Original Studies

Epidemiology of Meningitis and Encephalitis in Infants and

Children in the United States, 2011–2014
Rodrigo Hasbun, MD,* Susan H. Wootton, MD,† Ning Rosenthal, MD,‡
Joan Miquel Balada-Llasat, PharmD,§ Jessica Chung, PhD,‡ Steve Duff, MS,¶ Samuel Bozzette, MD,‡║ Louise
Zimmer,** and Christine C. Ginocchio, PhD,**††

Background: Large epidemiologic studies evaluating the etiologies, man-

States.1 Meningitis and encephalitis in infants and children are
agement decisions and outcomes of infants and children with meningitis
now commonly caused by viruses as bacterial etiologies become
and encephalitis in the United States are lacking.
less likely with the majority of them being admitted and receiv-
Methods: Children 0–17 years of age with meningitis or encephalitis as
ing empirical antimicrobial therapy resulting in substantial costs.2–4
assessed by International Classification of Diseases, Ninth Revision, codes
Furthermore, the majority of patients continue to have unknown
available in the Premier Healthcare Database during 2011–2014 were analyzed.
etiologies. Reasons for such high rates of diagnostic unknowns are
Results: Six thousand six hundred sixty-five patients with meningitis or
likely because of combination of factors including noninfectious or
encephalitis were identified; 3030 (45.5%) were younger than 1 year of age,
unidentified causes.5,6 In some centers, contributing factors include
underutilization of currently available diagnostic tests.3,4,7
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295 (4.4%) were 1–2 years of age, 1460 (21.9%) were 3–9 years of age,
and 1880 (28.2%) were 10–17 years of age. Etiologies included enterovi-
The use of adjunctive steroids in children with bacterial
rus (58.4%), unknown (23.7%), bacterial (13.0%), noninfectious (3.1%),
meningitis and encephalitis is primarily recommended for Haemo-
herpes simplex virus (1.5%), other viruses (0.7%), arboviruses (0.5%)
philus influenzae and possibly Streptococcus pneumoniae to pre-
and fungal (0.04%). The majority of patients were male [3847 (57.7%)]
vent hearing loss and other neurologic sequelae, not mortality.4,8
and healthy [6094 (91.4%)] with no reported underlying conditions. Most
In contrast, adjunctive steroids in adults are being used more fre-
underwent a lumbar puncture in the emergency department [5363 (80%)]
quently in pneumococcal meningitis primarily to impact mortal-
and were admitted to the hospital [5363 (83.1%)]. Antibiotic therapy was
ity.1,9 The use of steroids among children is variable as the inci-
frequent (92.2%) with children younger than 1 year of age with the high-
dence of H. influenzae meningitis has dramatically decreased post
est rates (97.7%). Antiviral therapy was less common (31.1%). Only 539
vaccination.2,4,9 Several large studies in children with viral menin-
(8.1%) of 6665 of patients received steroids. Early administration of adjunc-
gitis, bacterial meningitis and encephalitis2,4,8 have been done, but
tive steroids was not associated with a reduction in mortality (P = 0.266).
there are no large-scale epidemiologic studies evaluating all causes
The overall median length of stay was 2 days. Overall mortality rate (0.5%)
of meningitis and encephalitis in the pediatric population in the
and readmission rates (<1%) was low for both groups.
United States. The objective of our study was to compare the clini-
Conclusion: Meningitis and encephalitis in infants and children in the
cal epidemiology, management decisions and outcomes between
United States are more commonly caused by viruses and are treated empiri-
infants and children with meningitis and encephalitis in the United
cally with antibiotic therapy and antiviral therapy in a significant proportion
States from 2011 to 2014.
of cases. Adjunctive steroids are used infrequently and are not associated
with a benefit in mortality. MATERIALS AND METHODS
Key Words: meningitis, encephalitis, epidemiology, United States, chil- Study Population
dren, infants Infants and children 0–17 years of age with an admitting and
discharge diagnosis of meningitis or encephalitis as determined by
(Pediatr Infect Dis J 2019;38:37–41)
International Classification of Diseases, Ninth Revision (ICD-9), diag-
nostic codes between January 1, 2011, and December 31, 2014, were

T
he prevalence of bacterial meningitis has drastically declined
with the implementation of conjugate vaccines in the United
Accepted for publication February 9, 2018.
From the *Department of Internal Medicine and †Department of Pediatrics,
McGovern Medical School at UTHealth; ‡Premier Applied Sciences, Pre-
mier Inc., Charlotte, North Carolina; §Department of Pathology, The Ohio
State University Wexner Medical Center, Columbus, OH; ¶Veritas Health
Economics Consulting, Carlsbad, CA; ║School of Global Policy, University
of California, San Diego, CA; **bioMérieux, Durham, NC; and ††Depart-
ment of Pathology and Laboratory Medicine, Hofstra North Shore-LIJ/
School of Medicine, Hempstead, NY.
This project was supported by bioMerieux (Durham, NC) R.H. is speaker for
Pfizer, Medicine’s company, Merck, Biofire and consultant to bioMérieux;
C.C.G. is an employee of bioMérieux and owns stock in bioMérieux. bio-
Mérieux paid for the Premier database analysis and paid S.D., R.H. and
J.M.B.-L. as consultants on the project. C.C.G. is an employee of bioMéri-
eux. The authors have no other funding or conflicts of interest to disclose.
Address for correspondence: Rodrigo Hasbun, MD, MPH, Department of Inter-
nal Medicine, UT Health McGovern Medical School, 6431 Fannin St. MSB
2.112, Houston, TX 77030. E-mail: rodrigo.hasbun@uth.tmc.edu.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0891-3668/19/3801-0037
DOI: 10.1097/INF.0000000000002081
eligible for the study. Only the first admission was included for analy-
sis. Patients were excluded from the study if (1) the cerebrospinal fluid
(CSF) was obtained 2 days before or after admission or emergency
department visit (if not admitted), (2) they were electively admitted or
had a trauma-related admission, (3) they have chronic meningitis, and
(4) they have healthcare-associated ventriculitis or meningitis (CSF
shunt, craniotomies, spinal procedures, or head trauma with CSF leaks
during the 30 days before admission and at time of admission). We
excluded children who underwent a lumbar puncture more than 2 days
(1) before admission because of them having a low probability of men-
ingitis or encephalitis and (2) after admission because of the increased
likelihood of false-negative CSF cultures. All data were deidentified,
and no individual data were reported in accordance to the Health Insur-
ance Portability and Accountability Act.
Data Source
Data for the study were derived from the deidentified Premier
Healthcare Database (PHD), the largest hospital discharge database
in the United States. PHD currently contains data from >619 million
patient encounters, or 1 in every 5 hospital discharges in the United
States since January 2000 through June 2016. The PHD is a complete

The Pediatric Infectious Disease Journal  •  Volume 38, Number 1, January 2019 www.pidj.com | 37
Hasbun et al The Pediatric Infectious Disease Journal  •  Volume 38, Number 1, January 2019

TABLE 1.  Baseline Demographics, Comorbidities, Site of Care and Disposition Among Children With
Meningitis or Encephalitis in the United States by Age, 2011–2014

Younger Than 1 yr 1−2 yr of 3−9 yr of 10−17 yr of

Variables [Total n (%)] of Age [n (%)] Age [n (%)] Age [n (%)] Age [n (%)] P Value

Number of unique patients [6665 (100)] 3030 (45.46) 295 (4.43) 1460 (21.91) 1880 (28.21)
Male sex [3847 (57.7)] 1675 (55.28) 187 (63.39) 872 (59.73) 1113 (59.2) 0.0015
Race/ethnicity <0.0001
 Non-Hispanic white [2679 (40.2)] 1147 (37.85) 125 (42.37) 589 (40.34) 818 (43.51)
 Hispanic [1153 (17.35)] 494 (16.3) 50 (16.95) 284 (19.45) 325 (17.29)
 Non-Hispanic black [972 (14.6)] 426 (14.06) 45 (15.25) 242 (16.58) 259 (13.78)
 Non-Hispanic other [754 (11.3)] 421 (13.89) 31 (10.51) 132 (9.04) 170 (9.04)
 Unknown [1107 (16.6)] 542 (17.89) 44 (14.92) 213 (14.59) 308 (16.38)
Comorbidities
 Chronic pulmonary disease [401 (6.0)] 10 (0.33) 23 (7.8) 176 (12.05) 192 (10.21) <0.0001
 Cerebrovascular disease [93 (1.4)] 63 (2.08) 6 (2.03) 9 (0.62) 15 (0.8) <0.0001
 Malignancy [23 (0.003)] 0 (0) 2 (0.68) 9 (0.62) 12 (0.64) 0.0002
 Diabetes mellitus [20 (0.003)] 2 (0.07) 1 (0.34) 3 (0.21) 14 (0.74) 0.0004
 Human immunodeficiency virus [2 (0.0003)] 0 (0) 0 (0) 0 (0) 2 (0.11) 0.1652
 No comorbidity (Charlson score = 0) [6094 (91.4)] 2954 (97.49) 263 (85.15) 1251 (85.68) 1626 (86.49) <0.0001
Location of lumbar puncture <0.0001
 Emergency department/outpatient [5363 (80.4)] 2347 (77.69) 212 (71.86) 1218 (83.83) 1586 (84.63)
 Inpatient [1280 (19.2)] 674 (22.31) 83 (28.14) 235 (16.17) 288 (15.37)
Inpatient hospitalization [5536 (83.1)] 2761 (91.12) 256 (86.78) 1153 (78.97) 1366 (72.66) <0.0001
Type of inpatient admission <0.0001
 Admit from emergency department [4366 (65.5)] 2105 (76.24) 196 (76.56) 962 (83.43) 1103 (80.75)
 Outside facility transfer [396 (5.9)] 228 (8.26) 26 (10.16) 61 (5.29) 81 (5.93)
 Admit through clinics or other source [774 (11.6)] 428 (15.5) 34 (13.28) 130 (11.27) 182 (13.32)
Disposition (n = 5536) 0.1191
 Home/home health [5179 (93.5)] 2593 (94.26) 223 (88.84) 1085 (94.59) 1278 (93.83)
 Nursing home/rehabilitation/hospice [231(4.1)] 108 (3.93) 19 (7.57) 43 (3.75) 61 (4.48)
 Transfer to another facility [61(1.1)] 30 (1.09) 7 (2.79) 11 (0.96) 13 (0.95)
 Expired [35 (0.6)] 17 (0.62) 2 (0.8) 8 (0.7) 8 (0.59)
 Unknown [5 (0.09) 3 (0.11) 0 (0) 0 (0) 2 (0.15)

census of inpatient and hospital-based outpatient encounters from
nearly 700 hospitals in all 50 states in the nation. Hospitals of all sizes,
from large tertiary hospitals to small community hospitals in both
rural and urban areas, are included in the database. PHD data includes
patient demographics, admission and discharge diagnoses and dates,
etiologies of meningitis and encephalitis, inpatient mortality, and dis-
charge status. PHD also contains a date-stamped log of billed items,
including procedures, medications, laboratory test results and diag-
nostic and therapeutic services at the individual patient level. All pro-
cedures and diagnoses are captured for each patient, as well as all
drugs and devices received. Drug utilization information is available
by day of stay and includes quantity, dosing, strength used and cost.
Frequency and duration of antibiotic, antiviral, antifungal
and adjunctive intravenous steroid information was collected. Early
adjunctive steroid therapy was defined as receipt of steroids on day
1 of antibiotic therapy.
Data Analysis
Descriptive data was summarized using frequencies and per-
centages for categorical variables and using median and interquartile
range for each subgroup. χ2 or Fisher exact tests were used to compare
the differences among different age groups (younger than 1 year of
age, 1–2 years of age, 3–9 years of age and 10–17 years of age). Two
samples paired t tests were used for comparing differences in con-
tinuous variables. To adjust for multiple comparisons, we applied the
Bonferroni correction, and we considered P < 0.001 to be statistically
significant. All analyses were performed using SAS (version 9.4).9
RESULTS
Cohort Assembly
A total of 6665 patients with an admitting or discharge diag-
nosis of meningitis or encephalitis were identified; 3030 (45.5%)
were younger than 1 year of age, 295 (4.4%) were 1–2 years of age,
1460 (21.9%) were 3–9 years of age, and 1880 (28.2%) were 10–17
years of age.
Baseline Demographics, Comorbidities, Site of
Care and Disposition
As seen in Table 1, the majority were male [3847 (57.7%)],
and the most common ethnicities included non-Hispanic white [2679
(40.2%)], Hispanic [1153 (17.3%)] and non-Hispanic black [972
(14.6%)]. The majority of patients were healthy [6094 (91.4%)] with no
reported underlying conditions. The most common comorbidities were
chronic pulmonary disease [401 (6.0%)] and cerebrovascular diseases
[93 (1.4%)]. Human immunodeficiency virus infection/acquired immu-
nodeficiency syndrome (AIDS) was seen in only 2 patients (0.03%).
Chronic pulmonary diseases were higher in children than in infants
younger than 1 year of age, and cerebrovascular disease was more com-
mon in infants and children from 1 to 2 years of age (P < 0.001). Patients
were more likely to get a lumbar puncture in the emergency department
[5,363 (80%)] as opposed to in the hospital with infants being more
likely admitted than children (P < 0.001). The majority of patients were
discharged home [5179 (77.7%)], and mortality was low [35 (0.5%)]. A
minority were discharged to a nursing home, rehabilitation unit or hos-
pice [231 (4.1%)] or transferred to another hospital [61 (1.1%)].
Frequency and Duration of Antibiotic, Antiviral
and Antifungal Use
As shown in Table 2, antibiotic therapy was frequent among
all age groups [6147 (92.2%)] with children younger than 1 year of
age with the most common rates of antibiotic use [2961 (97.7%)].
Antiviral therapy was overall less commonly used [2076 (31.1%)]
with the highest prevalence among children younger than 1 year
of age [1286 (42.4%)]. Antifungals were rarely used [82 (1.2%)].

38 | www.pidj.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.

The Pediatric Infectious Disease Journal  •  Volume 38, Number 1, January 2019 Meningitis and Encephalitis in Children

TABLE 2.  Frequency and Duration of Antibiotic, Antiviral, Antifungal Medication and
Adjunctive Intravenous Steroids Use and Clinical Outcomes Among Children With Meningitis
or Encephalitis in the United States by Age, 2011–2014

Overall Younger Than 1−2 yr 3−9 yr 10−17 yr

Variables Sample 1 yr of Age of Age of Age of Age P Value

Number of unique patients 6665 3030 295 1460 1880

Antibiotic therapy
 Prevalence (%) 92.23 97.72 90.85 89.86 85.43 <0.0001
 Median duration (IQR, d) 3 (3) 3 (4) 3 (5) 3 (3) 3 (3) <0.0001
Antiviral therapy
 Prevalence (%) 31.15 42.44 29.15 18.56 23.03 <0.0001
 Median duration (IQR, d) 3 (2) 2 (2) 3 (3) 3 (2) 3 (2) 0.5398
Antifungal therapy
 Prevalence (%) 1.23 1.25 2.37 0.75 1.38 0.0989
 Median duration (IQR, d) 4 (9) 3 (6) 17 (23) 3 (11) 6 (12) 0.0454
Adjunctive intravenous steroid therapy*
 Prevalence (%) 8.09 3.63 11.86 10.48 12.82 <0.0001
 Median duration of steroids (IQR, d) 1 (2) 1 (2) 3 (4) 1 (3) 1 (2) 0.0195
Median length of inpatient stay† (IQR, d) 2 (4) 3 (5) 3 (6) 2 (3) 2 (3) <0.0001
Case-fatality rate during index admission‡ (%) 0.53 0.56 0.68 0.55 0.43 0.8429
30-day same-cause readmission rate§ (%) 0.72 0.5 1.36 0.75 0.96 0.1499
*Not associated with decrease mortality overall or in any age group (P > 0.2). Steroids were most commonly used among patients with viral
[227 (5.6%) of 4078], unknown [196 (12.7%) of 1546], and bacterial [97 (11.2%) of 869] etiologies.
†The longest duration of stays were among children with bacterial meningitis [mean = 11.5 days (SD = 10.4)], HSV [mean = 14.3 days
(SD = 11.5)] and arboviruses [mean = 5.8 days (SD = 3.1)].
‡Case-fatality rates were higher for HSV (1.94%), bacterial (1.84%) and arbovirus (2.78%).
§HSV (1.84%), bacterial meningitis (1.96%) and arbovirus (2.78%) had highest readmission rates.
HSV indicates Herpes simplex virus; IQR, interquartile range; SD, standard deviation.

FIGURE 1.  Etiology of meningitis or

encephalitis among infants and children
in the United States by age, 2011–2014.

Utilization of Adjunctive Steroids
Only 539 (8.1%) of 6665 of patients received steroids as part
of their admission treatment (see Table 2). Older children (10–17
years of age) had the highest rates [241 (12.8%)] of steroid use. The
duration of steroid use was short (median 1–3 days) across all age
groups. Steroids were most commonly used among patients with
viral [227 (5.6%) of 4078], unknown [196 (12.7%) of 1546], and
bacterial [97 (11.2%) of 869] etiologies. No difference was noted
in mortality between children who received steroids and those who
did not overall [2/304 (0.66%) vs. 33/6331 (0.52%); P value = 0.7)
or by age group (see Table 2).
Length of Stay, Readmission Rates and Outcomes
The overall median length of stay was 2 days with longer
stays noted among patients younger than 1 year of age (3 days)
and 1–2 years of age (3 days; P < 0.001). The longest duration of
stays was among children with bacterial meningitis [mean = 11.5
days (standard deviation = 10.4)], Herpes simplex virus [HSV;

© 2018 Wolters Kluwer Health, Inc. All rights reserved. www.pidj.com | 39

Hasbun et al The Pediatric Infectious Disease Journal  •  Volume 38, Number 1, January 2019
mean = 14.3 days (standard deviation = 11.5)] or arboviruses
[mean = 5.8 days (standard deviation = 3.1)]. The 30-day same-
cause readmission rate (0.72%) and mortality (0.53%) were low
overall and not different between age groups. Patients with HSV,
bacterial infections and arbovirus had highest readmission rates
(HSV = 1.94%; bacterial = 1.96%; arbovirus = 2.78%) and mortal-
ity (HSV = 1.94%; bacterial = 1.84%; arbovirus = 2.78%).
Etiology
The majority of patients were admitted with enterovi-
rus [n = 3892 (58.4%)] followed by unknown etiology [n = 1546
(23.2%)], bacteria [n = 869 (13.0%)] and HSV [n=103 (1.5%); Fig.
1]. Among age groups, children 1 to 2 years of age had the highest
percentage of HSV [n = 9 (3.05%)] and unknown etiologies [n = 79
(26.8%)]. Arboviruses were only diagnosed among children older
than 1 year of age (ie, 5 in children 1–2 years of age, 13 in children
3–9 years of age and 18 in children 10–17 years of age).
DISCUSSION
This is one of the largest studies to date (n = 6665) evalu-
ating the epidemiology, management and outcomes of meningitis
and encephalitis among infants and children in the United States
using the largest hospital database in the United States. As seen
in other studies, infants and children had high rates of hospitaliza-
tion and empiric antimicrobial use.2–4 Although the implementation
of guidelines for the prevention of perinatal group B streptococcal
invasive disease has been successful in reducing early-onset neo-
natal group B streptococcal diseases (sepsis),10 the guidelines have
not impacted late-onset disease (meningitis, bacteremia and arthri-
tis). Meningitis due to group B streptococci and Escherichia coli
remain the most common causes of bacterial meningitis in infants.11
The majority of infants and children (92.2%) received intra-
venous antibiotic therapy while waiting for CSF cultures even
though only a minority [869 (13.0%] had bacterial meningitis.
Even though the bacterial meningitis score has excellent diagnostic
accuracy to identify children at very low risk (0.1%),12 it is most
likely being underutilized in clinical practice and could account
for this excessive use of antibiotics.13 In addition, antivirals were
commonly used (31.1%) with almost half of infants younger than 1
year of age (42.4%) receiving antivirals despite HSV being docu-
mented in only 1.75%. Enterovirus was the most common etiology
seen (58.4%). Adults with meningitis and encephalitis in the United
States receive empirical antiviral therapy more often (57%) with
a median use of 3 days.9 Empiric intravenous antifungal therapy
was rarely used (1.3%) as only 3 patients had a fungal etiology.
This is in sharp contrast to adults where 3%–7% of meningitis and
encephalitis are caused by fungal etiologies.9,14
This is a large study documenting the use of adjunctive
steroids in infants and children with all types of meningitis and
encephalitis in the United States. Even though there is no mortality
benefit seen in bacterial meningitis or viral encephalitis,4,15 adjunc-
tive steroids have been reported to be utilized in 44% of children
with encephalitis in the United States.8 Our study documented a
lower overall proportion use of steroids (8.1%). Children (10–17
years of age) had the higher rates (12.8%). Among patients with
viral etiologies, only 5.5% received steroids, which is a similar rate
to prior reports.2 In contrast, 12.7% of children with unknown eti-
ologies were treated with steroids. This could possibly be explained
by the treatment of suspected autoimmune encephalitis, a clear
indication for empirical adjunctive steroids.15,16 Additionally, early
use of adjunctive steroids (within the first day of antibiotic therapy)
was not associated with a mortality benefit.
The overall median length of stay was 2 days and is con-
sistent with the practice of awaiting CSF bacterial cultures.2,3,9 The
40 | www.pidj.com
overall inpatient mortality and readmission rates for both infants
and children were low (all <1%). As expected and similar to other
studies, bacterial meningitis and HSV had longer duration of stay,
higher inpatient mortality and readmission rates.9,17 Children with
arboviral etiologies (n=36) also had a longer duration of stay (5.8
days), higher mortality (2.78%) and readmission rates (2.78%),
most likely due to diagnostic bias, as encephalitis patients are more
likely to be tested for West Nile Virus than those with meningitis.7
Our study had several advantages. First, this is a large study
comparing demographics, site of care, etiologies and outcomes in
infants and children with meningitis or encephalitis in the United
States. Furthermore, this is a large study describing the use of all
types of antimicrobial therapies (antibiotics, antivirals and anti-
fungals) and adjunctive steroids in children with meningitis and
encephalitis. Despite these advantages, our study had several limi-
tations. First, the etiologic diagnosis was based on ICD-9 diag-
nosis codes in hospital discharge data and was not corroborated
with diagnostic tests potentially resulting in misclassification bias.
Additionally, the use of ICD-9 codes also likely contributed to
underreporting of noninfectious causes. Second, available clinical
data were limited, and other factors that could impact mortality
were not available and prevented us from performing multivariable
analysis. Lastly, we were unable to perform a comparison between
meningitis and encephalitis presentation caused by the same eti-
ologies.
CONCLUSIONS
Meningitis and encephalitis among US children are com-
monly caused by viruses, and children are hospitalized and treated
empirically with antibiotic and antiviral therapy. Adjunctive ster-
oids are infrequently utilized and are not associated with a mortal-
ity benefit in any etiology. Earlier identification of the causative
agents could in the future reduce unnecessary antimicrobial thera-
pies for the majority of patients.
REFERENCES
1. Castelblanco RL, Lee M, Hasbun R. Epidemiology of bacterial meningi-
tis in the USA from 1997 to 2010: a population-based observational study.
Lancet Infect Dis. 2014;14:813–819.
2. Nigrovic LE, Fine AM, Monuteaux MC, et al. Trends in the manage-
ment of viral meningitis at United States children’s hospitals. Pediatrics.
2013;131:670–676.
3. Shukla B, Aguilera EA, Salazar L, et al. Aseptic meningitis in adults and chil-
dren: diagnostic and management challenges. J Clin Virol. 2017;94:110–114.
4. Bagdure D, Custer JW, Rao S, et al. Hospitalized children with encephalitis
in the United States: a pediatric health information system database study.
Pediatr Neurol. 2016;61:58–62.
5. Glaser CA, Gilliam S, Schnurr D, et al; California Encephalitis Project,
1998-2000. In search of encephalitis etiologies: diagnostic challenges in the
California Encephalitis Project, 1998-2000. Clin Infect Dis. 2003;36:731–742.
6. Bloch KC, Glaser CA. Encephalitis surveillance through the emerging
infections program, 1997-2010. Emerg Infect Dis. 2015;21:1562–1567.
7. Vanichanan J, Salazar L, Wootton SH, et al. Use of testing for West Nile
virus and other arboviruses. Emerg Infect Dis. 2016;22:1587–1593.
8. Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticosteroids and mor-
tality in children with bacterial meningitis. JAMA. 2008;299:2048–2055.
9. Hasbun R, Rosenthal N, Balada-Llasat JM, et al. Epidemiology of men-
ingitis and encephalitis in the United States, 2011-2014. Clin Infect Dis.
2017;65:359–363.
10. Dery MA, Hasbun R. Changing epidemiology of bacterial meningitis. Curr
Infect Dis Rep. 2007;9:301–307.
11. Ouchenir L, Renaud C, Khan S, et al. The epidemiology, management, and
outcomes of bacterial meningitis in infants. Pediatr. 2017;140:e20170476.
12. Nigrovic LE, Kuppermann N, Macias CG, et al; Pediatric Emergency
Medicine Collaborative Research Committee of the American Academy
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
The Pediatric Infectious Disease Journal  •  Volume 38, Number 1, January 2019 Meningitis and Encephalitis in Children
of Pediatrics. Clinical prediction rule for identifying children with cer-
ebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA.
2007;297:52–60.
13. Hagedorn PA, Shah SS, Kirkendall ES. Following the (clinical decision)
rules: opportunities for improving safety and resource utilization with the
bacterial meningitis score. Hosp Pediatr. 2016;6:305–309.
14. Sulaiman T, Salazar L, Hasbun R. Acute versus subacute community-acquired
meningitis: analysis of 611 patients. Medicine (Baltimore). 2017;96:e7984.
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
15. Esposito S, Picciolli I, Semino M, et al. Steroids and childhood encephalitis.
Pediatr Infect Dis J. 2012;31:759–760.
16. Barbagallo M, Vitaliti G, Pavone P, et al. Pediatric autoimmune encephalitis.
J Pediatr Neurosci. 2017;12:130–134.
17. Erdem H, Cag Y, Ozturk-Engin D, et al. Results of a multinational study
suggest the need for rapid diagnosis and early antiviral treatment at the
onset of herpetic meningoencephalitis. Antimicrob Agents Chemother.
2015;59:3084–3089.
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