Initial Management at Presentation
- Broad spectrum antibiotics supersede all else: Initial antimicrobial therapy is most commonly antibacterial, as most cases of acute meningitis have a bacterial cause. If obtaining a scan or any other diagnostic procedure will significantly delay the institution of therapy, then antibiotics should be administered before the study. Because the etiology of meningitis varies with patient age, initial empiric therapy should be directed against the expected pathogens but should remain with broad coverage until cultures are definitive. In cases where ambiguity persists, empiric antibiotic therapy can be administered until CSF bacterial cultures are negative for at least 48 hours.
- Diagnostic procedures: These should proceed as the clinical situation allows. Either a CT scan or MRI may be needed to determine if safety measures must be in place for a lumbar puncture. Oral antibiotic therapy prior to lumbar puncture usually does not significantly alter the CSF profile, but it might result in falsely negative cultures.
- Supportive care: Children with meningitis may be extremely ill. Optimal management requires, in addition to appropriate antimicrobial therapy, careful monitoring and treatment of fluid and electrolyte abnormalities, cardiac and respiratory management, and control of ICP and seizures.
- Steroids have proven efficacy for H. influenzae meningitis, possible efficacy for tuberculous meningitis: The use of corticosteroids has been suggested as adjuvant therapy in the treatment of meningitis from a variety of causes. By decreasing the tremendous immune response, which could further damage the CNS, corticosteroids may potentially reduce morbidity and mortality. Studies to date have shown steroid efficacy only in H. influenzae type b meningitis, which is becoming rarer with immunization (3, 11, 46, 72). Some studies suggest that the use of corticosteroids in tuberculous meningitis may improve survival and potentially lessen morbidity as well. This possibility will be further discussed in the adjuvant therapy section below (52).
- Rehabilitation: After completion of acute treatment, rehabilitation may be required for severe cases.
- Follow-up for sequelae of meningitis: Patients should be monitored for hearing loss, seizures, and late-onset hydrocephalus.
- Serial imaging: Once treatment is initiated, patients should be monitored with serial CT or MRI scans for development of hydrocephalus, subdural empyema, ventriculitis, or cerebral infarcts.
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