A 13-year-old female came to the emergency room with fever, headache and lethargy that were increasing over a few hours. On physical examination she was noted to have nuchal rigidity. A head computed tomography examination showed no mass and a lumbar puncture was performed that showed white blood cell pleocytosis, increased protein and decreased glucose. She was given ceftriaxone and vancomycin, and was transferred to a regional children’s hospital with a diagnosis of bacterial meningitis which the laboratory confirmed was caused by Streptococcus pneumoniae.
The patient’s clinical course showed that by day 4 of admission that patient was back to her clinical baseline and feeling well. The parents asked if she could be sent home on intravenous antibiotics. After discussion with an infectious disease expert, a plan was made to discharge the patient if appropriate care could be coordinated at home and if the child’s laboratory inflammatory markers had returned to normal. As the local community was rural, it was not possible to have consistent care for emergencies nor for replacement of her peripheral intravenous catheter if needed. Therefore, it was decided to stop her inpatient intravenous antibiotics between 10-14 days treatment if she continued to be well and her inflammatory markers returned to normal. This occurred on day 11 of treatment and the patient was discharged home. She did well long-term with no sequelae.
Fortunately, vaccination against Haemophilus influenza type b, Streptococcus pneumoniae and Neisseria meningitidis has decreased the rates of bacterial meningitis but still it is an important cause of morbidity and mortality.
Common pathogens by age:
- For neonates < 1 month of age – Streptococcus agalactiae, Escherichia coli, Klebsiella species, Listeria monocytogenes
- For infants and toddlers 1-23 months – Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus agalactiae, Haemophilus influenzae, Escherichia coli
- For children > 2 years – Neisseria meningitidis, Streptococcus pneumoniae,
Criteria for considering initiating outpatient antibiotic treatment for patients with bacterial meningitis includes:
- Inpatient antibiotic therapy for at least 6 days
- No fever for at least 24-48 hours before beginning outpatient therapy
- No significant neurologic dysfunction, focal findings, or seizures
- Clinically stable or improving condition
- Ability to maintain hydration orally
- Established plan for physician and/or nursing visits, laboratory testing, monitoring, and emergencies
- Access to home health nursing or other consistent, reliable place for antibiotic administration
- Reliable intravenous access device if needed, along with reliable location for replacing such a device if needed
- Daily availability of a physician and/or daily visits to a physician
- Patient and family consent and compliance with the plan
- Appropriately safe environment with access to a telephone, utilities, food, refrigerator, and transportation
It should be noted that each patient with bacterial meningitis needs to be treated individually, and these criteria are only guides. Consultation with an infectious disease expert should also be considered as part of the patient’s overall management.
Questions for Further Discussion
1. What antibiotics are recommended for empiric administration for suspected bacterial meningitis?
2. At what ages do you consider treating for possible herpes simplex meningitis?
3. What is the role of adjuvant dexamethasone in suspected bacterial meningitis?
4. What are the possible sequelae of bacterial meningitis?
- Age: Teenager
To Learn More
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Waler JA, Rathore MH. Outpatient management of pediatric bacterial meningitis. Pediatr Infect Dis J 1995; 14:89-92.
Tice AD, Strait K, Ramey R, Hoaglund PA. Outpatient parenteral antimicrobial therapy for central nervous system infections. Clin Infect Dis. 1999 Dec;29(6):1394-9.
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.
Kim KS. Acute bacterial meningitis in infants and children. Lancet Infect Dis. 2010 Jan;10(1):32-42.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital