Have a low threshold to start treatment for a suspected meningitis.
If meningococcal disease is suspected and unless there is a history of anaphylaxis to penicillins, give Penicillin G (benzylpenicillin) preferentially as an intravenous dose or alternatively as an IMI dose of benzyl or procaine penicillin. Note that IMI antibiotics are given proximally, into a warm part of the limb:
Benzylpenicillin Dose:
This is a rule of thumb dosing and, really, for most acute instances, it’s all you need:
- Infant: 300 mg
- Child 1-9 years: 600 mg
- Adult: 1200 mg
For an undifferentiated meningitis, give a third generation cephalosporin (see below), such as Ceftriaxone or Cefotaxime, preferably intravenously.
Obtain blood cultures, if possible, prior to giving the antibiotic. But don’t let this concern delay life-saving treatment with antibiotic — you can always collect 2-5 mL blood (EDTA tube), after treatment, for PCR testing.
EMERGENT DRUG TREATMENT
- 50 mg/kg Ceftriaxone or Cefotaxime
- 20 mL/kg Normal Saline — if shocked (otherwise, care with fluids as children often have increased ADH secretion)
- 0.15 mg/kg Dexamethasone (for undifferentiated meningitis) — within an hour of first antibiotics
- Arrange for immediate transfer to hospital
Alternative antibiotics (IDSA Guidelines):
- Ampicillin
- Chloramphenicol 50 mg/kg/day (in two divided doses)
- Aztreonam
- Ciprofloxacin (a 500 mg single oral dose is usually reserved for chemoprophylaxis)
Note: rapid deterioration, without prompt treatment, is the rule
POST-EMERGENT CARE
- Isolate cases (if possible) until they have had > 12 hours of antibiotic treatment
- Notifiable disease — in Aus., contact Department of Human Services (DHS) Infectious —Disease Unit: Nurse 03 9637 4124, Medical Officer 03 9637 4127
- Contact chemoprophylaxis within 24 hours — usually arranged and supplied by DHS: household, daycare, and intimate contacts exposed to index case within 7 days of onset; any person who gave mouth-to-mouth resuscitation to the index case; index case should also receive prophylaxis if penicillin only was used.
- Infants and children > 1 month of age: Rifampicin 10 mg/kg PO 12 hourly (max 600 mg) for 2 days
- Adults: Rifampicin 600 mg 12 hourly for 2 days
- Infants < 1 month of age: Rifampicin 5 mg/kg PO 12 hourly for 2 days
- Pregnancy: rifampicin contraindicated; give Ceftriaxone 250 mg STATIM
Other empirical therapy for an undifferentiated meningitis may include vancomycin and acyclovir. A 7-day course of intravenous ceftriaxone or penicillin is adequate for uncomplicated meningococcal meningitis.
The course of benzylpenicillin therapy is 200,000-300,000 U/kg/day, divided q2-4hr, x 24 doses.
References
- The Royal Children’s Hospital Melbourne: Clinical Practice Guidelines. Acute Meningococcal Disease. Available at http://www.rch.org.au/clinicalguide/guideline_index/Acute_Meningococcal_Disease/ as at 10 June 2016
- Gondim F, Singh M, Reynolds N — Medscape. Meningococcal Meningitis. Available at http://emedicine.medscape.com/article/1165557-overview as at 10th June 2016
- Meningitis Research Foundation. Meningococcal Meningitis and Septicaemia — Guidance Notes: Diagnosis and Treatment in General Practice. Available at http://www.meningitis.org/assets/x/50631 as at 10 June, 2016.
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Meningococcal disease: Clinical presentation and sequelae, Pace and Pollard – Vaccine
