric patients with possible meningitis.
Dr. Posadas and Dr. Fisher - 03/01/2019 After reading this article, I will consider doing more LP's in borderline cases. Consider the prior use of antibiotics as an increased risk factor.
Dr. Posadas and Dr. Fisher - 02/28/2019 I now have a better understanding of the use of procalcitonin.
Dr. Posadas and Dr. Fisher - 02/22/2019 I will start using the bacterial meningitis score in febrile patients with high WBC with suspicion of meningitis.
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