Meningitis: Evidence To Guide An Evolving Standard Of Care

Strange, Gary R MD, MA, FACEP
Ahrens, William R MD
Witt, Michael MD
Whiteman, Paula J MD

¹Authors
²Professor and Head, Department of Emergency Medicine, University of Illinois—Chicago, IL—Chicago, IL.
³Associate Clinical Professor of Emergency Medicine and Pediatrics; Director, Pediatric Emergency Medicine, University of Illinois—Chicago, IL.
⁴Peer Reviewers
⁵Fellow, Division of Emergency Medicine, Connecticut Children's Medical Center—Hartford, CT.
⁶Medical Director, Pediatric Emergency Medicine, Encino-Tarzana Regional Medical Center; Attending Physician, Cedars-Sinai Medical Center —Los Angeles, CA.

Date of original release: April 8, 2005.

Date of most recent review: April 4, 2005.

See “Physician CME Information” on back page.

Pediatric Emergency Medicine Practice 2(4):p 1-22, April 2005.

Parents of a 6-year-old boy bring him to your ED during a busy night shift. The triage nurse documents that he is “lethargic” and has a temperature of 40°C (104° F). She immediately places him on a gurney in the acute care area of the ED. After you finish intubating another patient, you have a chance to evaluate this boy. The mother reports that he has had a few days of “head cold” symptoms. Since then, he has seemed to get sicker. On the morning of presentation, he refused to eat. He has vomited a few times throughout the day and complained of headaches and body aches. He has no significant past medical history, is on no medications, and has no known allergies. On your examination, you note an ill-appearing boy who responds slowly to verbal and tactile stimulation. His mucous membranes are somewhat dry. He complains of pain on moving his neck.

You inform the parents that you are concerned about meningitis, order some laboratory studies and a computerized tomographic (CT) scan of the head. The CT scan is read as “normal” by the radiologist and you proceed with a lumbar puncture. You obtain several milliliters of slightly blood-tinged fluid and send it to the lab. You call his pediatrician and arrange for him to be admitted to the hospital. While you are resuscitating 2 other patients, his hospital bed becomes available and he is admitted. His entire ED stay is just under 3 hours long.

Shortly thereafter, the laboratory personnel call you to report positive cerebrospinal fluid (CSF) results, including a cell count of 728 × 10⁶ white blood cells per liter (728 cells per cubic millimeter), a glucose level of 0.9 mmol/L (16 mg/dL), a total protein of 2950 mg/L (295 mg/dL), and a Gram stain revealing many polymorphonuclear cells and occasional gram-positive cocci in short chains. You call the admitting pediatrician, who orders intravenous antibiotics to be given in the hospital.

You learn later that this boy did recover from meningitis, but he has a residual cognitive deficit and a new seizure disorder. On hearing of this, several questions come to mind.

Why didn't I just start the antibiotics in the ED?
Which empiric antibiotics are currently recommended for pediatric meningitis?
Are steroids indicated for either suspected or confirmed cases of pediatric meningitis?
Was the head CT indicated, or did it just delay care?
Since I am always so overcrowded, how did this kid get a bed so quickly?