Pediatrics (System-Integrated)

Pediatric meningitis: age-specific empiric therapy

Clinical Overview and When to Suspect Pediatric Meningitis

— Neonates (0–28 days): Group B Streptococcus (GBS), E. coli and other gram-negative rods, Listeria monocytogenes. HSV must be considered.

— 1–3 months: Transitional — GBS, E. coli, Listeria still possible, plus S. pneumoniae, N. meningitidis, H. influenzae type b (Hib) in unvaccinated.

— 3 months–10 years: S. pneumoniae (most common bacterial cause in vaccinated US children), N. meningitidis.

— Adolescents/college-age: N. meningitidis (especially dorm-living), S. pneumoniae.

— Any febrile neonate — meningitis is part of the rule-out sepsis workup regardless of how well they appear.

— Infant with fever + irritability, poor feeding, lethargy, bulging fontanelle, or paradoxical irritability when held.

— Older child with fever + headache + neck stiffness, photophobia, altered mental status, or new seizure.

— Petechial/purpuric rash + fever = meningococcemia until proven otherwise.

— Post-neurosurgical patient, VP shunt, cochlear implant, CSF leak, or asplenia — lowered threshold.

Board pearl: A neonate ≤28 days with fever ≥38.0°C gets full sepsis workup (blood, urine, CSF) and empiric ampicillin + cefotaxime (or gentamicin) + acyclovir — do not "wait and watch." Missing this is a classic Step 3 malpractice stem.

Definition: Inflammation of the meninges from bacterial, viral, fungal, or (rarely) parasitic invasion of the subarachnoid space. Bacterial meningitis remains a pediatric emergency: mortality 5–10%, neurologic sequelae in 20–30% of survivors (sensorineural hearing loss, seizures, cognitive deficits, hydrocephalus).

Epidemiology by age drives empiric antibiotic choice — the single most testable concept in this topic:

When to suspect:

Risk factors: incomplete immunization (Hib, PCV13/PCV15/PCV20, MenACWY, MenB), recent URI/otitis, daycare exposure, household contact with meningococcal disease, complement deficiency, sickle cell disease, CSF shunt.

Presentation Patterns and Key History

— Temperature instability (fever or hypothermia <36°C), poor feeding, vomiting, lethargy, hypotonia, high-pitched cry, apnea, jaundice, seizures, bulging fontanelle (late finding).

— Paradoxical irritability: cries more when picked up/rocked because meningeal movement hurts.

— Ask: birth history (maternal GBS status, intrapartum antibiotics, PROM >18h, chorioamnionitis, gestational age), HSV exposure, sick contacts.

— Fever, irritability, lethargy, vomiting, refusal to feed, seizures (15–30% of bacterial meningitis), bulging fontanelle if still open.

— Kernig/Brudzinski unreliable <12–18 months.

— Classic triad: fever + neck stiffness + altered mental status (all three only in ~40%, but ≥2 in ~95%).

— Headache (often severe, holocephalic), photophobia, phonophobia, vomiting, myalgias.

— Meningococcal: rapid progression over hours, petechiae/purpura fulminans, limb pain, cold extremities — these "early sepsis" features precede the rash.

— Immunization status — specifically Hib, PCV, MenACWY (routine at 11–12 with booster at 16), MenB (shared clinical decision-making 16–23, required for asplenia/complement deficiency/outbreak).

— Recent antibiotics (can partially treat and lower CSF yield).

— Travel, tick exposure (Lyme), TB exposure, immunodeficiency, sickle cell, cochlear implant, recent head trauma or neurosurgery, ventriculoperitoneal shunt.

— Sick contacts with meningitis (close contacts need chemoprophylaxis).

Key distinction: Viral (aseptic) meningitis — enterovirus is most common, summer/fall, child often looks better than vital signs predict, recovers in 7–10 days. Bacterial — toxic-appearing, rapidly progressive, focal deficits or seizures more common. But you cannot reliably distinguish on history alone — LP is the decider.

Neonatal/young infant presentation is nonspecific — the classic triad is usually absent:

Older infant/toddler (3 mo–2 yr):

Older child/adolescent:

High-yield history elements:

Physical Exam Findings and Hemodynamic Assessment

— Tachycardia out of proportion to fever, delayed capillary refill (>3 sec), cool/mottled extremities, narrow pulse pressure, hypotension (late, ominous in children).

— Tachypnea, hypoxia — consider concurrent pneumonia or ARDS from sepsis.

— Glasgow Coma Scale or AVPU — any decrement is concerning.

— Nuchal rigidity — resistance to passive neck flexion. Unreliable <18 months.

— Kernig sign — pain/resistance on knee extension with hip flexed.

— Brudzinski sign — involuntary hip/knee flexion with passive neck flexion.

— Jolt accentuation of headache (older child).

— Bulging, tense anterior fontanelle (late, ~30%), widened sutures, increased head circumference if chronic.

— Setting-sun sign (eyes deviated downward) suggests increased ICP/hydrocephalus.

— Hypotonia or hypertonia, weak suck, full fontanelle when upright.

— Petechiae below the nipple line + fever = meningococcemia until ruled out. Purpura fulminans = DIC, mortality climbs steeply.

— Vesicular rash in a neonate → think HSV (add acyclovir).

— Focal deficits, cranial nerve palsies (especially CN VI, VII, VIII), papilledema (uncommon in acute meningitis — if present, consider mass/abscess), pupillary asymmetry.

— Seizures, especially focal or prolonged, raise concern for pneumococcal, HSV, or complication (empyema, infarct).

Step 3 management: If signs of shock, fluid resuscitate (20 mL/kg isotonic crystalloid boluses) and give empiric antibiotics within 1 hour — do NOT delay antibiotics for CT or LP. Cultures (blood + CSF when safe) before antibiotics if it does not delay therapy >30 min.

Vital signs first — meningococcemia and pneumococcal sepsis kill via shock, not meningeal inflammation:

Meningeal signs:

Infant-specific findings:

Skin:

Neurologic:

Increased ICP signs: Cushing triad (hypertension, bradycardia, irregular respirations), posturing, blown pupil — defer LP, get imaging.

Diagnostic Workup — Initial Labs and Imaging

— Cell count + differential (tube 1 and 4 to assess traumatic tap)

— Glucose and protein

— Gram stain and bacterial culture

— HSV PCR (neonates, encephalopathic, vesicular rash)

— Enterovirus PCR (summer/fall, suspected viral)

— Meningococcal/pneumococcal/Hib PCR or multiplex panel (BioFire ME) when available — useful if pretreated

— Opening pressure when feasible (older cooperative child)

— Bacterial: WBC >1000 (neutrophil-predominant), glucose <40 (or CSF:serum <0.4), protein >100–200, positive Gram stain in 60–90%.

— Viral: WBC 10–500 (lymphocyte-predominant; early may be PMN), normal glucose, mildly elevated protein.

— TB/fungal: lymphocytic, very low glucose, very high protein.

— HSV: lymphocytic, RBCs common, temporal lobe involvement on MRI.

— Focal neurologic deficit, papilledema, GCS deterioration, recent seizure (within 30 min) with focal features, immunocompromise, known CNS lesion/shunt, signs of herniation.

— Not required for routine pediatric meningitis. Normal fontanelle in infants generally allows LP without imaging.

— CBC, CMP, glucose (paired with CSF glucose), CRP/procalcitonin, coags + fibrinogen + d-dimer (DIC in meningococcemia), lactate, blood cultures ×2, UA/urine culture in infants.

— Consider HIV testing in adolescents.

Board pearl: Antibiotics first, LP second if LP will be delayed. CSF cell count, chemistries, Gram stain, and PCR remain interpretable for several hours after antibiotics; culture yield drops within 1–2 hours (especially meningococcus). Never withhold antibiotics waiting for LP.

Lumbar puncture is the diagnostic gold standard. Send CSF for:

Typical CSF profiles:

When to image (CT) BEFORE LP — same as adults but rarer indications in children:

Concurrent labs:

Diagnostic Workup — Advanced and Confirmatory Studies

— Detect S. pneumoniae, N. meningitidis, H. influenzae, GBS, E. coli K1, L. monocytogenes, HSV-1/2, VZV, enterovirus, HHV-6, parechovirus, CMV, Cryptococcus.

— Especially valuable when patient pretreated with antibiotics or CSF cultures negative.

— False positives occur — interpret with clinical context.

— CSF HSV PCR (may be negative in first 24–48 h — repeat if suspicion high).

— Surface cultures (mouth, nasopharynx, conjunctivae, rectum) in neonates.

— Serum HSV PCR for disseminated disease.

— LFTs (HSV hepatitis) and CBC (thrombocytopenia).

— Indicated for persistent fever, focal deficits, prolonged altered mental status, recurrent seizures, suspected complication.

— Findings: leptomeningeal enhancement, ventriculitis, subdural empyema, cerebritis/abscess, infarction (vasculitis from pneumococcus or TB), hydrocephalus.

— HSV: temporal lobe T2/FLAIR hyperintensity.

— Neonatal gram-negative meningitis (document sterilization at 24–48 h)

— Failure to improve clinically by 48 h

— Resistant pneumococcus on suboptimal therapy

Key distinction: Partially treated bacterial meningitis can mimic viral CSF (lymphocytic shift, near-normal glucose). PCR and clinical trajectory disambiguate — treat as bacterial if uncertain.

CSF PCR panels (multiplex meningitis/encephalitis panel):

Bacterial antigen testing (latex agglutination) — largely supplanted by PCR; consider if culture-negative and pretreated.

HSV workup in neonates/encephalopathic children:

Neuroimaging (MRI > CT):

Audiologic evaluation: Brainstem auditory evoked response (BAER) or behavioral audiometry before discharge — sensorineural hearing loss occurs in up to 30% (highest with pneumococcus); early cochlear implantation depends on early detection before cochlear ossification.

EEG: if seizures, subclinical status, or persistent encephalopathy.

Repeat LP indications:

Risk Stratification and First-Line Management Logic

— 1. ABCs, IV access ×2, monitor, O₂ if needed.

— 2. Blood cultures, CBC, CMP, coags, lactate, glucose.

— 3. Empiric antibiotics + dexamethasone (when indicated) within 1 hour.

— 4. LP if no contraindication (do not delay antibiotics for it).

— 5. Fluid resuscitation for shock; pressors if refractory.

— 6. Admit to PICU for any infant <3 months, hemodynamic instability, altered mental status, seizures, purpura, or rapid progression.

— Indicated: children >6 weeks with suspected/confirmed H. influenzae type b meningitis — reduces sensorineural hearing loss.

— Consider for pneumococcal meningitis in children (data less definitive; AAP supports case-by-case use).

— Give with or just before the first antibiotic dose — efficacy drops if given after.

— Do not give in neonates or suspected viral/aseptic meningitis.

— N. meningitidis: rifampin, ciprofloxacin (≥1 month), or ceftriaxone IM. Within 24 h ideal.

— Hib: rifampin if any unvaccinated/incompletely vaccinated household contact <4 yr or immunocompromised.

— Pneumococcus: no chemoprophylaxis needed.

CCS pearl: On the CCS case, the order is "draw cultures → give antibiotics + dexamethasone → then LP/imaging." Advancing the clock without antibiotics in a febrile encephalopathic child is the most common point-loss action.

Time-critical sequence (the classic Step 3 CCS ordering):

Dexamethasone (0.15 mg/kg IV q6h × 2–4 days):

Droplet isolation for first 24 h of effective therapy (meningococcus, Hib).

Public health reporting: Meningococcal and Hib disease are reportable; identify close contacts for chemoprophylaxis.

Chemoprophylaxis for close contacts (household, daycare, kissing, intubation without PPE):

Pharmacotherapy — Age-Specific Empiric Regimens

— Ampicillin + cefotaxime (preferred) OR ampicillin + gentamicin.

— Cefotaxime preferred over ceftriaxone in neonates (ceftriaxone displaces bilirubin → kernicterus; also incompatible with calcium-containing IV fluids).

— Add acyclovir 20 mg/kg IV q8h if any concern for HSV (seizures, vesicles, hepatitis, ill-appearing, maternal genital HSV).

— If cefotaxime unavailable (US shortage): ampicillin + gentamicin, or ceftazidime.

— Ampicillin + ceftriaxone (or cefotaxime). Covers Listeria/GBS plus S. pneumoniae/meningococcus/Hib.

— Add vancomycin if pneumococcus suspected with possible resistance.

— Add acyclovir if HSV features.

— Vancomycin + ceftriaxone (or cefotaxime).

— Ceftriaxone 100 mg/kg/day (often divided q12h or once daily; meningitis dosing) — max 4 g/day.

— Vancomycin 15 mg/kg q6h, target trough 15–20 or AUC-guided — covers ceftriaxone-resistant pneumococcus.

— No ampicillin needed beyond ~1 month (Listeria risk minimal).

— S. pneumoniae susceptible: ceftriaxone alone (stop vanc). Resistant: vanc + ceftriaxone ± rifampin.

— N. meningitidis: ceftriaxone (or penicillin G if susceptible) × 7 days.

— H. influenzae: ceftriaxone × 7–10 days.

— GBS: ampicillin or penicillin G × 14–21 days.

— E. coli/gram-negatives: cefotaxime/ceftriaxone × 21 days, document CSF sterilization.

— Listeria: ampicillin + gentamicin × 21 days.

— HSV: acyclovir 60 mg/kg/day ÷ q8h × 21 days (CNS disease).

Board pearl: Never use ceftriaxone in a neonate receiving calcium-containing IVF (precipitates → fatal pulmonary/renal embolism). Use cefotaxime instead.

Neonates 0–28 days (cover GBS, E. coli, Listeria, ± HSV):

Infants 1–3 months (transitional flora):

Infants/children >3 months through adolescence:

Targeted therapy once organism known:

Adjunctive Management and Supportive Care

— Maintain euvolemia — historical "fluid restriction for SIADH" is outdated and may worsen cerebral perfusion. Use isotonic maintenance fluids and monitor sodium.

— Shock: 20 mL/kg isotonic boluses, reassess after each; escalate to vasopressors (norepinephrine first-line in septic shock) if fluid-refractory.

— Avoid hypotonic fluids — risk of cerebral edema.

— Benzodiazepine (lorazepam 0.1 mg/kg IV) → fosphenytoin or levetiracetam. Address hyponatremia, hypoglycemia, ICP.

— Prophylactic anticonvulsants not routinely given.

— Head of bed 30°, normocapnia, normothermia, normoglycemia, isotonic fluids.

— For impending herniation: 3% saline 3–5 mL/kg bolus or mannitol 0.5–1 g/kg. Neurosurgical consult for EVD if hydrocephalus.

— Index patient with meningococcal disease should also receive eradication therapy before discharge (ceftriaxone covers; if treated with penicillin, give rifampin/cipro before discharge).

— Notify school/daycare, public health within 24 h.

Step 3 management: Children with pneumococcal or meningococcal meningitis and functional/anatomic asplenia, complement deficiency, or HIV need additional immunizations (MenB, PPSV23) and daily penicillin prophylaxis if asplenic and <5 years old.

Dexamethasone (revisited): 0.15 mg/kg IV q6h × 2–4 days, ideally 10–20 minutes before or with first antibiotic dose. Strongest evidence for Hib (reduces SNHL). Reasonable for pneumococcal. Avoid in neonates and viral meningitis.

Fluid management:

Seizure management:

Increased ICP management:

Chemoprophylaxis logistics:

Vaccination catch-up: During convalescence, verify and complete Hib, PCV, MenACWY, MenB series. Post–pneumococcal meningitis, ensure age-appropriate PCV/PPSV23 schedule.

Special Populations — Renal/Hepatic Impairment and Pretreatment

— Vancomycin: dose-adjust by level/AUC; nephrotoxicity additive with aminoglycosides.

— Gentamicin/aminoglycosides: extend interval; monitor levels; avoid prolonged use in AKI.

— Ceftriaxone/cefotaxime: generally safe in renal impairment; cefotaxime may need dose reduction at severe CrCl reductions.

— Acyclovir: crystalline nephropathy risk — ensure adequate hydration, slow infusion over 1 hour, renal-dose if CrCl drops.

— Ceftriaxone: biliary sludging/pseudolithiasis — caution in cholestasis; switch to cefotaxime if symptomatic.

— Rifampin (prophylaxis): hepatotoxic — avoid in significant liver disease; use ciprofloxacin or ceftriaxone IM instead.

— CSF culture yield drops sharply — meningococcus within 2 h, pneumococcus within 4 h.

— CSF Gram stain, chemistries, cell count remain useful. PCR/multiplex panel becomes critical.

— Do not be falsely reassured by lymphocytic CSF — partially treated bacterial meningitis can look "viral."

— Continue full empiric course based on age until pathogen identified or 48–72 h of negative cultures with clinical improvement and reassuring profile.

Key distinction: Vancomycin "red man syndrome" (infusion-rate histamine release, not allergy) → slow infusion to >60 min. True IgE allergy is rare and requires alternative (linezolid + ceftriaxone or rifampin combinations after ID consult).

Renal impairment (uncommon at presentation but develops with sepsis/AKI):

Hepatic impairment:

Pretreated patient (received outpatient antibiotics before presentation):

Neonates with hyperbilirubinemia: avoid ceftriaxone (bilirubin displacement → kernicterus); use cefotaxime.

Premature infants: dosing intervals extended; consult NICU pharmacist; HSV threshold even lower.

Special Populations — Specific Pediatric Subgroups

— Add coverage for nosocomial gram-negatives and Staphylococcus (CoNS, MRSA) if recent hospitalization or indwelling devices: vancomycin + cefepime or meropenem.

— Pathogens: Staphylococcus epidermidis (most common), S. aureus, Cutibacterium acnes, gram-negatives.

— Empiric: vancomycin + cefepime (or ceftazidime or meropenem), intraventricular vancomycin/gentamicin in select cases. Hardware usually must be externalized/removed.

— Elevated pneumococcal meningitis risk. Ensure PCV + PPSV23 per ACIP. Empiric vanc + ceftriaxone.

— Encapsulated organisms: pneumococcus, Hib, meningococcus, Salmonella. Maintain penicillin prophylaxis to age 5; ensure all vaccines current.

— Recurrent meningococcal disease — get CH50 if recurrent or atypical serogroups (W, Y, X). Requires MenACWY + MenB.

— Broader differential: Cryptococcus, TB, CMV, toxoplasmosis. India ink, CrAg, AFB, CMV PCR. ID consult.

— College freshmen and military recruits: meningococcal risk; MenACWY required, MenB shared decision-making (16–23).

— Ask about substance use, sexual history (HIV testing); confidentiality applies for STI/HIV testing per state law.

Board pearl: Recurrent meningococcal meningitis in a child = screen for terminal complement deficiency (C5–C9) with CH50. Recurrent pneumococcal meningitis = rule out CSF leak (cribriform fracture, congenital dermal sinus) with high-resolution CT and β2-transferrin testing.

Premature/NICU graduates:

CSF shunt/device infections (VP shunt, EVD):

Cochlear implant recipients:

Sickle cell disease/asplenia:

Complement deficiency (C5–9, properdin):

HIV/immunocompromised:

Travel/immigrant children: TB meningitis (subacute, basilar enhancement, hyponatremia, low glucose), neurocysticercosis (calcifications, cysts).

Adolescents:

Complications and Adverse Outcomes

— Septic shock and DIC — meningococcemia classically; pneumococcus also. Purpura fulminans, adrenal hemorrhage (Waterhouse-Friderichsen syndrome).

— Cerebral edema and herniation — leading early cause of death.

— Seizures — 20–30% of bacterial meningitis; focal seizures suggest cortical involvement (infarct, empyema, HSV).

— SIADH — common; manage with isotonic fluids and sodium monitoring, not fluid restriction acutely.

— Subdural effusion (sterile, common, usually resolves) vs subdural empyema (requires drainage).

— Cerebritis, brain abscess, ventriculitis, hydrocephalus (especially neonates, gram-negatives, TB).

— Cerebral infarction (vasculitis) — pneumococcus, TB; presents with focal deficit.

— Cranial nerve palsies — VI (raised ICP), VII, VIII (deafness).

— Sensorineural hearing loss (most common; pneumococcus highest risk, up to 30%) — screen all survivors before discharge and at 1, 3, 6, 12 months.

— Cognitive impairment, learning disabilities, ADHD.

— Seizure disorder/epilepsy.

— Cerebral palsy, motor deficits.

— Behavioral problems.

— Hydrocephalus requiring shunt.

— Endocrinopathies (rare): GH deficiency, central DI.

— Skin necrosis, limb amputation from purpura fulminans.

— Adrenal insufficiency — consider stress-dose hydrocortisone in refractory shock.

Step 3 management: Every child with bacterial meningitis needs formal audiologic evaluation before discharge (ABR or behavioral audiometry by age). Hearing loss after pneumococcal meningitis can lead to cochlear ossification within weeks — early cochlear implant referral preserves implantation window.

Acute complications:

Long-term sequelae (occur in ~20–30%):

Meningococcal-specific:

Mortality: Bacterial meningitis overall 5–10%; pneumococcal 10–15%; meningococcal 10–15% (higher with septicemia); neonatal gram-negative up to 15–20%.

When to Escalate Care — ICU, Consult, Inpatient Triage

— Hemodynamic instability, shock, or requirement for vasopressors.

— Respiratory failure or need for airway protection (GCS ≤8).

— Status epilepticus or recurrent seizures.

— Signs of raised ICP, herniation, or need for ICP monitoring.

— Purpura fulminans, DIC, or rapidly evolving meningococcemia.

— All neonates with meningitis (frequent monitoring, ventilation risk).

— Severe metabolic derangement, AKI, or need for CRRT.

— Pediatric ID — antibiotic stewardship, duration, resistance.

— Neurology — seizures, focal deficits, EEG interpretation.

— Neurosurgery — shunt infection, hydrocephalus, abscess/empyema drainage, ICP monitoring.

— Audiology — formal hearing evaluation before discharge.

— Ophthalmology — papilledema, suspected HSV.

— Public health — meningococcal/Hib reporting, contact tracing within 24 h.

— Social work/child life — family support, school re-entry planning.

— No PICU capacity, neonates, complicated course, need for subspecialty (neurosurgery, ID), suspected immunodeficiency.

— Stabilize first: airway, antibiotics, dexamethasone (if indicated), fluids before transport. Do not delay antibiotics waiting for transport team.

CCS pearl: On a CCS case, advancing the clock without (1) antibiotics within 60 min, (2) ICU admission for the unstable child, and (3) public health notification for meningococcus are commonly missed actions. Order them early.

Universal inpatient admission: All confirmed/suspected bacterial meningitis is admitted. Viral meningitis in well-appearing older children may rarely be managed outpatient after observation, but most are admitted at least 24 h.

PICU admission criteria:

Consults to obtain early:

Transfer criteria (community ED → tertiary pediatric center):

Key Differentials — Other CNS Infections and Inflammation

— Enterovirus (most common cause overall): summer/fall, biphasic illness, lymphocytic CSF, normal glucose, mild protein elevation. Supportive care; recovery in 7–10 days.

— Parechovirus: neonates/young infants, fever + sepsis-like presentation + seizures, CSF may be nearly acellular — PCR essential.

— HSV encephalitis: temporal lobe focus, focal seizures, altered mental status > meningismus. Empiric acyclovir while awaiting PCR — do not wait.

— Arboviruses (West Nile, La Crosse, EEE): geography/season; CSF PCR/serology.

— Mumps, VZV, HIV (acute seroconversion).

— Brain abscess — focal deficits, ring-enhancing lesion on MRI; LP often contraindicated. Treat with combination IV antibiotics + drainage.

— Subdural empyema — sinusitis/otitis spread, focal seizures, urgent neurosurgical drainage.

— Lyme meningitis — endemic areas, CN VII palsy, lymphocytic CSF, weeks of headache. Treat with ceftriaxone or doxycycline.

— TB meningitis — subacute, basilar enhancement, hydrocephalus, very low glucose, very high protein, lymphocytic; treat RIPE + steroids.

— Neurosyphilis, neurocysticercosis, leptospirosis — exposure history.

Key distinction: Meningitis (meningeal inflammation, preserved cortical function) vs encephalitis (parenchymal involvement → altered mental status, focal deficits, seizures). HSV is the prototypic encephalitis — always cover empirically when altered mental status, even with "meningitis" picture, in neonates and encephalopathic patients.

Viral (aseptic) meningitis:

Bacterial mimics within CNS:

Fungal: Cryptococcus (immunocompromised, CrAg, India ink), Coccidioides (Southwest US), Histoplasma.

Parasitic: Naegleria fowleri (warm freshwater, rapidly fatal amoebic meningoencephalitis), Angiostrongylus.

Key Differentials — Non-Infectious and Systemic Mimics

— ADEM (acute disseminated encephalomyelitis) — post-infectious/post-vaccination, multifocal demyelination on MRI.

— Autoimmune encephalitis (anti-NMDA receptor) — adolescents, behavioral changes, dyskinesias, seizures, autonomic instability, ovarian teratoma association.

— Kawasaki disease — fever ≥5 days, mucocutaneous findings; aseptic meningitis can occur.

— Mollaret meningitis — recurrent aseptic, HSV-2 associated.

— Drug-induced aseptic meningitis — NSAIDs (ibuprofen), IVIG, TMP-SMX, lamotrigine.

Board pearl: Anti-NMDA receptor encephalitis in a teen with "psychiatric symptoms + seizures + dyskinesias + autonomic instability" — order CSF anti-NMDAR antibodies and pelvic imaging (teratoma). It mimics viral encephalitis early.

Febrile seizure — simple febrile seizure in 6 mo–5 yr child who returns to baseline does not require LP unless meningeal signs present. ACAAP/AAP guidance: LP only if meningismus, prolonged postictal state, focal features, or incomplete Hib/PCV vaccination with high suspicion.

Subarachnoid hemorrhage — sudden severe headache, "thunderclap," CSF with RBCs and xanthochromia. Trauma, AVM, aneurysm.

Migraine with photophobia/phonophobia — recurrent, family history, no fever, normal CSF if obtained.

Intracranial mass / posterior fossa tumor — morning headache, vomiting, papilledema, cerebellar signs. MRI before any LP.

Toxic ingestion — anticholinergic (fever, altered mental status, mydriasis, dry skin), sympathomimetic, salicylates. Tox screen.

Heat stroke — hyperthermia, altered mental status, no meningismus, exposure history.

Autoimmune/inflammatory:

Metabolic: hypoglycemia, hyponatremia, hepatic encephalopathy, inborn errors (urea cycle in neonate with lethargy and vomiting).

Nonaccidental trauma — abusive head trauma in infants with altered mental status; look for retinal hemorrhages, fractures of varying ages. Mandatory reporting.

Secondary Prevention and Discharge Planning

— Meningococcus 5–7 days

— Hib 7–10 days

— Pneumococcus 10–14 days

— GBS 14–21 days

— Gram-negative (E. coli, etc.) 21 days, document CSF sterilization

— Listeria 21 days

— HSV (acyclovir) 21 days

— PCV15 or PCV20: 2, 4, 6, 12–15 months; catch-up per ACIP.

— PPSV23: after age 2 for asplenia, sickle cell, immunocompromise, cochlear implant, CSF leak — at least 8 weeks after PCV.

— Hib: 2, 4, 6, 12–15 months.

— MenACWY: routine at 11–12, booster at 16. Earlier (2 mo–10 yr) for asplenia, complement deficiency, HIV, travel to meningitis belt, outbreak.

— MenB: shared decision-making 16–23 (preferred 16–18); required for asplenia, complement deficiency, eculizumab use, outbreak. Two- or three-dose series depending on product.

— Asplenia or sickle cell: daily penicillin V until age 5 (and longer if prior pneumococcal disease).

— Eculizumab/ravulizumab recipients: meningococcal vaccines + prophylactic penicillin (terminal complement blockade).

Step 3 management: Every patient discharged after meningococcal disease leaves with: (1) completed antibiotic course, (2) eradication therapy if not given ceftriaxone, (3) contacts on chemoprophylaxis, (4) reportable disease form filed, (5) MenB series initiated for adolescents.

Complete antibiotic course (typical durations):

Vaccination — primary prevention of recurrence and community transmission:

Chemoprophylaxis for index case before discharge (meningococcus): if treated with anything other than ceftriaxone/cefotaxime, give rifampin or ciprofloxacin to eradicate carriage.

Close contact chemoprophylaxis: confirmed ordered and administered within 24 h. Update contact list as new exposures identified.

Specific prophylaxis:

Reassess immunization status at discharge and ensure all catch-up doses are scheduled.

Follow-Up, Monitoring, and Rehabilitation

— ABR or behavioral audiometry before discharge.

— Repeat at 1, 3, 6, and 12 months. SNHL may be delayed or progressive.

— Pneumococcal meningitis with documented hearing loss → urgent ENT/cochlear implant referral within weeks to avoid cochlear ossification.

— Pediatrician visit within 1–2 weeks of discharge to reassess.

— Formal developmental screening at 1, 3, 6, 12 months and ongoing — Bayley/ASQ in infants, school-age assessment for academic difficulty.

— Refer to early intervention (0–3) or school-based services (3+) at first sign of delay.

— Seizures: continue AEDs, EEG, MRI as indicated; wean only after seizure-free interval per neurology.

— New focal deficit: physical, occupational, speech therapy.

— Repeat MRI if persistent symptoms, suspected hydrocephalus, abscess, or for baseline after complicated course.

— Counsel family on expected fatigue, behavioral changes, school accommodations (504 plan if needed).

— Screen for PTSD/anxiety in older children and parents after ICU stay.

— Signs of recurrence (rare): fever, headache, neck stiffness.

— Importance of completing vaccination series in siblings and household.

— Daily penicillin compliance in asplenic children.

Board pearl: Hearing screen at discharge + 1, 3, 6, 12 months is the single highest-yield post-discharge action — missed SNHL diagnosis means missed cochlear implantation window. Step 3 favors "hearing test before discharge" as the next-best step after recovery from pneumococcal meningitis.

Audiologic follow-up (highest yield long-term action):

Neurodevelopmental follow-up:

Neurology follow-up:

Imaging:

Mental health and school re-entry:

Vaccination updates at well-child visits; document MenACWY booster at 16.

Public health follow-up: ensure all contacts received prophylaxis; outbreak surveillance.

Counseling for parents:

Ethical, Legal, and Patient Safety Considerations

— Meningococcal disease and Hib are notifiable in all US states — within 24 hours to local public health. Failure to report risks community spread.

— Suspected child abuse (e.g., abusive head trauma mimicking meningitis in an infant): mandated report to CPS regardless of certainty.

— Vaccination refusal by parents is a recurring ethical scenario. Counsel, document, and use motivational interviewing; do not refuse care, but a clear discussion of risks of preventable meningitis is required.

— LP refusal in a critically ill child: empiric antibiotics should still be given; involve ethics/legal if refusal threatens life. In emergencies, treat under implied consent.

— Adolescent consent: most states allow minors to consent to STI/HIV testing, contraception, and mental health care. Confidentiality applies unless safety concern.

— Antibiotic timing is a quality metric — bacterial meningitis is a "time-zero" diagnosis like sepsis and STEMI. Delays >1 hour increase mortality.

— Handoffs (ED → PICU → floor → outpatient) are high-risk for missed audiology, missed vaccine doses, incomplete chemoprophylaxis lists. Use a structured discharge checklist.

— Medication reconciliation: avoid ceftriaxone + IV calcium in neonates (fatal precipitate) — institutional alert systems should flag.

— Closed-loop communication on positive cultures returning after discharge.

— Under-immunization disproportionately affects children with limited healthcare access. School-based and community vaccination programs reduce disparities.

— Language-concordant counseling improves vaccine uptake and follow-up adherence.

— Devastating outcomes (purpura fulminans, herniation): early palliative care consultation, family meetings, goals-of-care alignment.

Step 3 management: A parent declines lumbar puncture in an obtunded febrile infant — give empiric antibiotics + acyclovir + dexamethasone immediately, continue counseling, and if refusal persists despite clear risk of death, invoke emergency exception/court order. Treatment is not contingent on LP.

Mandatory reporting:

Informed consent and refusal:

Patient safety / transitions of care:

Health equity:

End-of-life considerations:

High-Yield Associations and Rapid-Fire Facts

— Petechial/purpuric rash + fever in adolescent = N. meningitidis.

— College freshman in dorm = N. meningitidis (serogroup B common in US outbreaks).

— Unvaccinated toddler with epiglottitis or meningitis = Hib.

— Neonate + maternal GBS-positive screen with inadequate IAP = GBS.

— Neonate + vesicles or seizures = HSV — add acyclovir.

— Sickle cell child = S. pneumoniae (#1), Hib, Salmonella.

— Cochlear implant = S. pneumoniae.

— VP shunt = S. epidermidis.

— Recurrent meningococcus = terminal complement deficiency (C5–C9), check CH50.

— Recurrent pneumococcus = CSF leak (β2-transferrin) or asplenia.

— Hispanic infant in summer, hyponatremia, brainstem signs = consider listeriosis (foodborne queso).

— Warm freshwater swimming + rapid fatal encephalitis = Naegleria fowleri.

— Bacterial: ↑↑ neutrophils, ↓↓ glucose, ↑↑ protein.

— Viral: ↑ lymphocytes, normal glucose, ↑ protein.

— TB/fungal: ↑ lymphocytes, ↓↓ glucose, ↑↑↑ protein.

— Neonate → NO ceftriaxone (kernicterus, calcium precipitate) → use cefotaxime.

— Dexamethasone helps Hib (proven SNHL reduction), debated for pneumococcus, not in neonates.

— Give steroids before/with first antibiotic dose — late dosing loses benefit.

Board pearl: The single most testable fact: 3 mo–18 yr empiric regimen = vancomycin + ceftriaxone. Add ampicillin <1 month (Listeria/GBS). Use cefotaxime instead of ceftriaxone in neonates.

Bug-by-clue:

CSF mnemonics:

Antibiotic pearls:

Vaccine timing: PCV/Hib at 2-4-6-12; MenACWY at 11–12 + booster at 16; MenB shared decision 16–23.

Chemoprophylaxis drugs: rifampin, ciprofloxacin, ceftriaxone (meningococcus); rifampin only (Hib).

Board Question Stem Patterns

CCS pearl: Common point losses — failing to give antibiotics in the first 60 min, forgetting dexamethasone before antibiotics, using ceftriaxone in a neonate, skipping audiology, and not reporting meningococcus to public health.

Stem 1 — Neonatal sepsis: 10-day-old, fever 38.5°C, poor feeding, irritable. → Workup includes blood + urine + CSF. Empiric: ampicillin + cefotaxime (or gentamicin) + acyclovir. Trap: answer choice with ceftriaxone (wrong in neonate).

Stem 2 — Hib in unvaccinated toddler: 18-month-old, fever, vomiting, bulging fontanelle, parents declined vaccines. CSF: PMN-predominant, low glucose, Gram-negative coccobacilli. → Ceftriaxone + vancomycin; dexamethasone before/with first dose; rifampin prophylaxis for unvaccinated household contacts <4 yr.

Stem 3 — Meningococcemia: 17-year-old college freshman, fever, headache, petechiae on trunk and legs, hypotensive. → Antibiotics within 1 h, do not delay for LP, droplet precautions, public health notification, chemoprophylaxis for close contacts (roommate, kissing contacts). MenB vaccination on recovery if not received.

Stem 4 — Post-pneumococcal hearing loss: 4-year-old recovered from pneumococcal meningitis; next step? → Audiologic evaluation before discharge (ABR). Trap: "MRI brain" or "repeat LP" if recovering well.

Stem 5 — Recurrent meningococcus: 14-year-old with second episode of meningococcal disease. → CH50 to evaluate terminal complement deficiency; ensure MenACWY + MenB; consider eculizumab-related risk if relevant.

Stem 6 — Vaccine refusal: 9-month-old unvaccinated, febrile, lethargic. → Empiric vancomycin + ceftriaxone + ampicillin (transitional age covers Listeria), counsel on vaccines for future; not contingent on consent for treatment.

Stem 7 — VP shunt fever: 6-year-old with VP shunt and fever, irritability. → Vancomycin + cefepime, neurosurgery consult, externalize shunt, tap shunt reservoir.

Stem 8 — Steroid timing: Question asks when to give dexamethasone. → With or just before the first antibiotic dose; not after.

Stem 9 — Pretreated child: outpatient amoxicillin for 2 days, now ill. → CSF cultures may be sterile; PCR panel; treat as bacterial.

One-Line Recap

Pediatric bacterial meningitis is a time-zero emergency: give age-appropriate empiric antibiotics (± dexamethasone, ± acyclovir) within 60 minutes, then complete diagnostics, ICU support, audiology, public-health notification, and contact chemoprophylaxis.

— 0–28 days: ampicillin + cefotaxime (or gentamicin) + acyclovir — never ceftriaxone in neonates.

— 1–3 months: ampicillin + ceftriaxone (± vancomycin).

— >3 months through adolescence: vancomycin + ceftriaxone.

— Dexamethasone with/before first antibiotic for Hib (proven), case-by-case for pneumococcus; not in neonates or viral disease.

— Acyclovir for any neonate or encephalopathic child until HSV excluded.

— Antibiotics before LP if LP will be delayed; do not delay therapy for imaging in a stable patient without focal deficits.

— Audiology before discharge and at 1, 3, 6, 12 months — pneumococcus drives SNHL.

— Verify and catch up PCV, Hib, MenACWY, MenB; daily penicillin in asplenia/sickle cell <5 yr.

— Chemoprophylaxis for close contacts of meningococcus (rifampin/cipro/ceftriaxone) and Hib (rifampin); report to public health within 24 hours.

— Recurrent meningococcus → terminal complement deficiency (CH50).

— Recurrent pneumococcus → CSF leak (β2-transferrin) or anatomic/functional asplenia.

— Ceftriaxone + IV calcium in neonate = fatal precipitate — use cefotaxime.

Board pearl: When in doubt on a Step 3 stem, the right answer is almost always "give empiric antibiotics now" — everything else (LP, imaging, consults, reporting) follows. The clock starts at triage, not at the lumbar puncture.

Age-based empirics:

Adjuncts and safety:

Post-acute essentials:

High-yield traps: