On the Horizon for Meningitis and Ventriculitis in Children

Bacterial Meningitis

• Prevention with vaccines: The best treatment strategy for meningitis is prevention. Vaccines provide the best prevention but are not available to all who could benefit from them. Immunization with H. influenzae type b vaccines has virtually eliminated meningitis caused by this organism. Pneumococcal vaccines are available but do not prevent all pneumococcal infections, as the antigens are not sufficiently immunogenic. Conjugate pneumococcal vaccine offers hope for infants. Vaccines are available for four serotypes of meningococcus (A, C, Y, and W-135). However, there is no effective vaccine against the most common serogroup, B. The vaccine against the serogroup A is protective in infants as young as 3 months, but the other vaccines are protective only in children over 2 years of age. The use of these vaccines in susceptible populations, such as the military or others living in very close quarters, has decreased the incidence of meningococcal meningitis. These vaccines are also useful in epidemic outbreaks.
• Wider use of prophylaxis for N. meningitidis meningitis: For patients who have contracted meningitis, it is imperative to impede the spread of the infection to others. Intimate contacts of the patient, such as household members, daycare contacts, military, college or dorm members, should be treated prophylactically with rifampin (10 mg/kg/dose divided every 12 hours for 2 days, maximum dose 600 mg/day) or, alternatively, with a single intramuscular dose of ceftriaxone (50 mg/kg).
• Prophylaxis for H. influenzae meningitis: Prophylactic therapy is also recommended for household members of patients with H. influenzae type b meningitis if there is a susceptible child under 4 years of age in the home. The preferred drug is again rifampin (20 mg/kg once a day for 4 days, maximum dose 600 mg/day). Prophylactic treatment of daycare contacts is recommended if there is more than one case in the daycare center but is controversial if there is only one case, particularly if there is a high vaccination rate at the center.

Tuberculous Meningitis

• BCG vaccination: Prevention of tuberculous meningitis is possible with Bacillus Calmette-Guerin (BCG) vaccination. The protective effect deteriorates with age, and there is inadequate protection against tuberculosis in adults. A second dose of BCG does not seem to improve efficacy. The BCG vaccine seems to provide some protection from tuberculous meningitis with decreased severity of illness and better outcomes, although the mechanism is unknown (39).

Viral Meningitis

• Means for rapid diagnosis: Advances in molecular biology offer the potential for more rapid diagnosis in cases of viral meningitis. Although there is still no effective therapy for most cases of viral meningitis, the ability to specifically diagnose a viral etiology and eliminate other possible causative agents will reduce the need for broad coverage of all possible etiologies and provide peace of mind and reassurance for patients and families (18).

Fungal Meningitis

• Development of new therapeutics: The development of new antifungal agents, preferably in oral preparations with good CNS penetration and fewer side effects than current antifungal agents, would provide significant advances over current therapy. New drugs would not necessarily be required to have broad spectrum activity, but specific activity against Candida or Cryptococcus would provide the greatest impact on the therapy of fungal meningitis (22). In addition, development of new vaccines may be of benefit, particularly for high-risk groups.