Jessica Kirk, MD
July 26, 2007
Features of Bacterial Meningitis
Features of Viral Meningitis
Bacterial Meningitis: an
Suspected bacterial meningitis is a medical
emergency, and IMMEDIATE steps must
taken to identify the specific cause.
These steps include:
Bacterial Meningitis: History
The History should include, at a minimum, the
Course of illness (progressive vs. acute and
Presence of symptoms c/w meningeal inflammation
Presence of seizures
Presence of predisposing factors (i.e. recent resp. or
ear infection, penetrating head trauma, travel to
endemic area, etc.)
Hx of drug allergies (may affect therapy)
Recent use of antibiotics
Important aspects of the physical exam are
Vital signs: provide clues about volume
status, presence of shock/increased ICP
HC in children <18mo
Meningeal signs (chin to chest/ Kernig/
Integumentary exam (petichiae and purpura
most commonly assoc. with N. meningitidis)
Signs of other bacterial infections (i.e.
cellulitis, sinusitis, otitis media, etc.)
CBC with diff
Coags if any petechiae or purpura noted
Glucose and protein
Culture and sensitivity
Other (meningococcal panel)
Bacterial Meningitis: Imaging
CT scan may be performed to rule out an
intracranial process that would
contraindicate an LP, but does not exclude
Indications for CT before LP:
Hx of hydrocephalus
Hx of trauma/neurosurgery
Focal neurologic deficit
A HIGH LEVEL OF SUSPICION IS KEY TO
DIAGNOSING MENINGITIS IN CHILDREN.
Acute bacterial meningitis should be suspected in
children with fever and signs of meningeal
In infants the signs may include fever, hypothermia,
lethargy, resp. distress, jaundice, poor feeding,
vomiting, diarrhea, seizures, restlessness, irritability,
and/or bulging fontanel.
No single clinical sign is pathognomonic.
Either isolation of bacteria in CSF, OR isolation of
bacteria in blood cultures in a patient with CSF
pleocytosis confirms the diagnosis.
1mo – 2yr:
S. pneumoniae (*penicillin resistance)
2yr – 18yr:
Empiric treatment of meningitis should be started
immediately after the LP is performed. You cannot
delay treatment of there is a contraindication or
inability to perform an LP. For example, if the LP is
delayed due to a need for imaging, blood cultures
should be obtained and antibiotics started before the
Empiric treatment consists of bactericidal antibiotics
that have good CSF penetrance, usually a third-
generation cephalosporin (eg cefotaxime, ceftriaxone)
If cephalosporins or Vanc are contraindicated in a
patient, consult ID.
Cefotaxime 200mg/kg/day or
50mg/kg/dose IV Q6hrs
Ceftriaxone 100mg/kg/day or
50mg/kg/dose IV Q12hrs
75mg/kg loading dose
Vancomycin 60mg/kg/day or
15mg/kg/dose IV Q6hrs
Duration of treatment is determined
on a case-by-case basis with
assistance from Peds ID. Contributing
factors may include positive CSF cx,
clinical course, causative pathogen,
and response to therapy.
The mortality rate of untreated bacterial
meningitis approaches 100%.
Meta-analysis has shown a mortality rate of
~5% in developed countries, depending on
The most common sequelae are neurologic,
and occur in 15-25% of survivors:
Hearing Evaluation: at or shortly after
Viral Meningitis: an overview
Viral, or aseptic, meningitis is the
most common type of meningitis. It is
A febrile illness with clinical signs and
symptoms of meningeal irritation
No associated neurologic dysfunction
No evidence of bacterial pathogens in
the CSF (in a pt. who hasn’t received
Viral Meningitis: Clinical
Common features include:
Acute onset of fever, headache,
nausea, vomiting, stiff neck.
Physical findings are generally limited,
nonspecific, and not necessarily
present. The most prevalent are:
Nuchal rigidity, bulging fontanel, and
other signs of viruses such as rash,
conjunctivitis, and pharyngitis.
Viral Meningitis: Laboratory
Viral Meningitis: Causative
Viral Meningitis: Treatment
Herpes meningitis in children is treated with
Acyclovir 30mg/kg/day, or 10mg/kg/dose IV
Q8hrs, for a minimum of 14-21 days
Neonatal dosing is 60mg/kg/day, or
20mg/kg/dose IV Q8hrs for 21 days.
EV infections are treated symptomatically
and rarely require hospitalization beyond
the neonatal period.
Treatment for EBV, Arbovirus, and
Influenza meningitis is mainly supportive.
Suspected CNS infection
Introducing chemotherapy or contrast
Removal of CSF
Soft tissue infection at puncture site
• Active bleeding
• Platelet count <50,000
• INR > 1.4
Lumbar Puncture: Patient
Your job is to provide a clear
explanation of the urgent indications
of the procedure, as well as the
details of the procedure itself.
In order to obtain informed consent,
you must list both risks and benefits.
Lumbar Puncture: Patient
The benefit of early diagnosis far outweighs
the risk of the procedure if there are no
Lumbar Puncture: Anatomy
In older children, LP can be performed
from the L2-L3 interspace to the L5-
S1 interspace. In children younger
than 12mo, LP must be performed
below the L2-L3 interspace.
An imaginary line that connects the 2
PSIC intersects the spine at
Local anesthesia can be provided with
either lidocaine and/or EMLA.
The patient must be well-positioned to see
Hips and shoulders should be perpendicular
to the exam table
The gluteal crease should align with the
Feel free to ask the nurse to reposition the
Watch for respiratory function throughout
the entire procedure!
An LP is performed using universal
precautions and sterile technique.
Put on sterile gloves and clean the puncture
site with betadyne. The area should be
large, including the PSIS to use as a
Place sterile drapes around the puncture
If infiltrating with Lidocaine, do this now.
Check your spinal needle- Is the stylet in
place? Is it the appropriate diameter and
length? Is it a spinal needle?
Are your collection tubes upright and open?
Find your landmark- you may want to mark
it with your fingernail.
Advance the spinal needle, bevel up,
parallel to the exam table, with the tip of the
needle advancing toward the patient’s
Advance SLOWLY. In newborns, you may
only get the bevel in before you are in the
The stylet may be removed as the needle is
advanced to look for CSF.
Use of a manometer is optional at this time
to measure opening pressure.
Put ~1cc, or about 15-20 drops in each of
the 4 tubes.
Replace the stylet and remove the needle.
DISPOSE OF YOUR SHARPS IMMEDIATELY.
Lumbar Puncture: Fluid
You should label your own CSF. The label
must include the tube number and what test
you want ordered, as well as your initials,
time, and date.
CSF #1: Gram stain and culture
CSF #2: Glucose and protein
CSF #3: Cell count
CSF #4: Save (or Herpes PCR, EV PCR,
mening. Panel, etc.)
Lumbar Puncture: Misc.
clean up your own
mess. Dispose of
all unused sharps
away the kit.
Increase flexion of patient, or
Withdraw needle to soft tissue and re-
palpate to make sure spine is not rotated.
Rotate needle by 90 degrees
Replace stylet and advance slightly
Pull needle back and redirect
Remove needle and attempt different site
*You must use a new needle at this time.
Occurs when needle hits venous
CSF typically clears if in subarachnoid
Remove needle and reattempt with
new needle if clot forms or fluid
Interpreting Results Cont.
Glucose Protein # of Organism
Bacterial ↓ ↑ >1000 Gram stain
Meningitis ↑neutros CSF/bld cx
Viral Nl or Nl or ~10-500 no
Meningitis slightly↓ slightly↑ ↑lymphs
Interpreting Results cont.
When a tap is bloody it may be a
traumatic tap, or it could be blood in
the CSF. Your CSF analysis will
provide % crenated and uncrenated
RBC’s. Crenated means the RBC’s
have started breaking down, and
therefore have likely been in the CSF
longer. This may be a sign that you
are dealing with Herpes meningitis.
Interpreting CSF can be subjective in many
cases. Results will vary based on timing of
the tap in the course of the illness,
antibiotics given, other cultures obtained,
and quality of the tap.
You should use the resources available to
you such as your teammates’ experience
and Peds ID consult to help you decide on a
course of action.
Demonstration of the LP kit
Meningitis and Lumbar
Sources will be available on website.