Pediatric Bacterial Meningitis: November 2018

Volume 15, Number 11

An Update on Early Identification Authors

Emerson Posadas, MD, MBA

and Management Department of Emergency Medicine, University of Nevada, Las Vegas

Abstract
The presentation of bacterial meningitis can overlap with viral
meningitis and other conditions, and emergency clinicians must
remain vigilant to avoid delaying treatment for a child with
bacterial meningitis. Inflammatory markers, such as procalcito-
nin, in the serum and cerebrospinal fluid may help distinguish
between bacterial meningitis and viral meningitis. Appropri-
ate early antibiotic treatment and management for bacterial
meningitis is critical for optimal outcomes. Although debated,
School of Medicine, Las Vegas, NV
Jay Fisher, MD, FAAP, FACEP
Clinical Professor of Emergency Medicine and Pediatrics, University
of Nevada, Las Vegas School of Medicine; Medical Director, Pediatric
Emergency Services, Children’s Hospital of Nevada at University Medical
Center, Las Vegas, NV
Peer Reviewers
Sheldon L. Kaplan, MD
Professor and Executive Vice Chair, Head, Section of Infectious
Diseases, Department of Pediatrics, Baylor College of Medicine; Chief,
Infectious Disease Service, Texas Children’s Hospital, Houston, TX
Lise Nigrovic, MD, MPH
Associate Professor, Pediatrics and Emergency Medicine, Harvard
Medical School; Division of Emergency Medicine, Boston Children’s
Hospital, Boston, MA

corticosteroids should be considered in certain cases. This issue Prior to beginning this activity, see “Physician CME Information”
provides evidence-based recommendations for the early identi- on the back page.

fication and appropriate management of bacterial meningitis in

pediatric patients.

Editors-in-Chief
Ilene Claudius, MD
Associate Professor; Director,
Process & Quality Improvement
Program, Harbor-UCLA Medical
Center, Torrance, CA
Tim Horeczko, MD, MSCR, FACEP,
FAAP
Associate Professor of Clinical
Emergency Medicine, David Geffen
School of Medicine, UCLA; Core
Faculty and Senior Physician, Los
Angeles County-Harbor-UCLA
Medical Center, Torrance, CA
Editorial Board
Jeffrey R. Avner, MD, FAAP
Chairman, Department of
Pediatrics, Professor of Clinical
Pediatrics, Maimonides Children's
Hospital of Brooklyn, Brooklyn, NY
Steven Bin, MD
Associate Clinical Professor, UCSF
School of Medicine; Medical Director,
Pediatric Emergency Medicine, UCSF
Benioff Children's Hospital, San
Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine
and Pediatrics; Section Chief,
Pediatric Emergency Medicine;
Medical Director, Upstate Poison
Control Center, Golisano Children's
Hospital, Syracuse, NY
Steven Choi, MD, FAAP
Chief Quality Officer and Associate
Dean for Clinical Quality, Yale
Medicine/Yale School of Medicine;
Vice President, Chief Quality Officer,
Yale New Haven Health System,
New Haven, CT
Ari Cohen, MD, FAAP
Chief of Pediatric Emergency
Medicine, Massachusetts General
Hospital; Instructor in Pediatrics,
Harvard Medical School, Boston, MA
Jay D. Fisher, MD, FAAP, FACEP
Clinical Professor of Emergency
Medicine and Pediatrics, University Madeline Matar Joseph, MD, FACEP,
of Nevada, Las Vegas School of
Medicine, Las Vegas, NV
Marianne Gausche-Hill, MD, FACEP,
FAAP, FAEMS
Medical Director, Los Angeles
County EMS Agency; Professor of
Clinical Emergency Medicine and
Pediatrics, David Geffen School
of Medicine at UCLA; Clinical
Faculty, Harbor-UCLA Medical
Center, Department of Emergency
Medicine, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of Emergency
Medicine, Icahn School of Medicine
at Mount Sinai; Director, Pediatric
Emergency Medicine, Goryeb
Children's Hospital, Morristown
Medical Center, Morristown, NJ
Sandip Godambe, MD, PhD
Chief Quality and Patient Safety Officer,
Professor of Pediatrics, Attending
Physician of Emergency Medicine,
Children's Hospital of The King's
Daughters Health System, Norfolk, VA
Ran D. Goldman, MD
Professor, Department of Pediatrics,
University of British Columbia;
Research Director, Pediatric
Emergency Medicine, BC Children's
Hospital, Vancouver, BC, Canada
Joseph Habboushe, MD, MBA
Assistant Professor of Emergency
Medicine, NYU/Langone and
Bellevue Medical Centers, New
York, NY; CEO, MD Aware LLC
Alson S. Inaba, MD, FAAP
Pediatric Emergency Medicine
Specialist, Kapiolani Medical Center
for Women & Children; Associate
Professor of Pediatrics, University
of Hawaii John A. Burns School of
Medicine, Honolulu, HI
FAAP
Professor of Emergency Medicine
and Pediatrics, Assistant Chair,
Pediatric Emergency Medicine
Quality Improvement, Pediatric
Emergency Medicine Division,
University of Florida College of
Medicine-Jacksonville,
Jacksonville, FL
Stephanie Kennebeck, MD
Associate Professor, University of
Cincinnati Department of Pediatrics,
Cincinnati, OH
Anupam Kharbanda, MD, MS
Chief, Critical Care Services
Children's Hospitals and Clinics of
Minnesota, Minneapolis, MN
Tommy Y. Kim, MD, FAAP, FACEP
Associate Professor of Pediatric
Emergency Medicine, University of
California Riverside School of Medicine,
Riverside Community Hospital,
Department of Emergency Medicine,
Riverside, CA
Melissa Langhan, MD, MHS
Associate Professor of Pediatrics and
Emergency Medicine; Fellowship
Director, Director of Education,
Pediatric Emergency Medicine, Yale
University School of Medicine, New
Haven, CT
Robert Luten, MD
Professor, Pediatrics and
Emergency Medicine, University of
Florida, Jacksonville, FL
Garth Meckler, MD, MSHS
Associate Professor of Pediatrics,
University of British Columbia;
Division Head, Pediatric Emergency
Medicine, BC Children's Hospital,
Vancouver, BC, Canada
Joshua Nagler, MD, MHPEd
Assistant Professor of Pediatrics
and Emergency Medicine, Harvard
Medical School; Associate Division
Chief and Fellowship Director, Division
of Emergency Medicine, Boston
Children’s Hospital, Boston, MA
James Naprawa, MD
Attending Physician, Emergency
Department USCF Benioff
Children's Hospital, Oakland, CA
Joshua Rocker, MD
Associate Chief and Medical
Director, Assistant Professor
of Pediatrics and Emergency
Medicine, Cohen Children's Medical
Center of New York, New Hyde
Park, NY
Steven Rogers, MD
Associate Professor, University of
Connecticut School of Medicine,
Attending Emergency Medicine
Physician, Connecticut Children's
Medical Center, Hartford, CT
Christopher Strother, MD
Associate Professor, Emergency
Medicine, Pediatrics, and Medical
Education; Director, Pediatric
Emergency Medicine; Director,
Simulation; Icahn School of Medicine
at Mount Sinai, New York, NY
Adam E. Vella, MD, FAAP
Associate Professor of Emergency
Medicine, Pediatrics, and Medical
Education, Director of Pediatric
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
David M. Walker, MD, FACEP, FAAP
Director, Pediatric Emergency
Medicine; Associate Director,
Department of Emergency Medicine,
New York-Presbyterian/Queens,
Flushing, NY
Vincent J. Wang, MD, MHA
Professor of Pediatrics and
Emergency Medicine; Division
Chief, Pediatric Emergency
Medicine, UT Southwestern
Medical Center; Director of
Emergency Services, Children's
Health, Dallas, TX
International Editor
Lara Zibners, MD, FAAP, FACEP,
MMed
Honorary Consultant, Paediatric
Emergency Medicine, St. Mary's
Hospital Imperial College Trust,
London, UK; Nonclinical Instructor
of Emergency Medicine, Icahn
School of Medicine at Mount Sinai,
New York, NY
Pharmacology Editor
Aimee Mishler, PharmD, BCPS
Emergency Medicine Pharmacist,
Program Director – PGY2
Emergency Medicine Pharmacy
Residency, Maricopa Medical
Center, Phoenix, AZ
CME Editor
Brian S. Skrainka, MD, FACEP, FAAP
Clinical Assistant Professor,
Department of Emergency
Medicine, Oklahoma State
University Center for Health
Sciences, Tulsa, OK
Case Presentations
On a warm day in June, an unvaccinated 9-year-old girl
is sent to your ED. Earlier that day, she was seen at her
primary care physician’s office by a physician assistant
who reported that the child had headache and fever inter-
mittently for 3 to 4 days. The PA was concerned that she
might have meningitis. The patient arrives, ambulatory
and alert, complaining of a bitemporal headache. Her fever
at home was 38.3°C (101°F). There has been no photo-
phobia or rash, and there are no ill contacts. The child
took acetaminophen 2 hours prior to arrival. On physical
examination, the child is tired but not toxic-appearing. She
had an episode of vomiting in triage. Her vital signs are:
temperature, 38.7°C (101.6°F); heart rate, 142 beats/min;
respiratory rate, 22 breaths/min; blood pressure, 119/77
mm Hg; and oxygen saturation, 95% on room air. Her pain
score is 8/10. Her physical examination is notable for head
and neck discomfort when moving from sitting to the su-
pine position. Her neck has full range of motion and she is
negative for Kernig sign and Brudzinski sign. The remain-
der of her examination is normal. The patient is given a 20
mL/kg normal saline bolus IV, 6 mg ondansetron IV, and
10 mg/kg ibuprofen orally. An hour later, her vital signs
are: temperature, 37.2°C (99°F); heart rate, 126 beats/min;
respiratory rate, 20 breaths/min; and blood pressure 111/67
mm Hg. Her pain score is now 4/10. Her peripheral white
blood cell count is 16,000 with a left shift, and her chemis-
try is notable only for a glucose level of 146 mg/dL. Given
the girl’s lack of frank meningismus and improvement
with ibuprofen, is a lumbar puncture indicated? What are
the most common causes of meningitis in this age group?
Should antibiotics be given?
A 4-month-old boy presents with a history of cough,
pallor, fever to 38.9°C (102°F), and decreased feed-
ing on the morning of presentation. The infant drank 6
ounces about 4 hours before arrival, but would not feed
at presentation. The boy’s parents state he did not vomit
or have diarrhea. His past medical history is notable
for cesarean delivery at 36 weeks' gestation. There was
prolonged rupture of membranes and he was hospital-
ized for 3 days after delivery. The boy’s parents report no
prior illnesses, and his immunizations are up-to-date. On
physical examination, the boy’s vital signs are: tempera-
ture, 38.9°C (99.6°F); heart rate, 158 beats/min; respira-
tory rate, 50 breaths/min; and oxygen saturation, 98% on
room air. The boy is arousable but sleepy and does not fix
and follow. His fontanel is flat. His HEENT examination
is notable for nasal congestion with mucus secretions. The
boy’s cardiopulmonary and abdominal examinations are
unremarkable. The boy’s capillary refill is < 2 seconds,
but his muscle tone is decreased. He is fussy during the
examination. Is this merely an upper respiratory infection
or should meningitis be considered? What are common
clinical features of meningitis in this age group? What
further management is indicated? Which empiric antibi-
otics—if any—are indicated at this time?
Copyright © 2018 EB Medicine. All rights reserved.
Introduction
Bacterial meningitis in children is one of the most
high-risk diagnostic and management challenges for
the emergency clinician. Widespread implementa-
tion of vaccination strategies against pneumococcal,
meningococcal, and Haemophilus influenzae type b
diseases has led to a dramatic decline in the frequency
of this condition over the past 3 decades.1,2 In some
ways, however, this has made the early identification
of bacterial meningitis more difficult for the emergency
clinician. The rare occurrence of the condition means
that a high-volume pediatric emergency clinician may
evaluate only 1 child with bacterial meningitis every 3
to 5 years. Since bacterial meningitis can present with
many signs and symptoms, differentiation of bacterial
meningitis from viral meningitis and from other mim-
ics can be difficult. If the presentation is not “classic” in
nature, diagnostic and therapeutic delay can occur, fre-
quently with devastating consequences. Inflammatory
markers in the serum and cerebrospinal fluid, such as
procalcitonin, may help distinguish between bacte-
rial meningitis and viral meningitis. Children with
suspected bacterial meningitis should be treated
early and aggressively. Adjunct therapies such as
corticosteroids are still highly debated but may be
indicated in select cases. Until better diagnostic tools
and therapies are established, emergency clinicians
must remain vigilant to avoid treatment delays for a
child with bacterial meningitis.
This issue of Pediatric Emergency Medicine Practice
reviews the classic clinical findings associated with
bacterial meningitis, offers guidance for using studies
and scoring systems to aid in the diagnosis of bacterial
meningitis, and provides evidence-base recommenda-
tions for the management of patients with bacterial
meningitis.
Critical Appraisal of the Literature
A literature search was performed in PubMed and
the Cochrane Database of Systematic Reviews using
the search terms: pediatric bacterial meningitis, viral
meningitis, pediatric lumbar puncture, neonatal fever,
antibiotics for pediatric meningitis, and pediatric menin-
gitis diagnostic studies. A total of 98 articles published
between 1992 and 2018 were reviewed.
The literature regarding bacterial meningitis
management and therapy contains multiple mul-
ticenter trials and systematic reviews presenting
strong evidence. More-recent articles, including
several prospective cohort studies, have evaluated
novel markers of bacterial meningitis.
Etiology and Pathophysiology
Research from the United States Centers for Disease
Control and Prevention (CDC) confirms a decline
2 Reprints: www.ebmedicine.net/pempissues
in the overall incidence of pediatric bacterial men-
ingitis in the United States, due to effective vaccine
strategies as well as herd immunity. This multicenter
surveillance effort, representing nearly 8% of the
United States population, demonstrated that the
incidence of bacterial meningitis in children aged 2
months to 17 years declined by > 50% from 1998 to
2007. Rates of bacterial meningitis in children aged
< 2 months, and specifically those due to group B
Streptococcus (GBS), have not declined as much. The
case fatality rate from this large national database
was 6.9%, representing a slight improvement from
the rates reported in the prevaccine era.2
Although the prevalence is decreasing, further
efforts to prevent bacterial meningitis in children are
still required. The 7-valent and subsequent 13-valent
pneumococcal conjugate vaccines (PCV-13), while
effective, have resulted in a rise in the prevalence of
non–PCV-13 pneumococcal serotypes causing bacte-
rial meningitis (serotype replacement).3 Thus, while
there has been a reduction in invasive pneumococcal
infection of all varieties (ie, pneumonia and bactere-
mia), the observed reduction in pneumococcal men-
ingitis cases has been smaller.4 In addition, effective
vaccination against the meningococcal serogroup
that most frequently causes meningitis in young
children (serogroup B) has not yet been achieved in
young children.5
Causative Pathogens and Mechanisms of
Infection
The most common pathophysiologic mechanism
that results in bacterial meningitis is the spread of
the pathogen to the central nervous system (CNS)
due to bacteremia. Neonates, young infants, and
immunocompromised older children are at highest
risk. In neonates, Escherichia coli and GBS are the
most common causative agents. After the first month
of life, Streptococcus pneumoniae and meningococ-
cus are the most frequent bacterial pathogens. For
reasons that are poorly understood, infants born
prematurely remain at higher risk for GBS meningi-
tis beyond the neonatal period.6
Practice guidelines advocating the use of intra-
partum antibiotics to prevent neonatal GBS infection
have reduced the prevalence of early-onset disease.
However, late-onset disease (6-90 days of age) and
very-late-onset disease (> 90 days of age) may have
actually increased in prevalence since the implemen-
tation of widespread intrapartum antibiotic use.7
Meningitis due to Listeria monocytogenes, nontype-
able H influenzae, and group A Streptococcus is more
unusual in the neonatal period, and gram-positive
organisms other than GBS account for < 4% of cases
overall.8 The pathogens that cause bacterial menin-
gitis in patients aged ≥ 1 month are summarized in
Table 1.
For children who are no longer in the neona-
November 2018 • www.ebmedicine.net
tal period, bacterial meningitis typically begins
with nasopharyngeal colonization by the causative
pathogen. The bacterial pathogen then penetrates a
microscopic violation of the nasopharyngeal mu-
cous membrane barrier and enters the interstitial
space. This can be precipitated by disruption of the
nasopharyngeal mucous membrane from tobacco
smoke or upper respiratory infection. Failure of local
immunity in this space results in entry of the bacte-
ria into the capillary bloodstream and delivery of the
pathogen to the microvasculature of the meninges
or choroid plexus. A potent local and generalized in-
flammatory response occurs as the pathogen pene-
trates the blood-brain barrier and gains access to the
subarachnoid space. This results in increased blood
flow to these tissues, initiation of the inflammatory
cascade, and swelling of the meningeal interstitium.
Without rapid treatment, penetration of the infection
into the cerebral interstitium and vascular structures
can follow. Generalized brain edema and localized
perivascular inflammation can lead to the creation of
an epileptogenic focus, ischemic stroke, or cerebral
venous thrombosis. Subdural effusion and subdural
empyema can also occur, limiting the volume of the
intracranial space available for normal structures.
Increased intracranial pressure can be worsened by
ependymal inflammation, narrowing of the mesen-
cephalic cisterns, abnormal flow of cerebrospinal
fluid (CSF), and acute hydrocephalus. Once this
cascade of events begins, herniation of the temporal
lobe or cerebellar tonsils can follow, often with fatal
consequences.
Bacterial meningitis can also occur via other
pathophysiologic mechanisms. Pathogens can gain
access to the subarachnoid space directly when
there is a violation of the subarachnoid space by
mechanisms that are traumatic (eg, basilar skull
fracture, open skull fracture), iatrogenic (eg, cochlear
implantation, ventriculoperitoneal shunt placement,
neurosurgery), or congenital (eg, dermal sinus).
Bacterial meningitis can also spread from infections
from contiguous structures such as the frontal or
Table 1. Pathogens That Cause Bacterial
Meningitis, Based on Patient Age9
Patient Age Causative Agent (Percent of Cases)
≥ 1 month to < 3 months • Group B Streptococcus (39%)
• Gram-negative bacilli (32%)
• Streptococcus pneumoniae (14%)
• Neisseria meningitidis (12%)
≥ 3 months to < 3 years • S pneumoniae (45%)
• N meningitidis (34%)
• Group B Streptococcus (11%)
• Gram-negative bacilli (9%)
≥ 3 years to < 10 years • S pneumoniae (47%)
• N meningitidis (32%)
≥ 10 years to < 19 years • N meningitidis (55%)
3 Copyright © 2018 EB Medicine. All rights reserved.
sphenoid sinuses, middle ear structures, or mastoid
air cells. Bacterial meningitis from direct spread of
infection can present with a localized CNS infec-
tion, specifically subdural empyema, but meningeal
spread may also occur.
Differential Diagnosis
Due to the nonspecific symptoms that are pres-
ent early in the illness, the differential diagnosis of
bacterial meningitis in children is expansive. Cat-
egories of diseases that can mimic the presentation
of bacterial meningitis include vascular, oncologic,
infectious, rheumatologic, structural, metabolic,
traumatic, and toxicologic conditions. Age has been
shown to be the biggest factor in clinical presenta-
tion. In infants and young children, fever, vomiting,
seizures, and altered mental status predominate as
presenting signs. In older children and adolescents,
headache, photophobia, and neck pain become
progressively more likely manifestations, and behav-
ioral changes remain possible. In a 2015 study of
children aged 1 month to 4 years, headache occurred
in 5% of patients, while in older children (aged 5-17
years) headache was observed in 71% of patients.10
In infants and young children, infectious dis-
eases of many varieties can mimic the symptoms of
bacterial meningitis.11,12 Otitis media, pharyngitis,
and upper lobe pneumonia are common offenders.
Less frequently, a diagnostic dilemma can occur
when infants and young children present with
idiopathic torticollis, neck stiffness due to retropha-
ryngeal abscess, or lymphadenitis of the neck. These
children do not typically have a toxic appearance.
The initial presentation of neurologic malignancy
must also be considered. CNS tumors are the most
common solid-tissue cancer in this age group, and
can present with symptoms similar to CNS infection,
such as altered mental status, seizures, or torticollis.
Abusive head injury must also be considered in the
appropriate clinical setting.13,14 In older children,
migraine headache, idiopathic intracranial hyperten-
sion, substance abuse, lupus cerebritis, and NMDA
(N-methyl-D-aspartate) receptor encephalitis should
be considered.
Children with viral meningitis can present
similarly to those with bacterial meningitis. Due to
the significant clinical overlap between bacterial and
viral etiologies, CSF analysis and bacterial culture
is required to confirm the diagnosis. For well-
appearing and otherwise healthy children aged > 2
months who have not received antibiotics within 72
hours, the bacterial meningitis score may be helpful
while awaiting culture results. It should not be used
in children with underlying illness, proof of another
bacterial infection, or suspicion of Lyme disease. For
more information on the bacterial meningitis score,
see the “Lumbar Puncture” section on page 7.
Copyright © 2018 EB Medicine. All rights reserved.
Prehospital Care
Prehospital and emergency medical services (EMS)
care should be standardized according to local proto-
cols. Children who arrive by EMS tend to have higher
illness severity.15 Initial stabilization of the patient
is paramount, with attention to the airway, breath-
ing, and circulation. Intravenous (IV) access should
be established, and rapid sequence intubation may
need to be performed if the patient becomes hypoxic
or unable to protect the airway (if advocated by local
EMS protocols). Prolonged seizures must be treated
with anticonvulsants, as delays in seizure control can
lead to extended seizure duration as well as increased
adverse outcomes, including death, and more fre-
quent hypotension.16 For patients with altered mental
status or suspicion for bacterial meningitis, glucose
should always be measured in the prehospital set-
ting. Any changes in mental status or any important
clinical details should be relayed immediately to the
receiving facility. After stabilization, the emergency
clinician at the receiving facility should decide further
management and therapy. In general, patients who
are brought in by EMS who are ultimately diagnosed
with bacterial meningitis will often have a chief
complaint of fever, lethargy, or headache. In a study
of patients who arrived by EMS, those with a chief
complaint of headache were more likely to have a
serious cause.15
In general, chemoprophylaxis is not indicated un-
less healthcare workers are exposed to specific patho-
gens (eg, meningococcus), with intimate exposure
such as mouth-to-mouth resuscitation or other close-
contact airborne exposure.17 Appropriate personal
protective equipment includes contact and droplet
precautions, including face mask with face shield
and gloves. Other susceptible populations include
household members or roommates who may have
had prolonged exposure (> 8 hours) to the patient’s
oral secretions. EMS can be valuable in providing
information regarding these contacts. If close-contact
exposure is suspected, treatment should be given as
early as possible, ideally within 24 hours.18 The CDC
has listed several regimens for antimicrobial prophy-
laxis, most commonly rifampin, ciprofloxacin, and
ceftriaxone. However, there has been growing bacte-
rial resistance to the use of ciprofloxacin for meningo-
coccal disease.19
Emergency Department Evaluation
History
Due to the symptomatic overlap between bacterial
meningitis and numerous viral illnesses, a large pro-
portion of pediatric ED visits will involve a clinical
assessment for bacterial meningitis. The burden is
on the emergency clinician to consider the diagnosis
for every child presenting with fever, vomiting, ir-
4 Reprints: www.ebmedicine.net/pempissues
ritability, headache, neck pain, photophobia, altered
mental status, seizure, or focal neurologic findings.
The younger the patient, the more important the
history and physical examination become in assess-
ing the potential for bacterial meningitis. Particular
care is required when there are language barriers or
if the historian presenting with the child is not the
primary caregiver.
In our experience, assessment of these patients
during the night can be particularly difficult, con-
sidering that somnolence—present in virtually all
young children in the middle of the night—is also a
common presenting feature of bacterial meningitis.
Febrile children who remain sleepy, are not playful,
or are not eating are of particular concern. Children
with fever of many days’ duration who have be-
come less active or more somnolent as the illness has
lingered should also raise suspicion. The absence
of fever on presentation, while reducing the likeli-
hood of bacterial meningitis, does not rule out the
disease, particularly in the young infant.17 Frequent
administration of antipyretics by a caretaker prior to
presentation can impact the fever history, and must
be taken into consideration.
Physical Examination
Early diagnosis of bacterial meningitis can be dif-
ficult, even for experienced emergency clinicians in
optimal settings. A systematic review attempting to
codify a set of clinical criteria that would accurately
determine the diagnosis of bacterial meningitis in
the acute setting concluded that a set of diagnostic
criteria with excellent test characteristics remains
elusive.20 This result is not surprising, given that
many of the classic clinical findings are absent in
some cases, while other findings overlap with other
clinical mimics.21 Of particular challenge, some
children with bacterial meningitis will not develop
meningismus.22
The physical examination of a child with po-
tential bacterial meningitis should be thorough and
detailed, with particular focus on vital signs and the
neurologic assessment. In the young infant and tod-
dler, a period of observation is often required, and
careful monitoring of vital signs can be essential to
early diagnosis. As with all invasive bacterial infec-
tions, unexplained tachycardia, tachypnea, or abnor-
mal blood pressure should prompt closer evaluation.
Neonates should be able to fix and follow on the
examiner’s face, be consoled by the mother, and pos-
sess normal muscle tone. Older infants and toddlers
should be able to be distracted by their environment
or toys and should be able to perform physical tasks
that are consistent with their developmental stage.
November 2018 • www.ebmedicine.net
Neck Findings
Examination for neck findings should be performed
universally when bacterial meningitis is being con-
sidered. Findings of nuchal rigidity are less frequent
in infants and younger children and can also be
absent in older children. The optimal mechanism
used to elicit neck stiffness or meningismus has not
been systematically studied or universally accepted,
but assessment of the range of motion in the sagit-
tal plane is easily employed. A small study demon-
strated that the sensitivity of this technique can be
maximized with the child is sitting on the bed with
legs outstretched rather than with the legs over the
bed’s edge.23 Kernig and Brudzinski signs can also
be evaluated, though cooperation in the younger
child may be difficult and the specific diagnostic
utility of these techniques is not well established.24
Most of the data on the diagnostic accuracy of neck
findings are from small and often retrospective stud-
ies, raising concerns for both generalizability and
bias. Because of these limitations in research design,
the sensitivity of neck findings for bacterial menin-
gitis has ranged from 45% to 95%, making it difficult
to ascertain the reliability of these physical examina-
tion findings.10,21
Skin Findings
A skin examination must be carefully performed to
look for signs of petechial eruption, which can be
seen in any severe bacterial infection, but are most
often seen with invasive meningococcal disease.
Petechial eruption can be associated with later
disease course, as it indicates the severity of throm-
bocytopenia. Other clinical features, including poor
capillary refill and a blanching rash, may precede
the petechial rash.25 Like all of the other signs and
symptoms discussed, this finding is neither sensi-
tive nor specific for bacterial meningitis but can be
an early finding and is worthy of careful observation
and repeated examinations.
Findings That Indicate a Patient Should Undergo
Lumbar Puncture
Universal confirmation of reassuring physical exam-
ination findings can be difficult in the busy ED but
can help to determine which patients require lumbar
puncture. While there is a small—but critical—per-
centage of bacterial meningitis cases that present in
an atypical manner with features that are not classic,
the large majority of cases will present with signs
and symptoms that are identifiable by a thorough
physical examination. Patients with fever and neck
stiffness, meningismus, ill appearance, photophobia,
severe headache, or excessive somnolence should
undergo lumbar puncture.20
5 Copyright © 2018 EB Medicine. All rights reserved.
Diagnostic Studies
Scoring Systems
Several diagnostic criteria and scoring systems have
been developed to aid in the detection of bacte-
rial meningitis. Many of these scoring systems
are designed to help prevent unnecessary lumbar
punctures. The Rochester criteria take into account
the medical history; symptoms or ill appearance;
results of urinalysis; CBC; CSF testing (if obtained);
and blood, urine, and CSF culture. In a study pub-
lished in 2018, the model had a sensitivity of 93%
for infants aged < 60 days with high-risk infection.26
However, for emergency clinicians, this still misses a
large group of patients, and any at-risk patient must
be admitted for further management and evaluation.
Serum Studies
Since a broad range of abnormalities can be present
as a result of bacterial meningitis, baseline clinical
hematology and chemistry studies are indicated.
Electrolyte disturbances can occur, as many patients
will have symptoms of decreased oral intake, nau-
sea, vomiting, and diarrhea. Syndrome of inappro-
priate antidiuretic hormone secretion (SIADH) can
also occur in the setting of acute bacterial meningitis,
thereby causing hyponatremia.27 Patients may have
respiratory alkalosis secondary to tachypnea early
in the disease process and can develop metabolic
acidosis during shock states. Further, severe bacte-
rial illness can cause coagulopathies secondary to
bacterial toxins and shock states.28
A peripheral blood white blood cell (WBC)
count alone does not accurately identify children
aged ≤ 90 days with bacterial meningitis.29 In a re-
cent study, leukopenia, thrombocytopenia, and high
C-reactive protein (CRP) levels were demonstrated
to be significant predictors of mortality in children
with invasive pneumococcal disease. Peripheral
absolute neutrophil counts > 10,000/mcL have also
been shown to be associated with bacterial menin-
gitis.30 However, studies in infants aged ≤ 60 days
have shown that traditional complete blood cell
count (CBC) parameters may have poor sensitivity
for detecting invasive bacterial illness.31
Procalcitonin
A number of inflammatory markers have been stud-
ied to assess their ability to detect serious bacterial
illness. Procalcitonin has been studied extensively
recently and seems to be the most promising marker.
Serum procalcitonin has been shown to have better
diagnostic accuracy than CRP for detecting serious
bacterial infection in young febrile infants.32 In a
prospective cohort study of 1060 admitted children
with a mean age of 17 months, both procalcitonin
and CRP assays were found to perform better than
absolute neutrophil counts and WBC counts at
Copyright © 2018 EB Medicine. All rights reserved.
detecting invasive bacterial infection. However, only
0.4% (n = 4) of patients in their sample were found
to have bacterial meningitis.33 CRP alone is less sen-
sitive and specific for the diagnosis of bacterial men-
ingitis when compared to procalcitonin. CRP levels
take 12 to 24 hours to rise after the onset of infection,
reducing sensitivity, and they remain high even
after an infection has resolved, reducing specificity.34
In a retrospective study, procalcitonin assessment
achieved a 97% sensitivity and 100% specificity in
diagnosing bacterial meningitis.35 In another study, a
procalcitonin level > 0.5 ng/mL had a 99% sensitiv-
ity and 83% specificity, making it a strong predictor
of bacterial meningitis.36 A 2015 study also showed
that higher procalcitonin was related to increased
severity of disease; however, studies in neonates
have shown lower sensitivity and further studies are
ongoing.37,38
Lumbar Puncture
Methods for determining which young infants with
fever require routine lumbar puncture have been
studied for several decades. Multicenter research
has concluded that febrile infants aged ≤ 4 weeks
require routine lumbar puncture, admission, and
empiric broad-spectrum antibiotics.39 Febrile infants
aged 4 to 8 weeks can be managed as those in the 0
to 4 week age range or with one of the many algo-
rithms aimed at reducing the frequency of routine
lumbar puncture in low-risk patients (eg, modified
Philadelphia criteria, Rochester criteria, “Step by
Step”approach).40,41
Determining which children aged > 8 weeks
should undergo lumbar puncture in the ED has
proven to be difficult. While it is clear that the most
widely recognized signs of bacterial meningitis—fe-
ver, bulging fontanel, meningismus, altered men-
tal status, headache, and vomiting—significantly
increase the likelihood of bacterial meningitis, a
number of cases have been published in which these
signs were absent.42-45 The high frequency with
which these signs can occur in children who have
alternative diagnoses is also a factor that influences
the decision to perform a lumbar puncture. For
example, more than one-quarter of infants present-
ing with fever due to Human herpesvirus 6 (exanthem
subitum, roseola infantum) were found to have a
bulging fontanel on clinical examination.46
For children with CSF pleocytosis, emergency
clinicians must distinguish more common viral
causes from less common (but more serious) bacte-
rial cases. The use of a validated clinical prediction
model, such as the bacterial meningitis score (see
Table 2, page 7), can be used to identify children at
low risk for bacterial meningitis who might be safely
managed as outpatients while awaiting culture
results.47 The bacterial meningitis score includes 5
criteria; the risk of bacterial meningitis in patients
6 Reprints: www.ebmedicine.net/pempissues
who had none of these criteria was very low (nega-
tive predictive value, 99.9%; 95% confidence inter-
val, 99.6%-100%). The bacterial meningitis score has
been subsequently validated in a variety of clinical
settings, with excellent diagnostic accuracy. As pre-
viously stated, it is best applied to otherwise healthy
children aged > 2 months without Lyme disease or
another bacterial infection, who have not yet re-
ceived antibiotics.
An MDCalc online tool for the bacte-
rial meningitis score, is available at:
https://www.mdcalc.com/bacterial-
meningitis-score-children
Cerebrospinal Fluid Analysis
Most children with bacterial meningitis will have
CSF pleocytosis, with bacterial infections causing
higher CSF WBC counts than viral infections. Clas-
sic teaching has been that bacterial meningitis is
characterized by predominantly polymorphonucle-
ar cells versus mononuclear cells in aseptic menin-
gitis. CSF WBC counts are age-dependent, and it is
important to have age-dependent reference values.
In an observational study, the median CSF WBC
count was significantly higher in infants aged ≤ 28
days (3 cells/mcL; 95th percentile, 19 cells/mcL)
than in infants aged 29 to 56 days (2 cells/mcL; 95th
percentile, 9 cells/mcL, P < .001).48 Children aged >
6 months with ≤ 30 CSF WBCs per microliter are at
low risk for bacterial meningitis.49 CSF protein con-
centrations were higher in infants aged ≤ 28 days
(upper bound: 127 mg/dL) than in infants aged 29
to 60 days (upper bound: 99 mg/dL; P < .001). CSF
glucose concentrations were lower in infants aged
≤ 28 days (lower bound: 25 mg/dL) than in infants
aged 29 to 60 days (lower bound: 27 mg/dL;
P < .001). These values need to be taken into
consideration when evaluating infants aged < 60
days.50 Other classically taught concentrations
found in patients with bacterial meningitis include
an elevated CSF protein and a decreased CSF
glucose-to-blood glucose ratio < 0.60.51
Table 2. Bacterial Meningitis Score for
Children47
Variables in the Bacterial Meningitis Score
• Positive cerebrospinal fluid Gram stain
• Cerebrospinal fluid absolute neutrophil count ≥ 1000 cells/mcL
• Cerebrospinal fluid protein ≥ 80 mg/dL
• Peripheral blood absolute neutrophil count ≥ 10,000 cells/mcL
• History of seizure before or at the time of presentation
None of the above criteria = low risk
One or more of the criteria = NOT low risk
November 2018 • www.ebmedicine.net
CSF analysis can sometimes be difficult to
interpret when using traditional markers. Antibiotic
pretreatment and low bacterial density can diminish
CSF culture yield. There have been multiple reports
of patients whose ultimate diagnosis of bacterial
meningitis was missed initially due to negative CSF
analysis.52 Inflammatory markers in the CSF have
been studied for their ability to be markers of serious
bacterial illness; CSF cytokine levels may aid in the
diagnosis of bacterial meningitis.53 CSF procalcitonin
has been shown to have a diagnostic efficiency similar
to established CSF markers and may have clinical
utility in otherwise inconclusive or contaminated CSF
fluid from lumbar punctures.54 Another study also
suggested similar findings, and patients with elevated
CSF procalcitonin, ferritin, and CRP were more likely
to have bacterial meningitis than aseptic meningitis.55
In our experience, when the clinical diagnosis
of bacterial meningitis is not made on the initial
presentation, it is most often due to failure to con-
sider the diagnosis and perform a lumbar puncture,
rather than a mistake in the interpretation of CSF
results. This concern is supported by a search of jury
verdicts found in medical malpractice databases.
A search of such a database in 2017 revealed 1 to 2
plaintiff verdicts in the United States annually that
pertained to missed or delayed therapy for pediatric
bacterial meningitis beyond the neonatal period;56
the majority of these cases were due to delayed clini-
cal recognition.
A lumbar puncture should be performed as soon
as possible for any patient with suspected menin-
gitis. Although antibiotic pretreatment can render
the CSF culture falsely negative and may impact the
CSF analysis as well, antibiotic therapy should not
be delayed for patients when bacterial meningitis
is highly suspected. The time between antibiotic
administration and CSF sterilization depends on the
route of administration (oral vs parenteral) as well
as the bacterial pathogen. One study demonstrated
sterilization of CSF for meningococcus after 2 hours.
Antibiotic pretreatment can also impact CSF glucose
and protein levels for children with confirmed bacte-
rial meningitis.57
Imaging
Neuroimaging is not typically required in the ED
management of a child with suspected meningitis.
However, head computed tomography (CT) should
be used when the neurological examination shows
focal findings. In these instances, CT can be used to
rule out other intracranial pathologies, including
a tumor, abscess, or cerebrovascular accident. As
such, CT prior to lumbar puncture is indicated when
there is evidence of or risk for elevated intracranial
pressure such as with papilledema, coma, focal
neurological deficits, or history of recent trauma or
neurosurgery. Nonetheless, CT should not delay
7 Copyright © 2018 EB Medicine. All rights reserved.
the administration of empiric antibiotic therapy.
Furthermore, a review of the literature found that
herniation was unlikely in children without focal
neurological findings or coma.58
Treatment and Complications
Initial Approach
The initial approach to the treatment of any patient
with suspected bacterial meningitis is to focus on the
airway, breathing, and circulation. Severely septic
patients may need airway support and intubation;
rapid sequence induction may be necessary. As with
any shock patient, IV access is imperative and in-
traosseous access should be established if IV access
cannot be obtained.
Intravenous Fluids
Isotonic crystalloid solution should be used for ini-
tial IV fluid resuscitation. An initial IV fluid bolus of
20 mL/kg of 0.9% saline (normal saline) is appropri-
ate. If there is insufficient response from the initial
fluid bolus, vasopressors may be required to achieve
adequate perfusion. Following initial resuscitation,
careful management of fluid and electrolyte balance
is an important aspect of supportive therapy. In the
past, fluid restriction to one-half to two-thirds of
maintenance was recommended to prevent overhy-
dration and cerebral edema.59 A Cochrane analysis
published in 2016 found that there was no signifi-
cant evidence to guide practice for the use of main-
tenance IV fluid versus restricted IV fluids in the
treatment of acute bacterial meningitis. However,
when further neurological sequelae were defined,
there was a statistically significant reduction in
the rates of early spasticity and seizures and later
overall neurological sequelae in children receiving
maintenance fluids.60 Nevertheless, strict monitoring
of intake and output is required for these patients,
and IV fluids should be titrated appropriately.
Antimicrobial Therapy
Empiric Antimicrobial Therapy
Broad-spectrum antibiotics should be initiated as
soon as possible after bacterial meningitis is suspect-
ed. Delay in administration of antibiotics is associat-
ed with increased morbidity and mortality.12 Antibi-
otic selection is predicated on 2 general principles.
The antibiotic agents: (1) should be bactericidal and
(2) must be able to penetrate the blood-brain barrier.
Lumbar puncture should not delay initiation of an-
tibiotics, despite evidence that antibiotics may affect
culture results. Although antibiotics can sterilize CSF
fluid as quickly as 2 hours after administration,61
studies have shown that the combination of blood
and CSF culture within the setting of antibiotic ad-
ministration shows similar diagnostic sensitivity as
lumbar puncture without antibiotic administration.62
Copyright © 2018 EB Medicine. All rights reserved.
Since early administration of antibiotics is critical to
treatment, we recommend initiation of empiric anti-
biotics prior to CSF collection from patients in whom
there is suspicion for bacterial meningitis. Local an-
timicrobial resistance patterns should be considered
when selecting empiric antibiotics.
Because CSF cultures may not return results for
several days, early antibiotic therapy must be begun
before the specific bacterial pathogen has been iden-
tified. In general, empiric antibiotics should cover
penicillin–resistant S pneumoniae and N meningitidis,
which are the most common causes of bacterial
meningitis in children. Other factors such as the
child’s age and immune status should be considered.
An appropriate initial empiric regimen includes
vancomycin (60 mg/kg/day IV, divided every 6
hours) and a third-generation cephalosporin such
as ceftriaxone (100 mg/kg/day IV, divided every 12
hours). However, ceftriaxone should be used only
in patients aged > 1 month. There is no significant
difference in the efficacy of ceftriaxone and cefo-
taxime in the initial treatment of bacterial meningi-
tis.63 A Cochrane review that was published in 2007
demonstrated that, for areas with limited resources,
there was no clinically important difference between
third-generation cephalosporins and conventional
antibiotics, including chloramphenicol and ampicil-
lin.64
Antimicrobial Therapy for Patients Aged < 1 Month
The major bacterial entities responsible for bacterial
meningitis in the neonatal period are GBS, E coli,
and L monocytogenes. Appropriate initial empiric
coverage includes ampicillin (150 mg/kg/day IV,
divided every 8 hours) plus cefotaxime (150 mg/kg/
day IV, divided every 8 hours) or an aminoglycoside
such as gentamicin (5 mg/kg/day IV) or amikacin
(15 mg/kg/day IV). If cefotaxime is unavailable,
ceftazidime may be substituted. In dual therapy,
third-generation cephalosporins have largely sup-
planted aminoglycosides due to microbial resistance,
increased bactericidal activity, and better safety pro-
files.65 In the neonatal period, methicillin-resistant
Staphylococcus aureus (MRSA) is an uncommon cause
of meningitis. However, if there is any suspicion for
MRSA or resistant S pneumoniae, vancomycin (30
mg/kg/day IV, divided every 8-12 hours) can also
be added. This may be more common in patients
with prolonged neonatal intensive care unit stays or
other hospital exposures. Acyclovir (60 mg/kg/day
IV, divided every 8 hours) can also be considered in
patients with suspected herpes simplex virus (HSV),
based on maternal history and physical examina-
tion.66 However, acyclovir should be discontinued if
a bacterial pathogen is identified on Gram stain or
by polymerase chain reaction of a blood sample and
the CSF is negative for HSV.
8 Reprints: www.ebmedicine.net/pempissues
Antimicrobial Therapy for Patients Aged ≥ 1 Month
In patients aged ≥ 1 month, there is an increased
incidence of S pneumoniae infection, and vancomycin
should be added for concerns related to resistance to
ceftriaxone. Recent studies show that coverage of L
monocytogenes in infants aged > 1 month may not be
necessary. In a 2017 multicenter retrospective cohort
study of 470 patients with bacterial infections, a third-
generation cephalosporin would have empirically
treated 90% of all ages, 89% of infants aged 7 to 28
days, and 91% of infants aged 29 to 89 days. The addi-
tion of ampicillin would have improved coverage in
only 4 cases of bacteremia and meningitis.67 A recent
meta-analysis showed the rate of L monocytogenes and
Enterococcus spp in febrile infants aged < 90 days was
0.02% and 0.03%, respectively, making these infec-
tions much more rare than initially perceived.67 To err
on the side of caution, we recommend that ampicillin
still be used as initial empiric treatment in the ED for
infants aged up 6 weeks or if the patient is immuno-
compromised, as antibiotics can always be curtailed
once cultures result.
Alternative and adjunct antibiotic regimens have
also been proposed. In a recent randomized con-
trolled pilot trial, pretreatment with a single dose of
rifampin 30 minutes before ceftriaxone administration
reduced the concentration of markers of inflamma-
tion and neuronal damage in children with bacterial
meningitis;68 however, more studies need to be done
to ascertain the safety and clinical effectiveness of this
approach.
Patients with an organism identified on CSF
Gram stain can have their antibiotics narrowed. In
patients with a history of a severe beta-lactam al-
lergy, aztreonam (90 mg/kg/day IV, divided every
8 hours) can be used in place of a cephalosporin for
susceptible gram-negative pathogens. Consulta-
tion with a pediatric infectious disease specialist is
recommended in patients with contraindications to
traditional empiric antibiotic therapy.
Neurologic Complications
Neurologic complications occur in 20% to 30% of
cases of bacterial meningitis.69 Seizures have been
independently associated with increased morbid-
ity and may occur during any phase of the bacte-
rial meningitis disease process. The recommended
initial therapy includes IV benzodiazepines such as
lorazepam or diazepam. If IV access has not been es-
tablished, alternative options include rectal adminis-
tration of diazepam and intramuscular or intranasal
midazolam. Other etiologies of seizure must also
be taken into consideration, including metabolic
and electrolyte causes. Electrolyte abnormalities,
including hypoglycemia, hypocalcemia, and hypo-
natremia, can also occur in the setting of bacterial
meningitis, and must be considered in seizures that
are refractory to anticonvulsant therapy.
November 2018 • www.ebmedicine.net
Conversely, very few febrile seizures are due to
meningitis. Recent research has demonstrated that
the prevalence of bacterial meningitis in the child
with complex febrile seizure without other con-
cerning clinical features is quite low.70,71 A 7-center
European study reported that < 1% of their sizable
cohort with complex febrile seizure had bacterial
meningitis. All of the patients with bacterial menin-
gitis had concerning clinical features, such as altered
mental status, abnormal neurologic examination,
or ill appearance. While these are valuable data, the
clinical implications must be interpreted with cau-
tion, given the retrospective design of this research.70
This minimizes the potential clinical implications
of children presenting with subtle clinical findings
because the clinical findings extracted during the
research process may have been documented after
the diagnosis of meningitis was made. This meth-
odology may create results that suggest that the
emergency clinician’s clinical acumen in real time
was more sensitive than it actually was.
Hearing loss due to bacterial meningitis may be
transient or permanent. It is more common in pneu-
mococcal meningitis and can occur in up to 30% of
affected children. Hearing loss is secondary to dam-
age to the eighth cranial nerve, cochlea, or labyrinth,
or direct bacterial invasion. Other focal neurologic
deficits may occur, including other cranial nerve
palsies and ataxia.72,73
Increased intracranial pressure can also be a
complication of bacterial meningitis. Increased
intracranial pressure often presents as headache in
older children and as a bulging fontanel in infants.
However, a bulging fontanel is neither sensitive nor
specific for bacterial meningitis and has been found
to be present in infants with normal CSF and those
with viral infections.12 Management of increased in-
tracranial pressure includes endotracheal intubation,
with debate over the efficacy of hyperventilation on
improving mortality outcomes. Serial neurological
examinations should be performed, with assessment
of neurologic function performed for several days.
Head circumference should be measured daily in
children aged < 18 months.
Special Circumstances
Aseptic Meningitis
Aseptic meningitis accounts for the majority of men-
ingitis cases and is mostly caused by viral pathogens
that initially infect mucosal surfaces and spread to
the CNS.74 Peak incidence occurs in late spring to
autumn. Enterovirus is the most common cause of
viral meningitis, accounting for 85% to 95% of cases
of viral meningitis.75 Children with enteroviral infec-
tions generally have favorable clinical outcomes.
A predictive model was created using 3 baseline
variables independently associated with a positive
9 Copyright © 2018 EB Medicine. All rights reserved.
 Clinical Pathway Clinical PathwayDepartment
For Emergency for the Management of Of Multiple
Management
Shocks Pediatric Patients With Suspected Bacterial Meningitis

Patient presents with suspected

bacterial meningitis

• Obtain IV access
• Place on cardiac monitor
• Provide O2 face mask
• Obtain IV access
YES Is the patient stable? • Perform RSI, if needed
• Place on a cardiac monitor NO
• Obtain IO access if IV access cannot
• Administer oxygen as needed
be achieved
• Obtain serum studies
• Order blood culture (Class II)

Is the patient in shock?

Is there evidence of increased ICP NO YES

or focal neurological deficit?

NO YES • Obtain serum studies • Initiate IV fluid

• Order blood culture resuscitation with
• Initiate empiric antibiotic 20 mL/kg NS
Obtain a noncontrast treatment (Class II) • Provide vasopressors
head CT (Class II) if unresponsive to IV
fluids
NORMAL ABNORMAL

Is there evidence of increased ICP

• Perform lumbar puncture (Class II)
or focal neurological deficit?
• Start empiric antibiotics (Class II)
• Initiate IV fluid resuscitation with YES NO
20 mL/kg NS

Obtain a noncontrast head CT

Work up alternate (Class II)
ABNORMAL
diagnosis or empirically
treat meningitis NORMAL

• Admit to ICU Perform lumbar puncture (when patient is stable

• Narrow antibiotics based on enough to tolerate) and CSF studies (Class II)
CSF studies and sensitivities

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; ICP, intracranial pressure; ICU, intensive care unit; IO, intraosseous; IV, intravenous;
NS, normal saline (0.9% sodium chloride); RSI, rapid sequence intubation.

Class of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness
Level of Evidence:
• One or more large prospective studies
are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and
compelling
Class II Class III Indeterminate
• Safe, acceptable • May be acceptable • Continuing area of research
• Probably useful • Possibly useful • No recommendations until further
• Considered optional or alternative treat- research
Level of Evidence: ments
• Generally higher levels of evidence Level of Evidence:
• Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2018 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2018 EB Medicine. All rights reserved. 10 Reprints: www.ebmedicine.net/pempissues

Enterovirus polymerase chain reaction result: (1) May
to November presentation, (2) CSF protein < 100
mg/dL, and (3) absence of neurologic signs.76 While
routine CSF testing for Enterovirus is not currently
advocated, one study has shown that it may reduce
length of stay and achieve cost savings, especially
during seasons of high Enterovirus prevalence.77
All members of the Herpesviridae family can
cause aseptic meningitis; however, HSV has been
classically associated with encephalitis.78 Neonates
in the first 2 weeks of life are at highest risk for
herpetic CNS infection. HSV infections tend to be
more virulent and more likely to result in increased
morbidity and mortality.79 HSV infections are often
associated with mucosal lesions preceding the onset
of meningeal symptoms and viremia, with a mean
interval of 1 week.80 Acyclovir is the initial treatment
of choice for any suspected HSV infection.
Arbovirus infections have been increasing in
frequency.81 Although mostly associated with en-
cephalitis, many arboviruses can also cause men-
ingeal infection. Common arboviruses include the
West Nile virus, St. Louis encephalitis virus, and
California encephalitis virus. In the United States
and Europe, the West Nile virus has become a public
health concern, especially when there is increased
mosquito activity.82
Empiric antibiotic treatment for bacterial infec-
tion must be given while awaiting results of cul-
tures, even with suspicion of aseptic meningitis. In
patients with CSF pleocytosis, encephalitis, or focal
findings on examination, acyclovir for HSV and
varicella-zoster virus can be initiated. Further clini-
cal features suggestive of HSV CNS infection include
mucocutaneous vesicles, seizures, hypothermia,
and sepsis-like illness. Previous maternal history or
patient history of HSV can also be risk factors, and
should prompt treatment with acyclovir. In most
cases, viral meningitis is treated symptomatically,
with no targeted therapy. Supportive care includes
rest and antipyretic and IV fluid therapy.83
Lyme Meningitis
In susceptible areas, Lyme disease may also be a
cause of meningitis and often presents in a similar
manner to aseptic meningitis. Children with Lyme
disease tend to be older, with a median age of 10.5
years, versus 5.5 years in viral meningitis. CSF
analysis usually shows proportionally less polymor-
phonuclear cells. In addition, the other clinical fea-
tures of Lyme disease, including erythema migrans,
cranial nerve palsies, and carditis, are not often
found in viral meningitis.84 For more information
regarding Lyme meningitis, see the September 2018
issue of Pediatric Emergency Medicine Practice, “Tick-
Borne Illnesses: Identification and Management
in the Emergency Department,” available at
www.ebmedicine.net/ticks.
November 2018 • www.ebmedicine.net
Tuberculous Meningitis
In affected areas, tuberculous meningitis dispro-
portionately affects young children. It is, by far, the
most deadly and debilitating form of tuberculosis. In
one study, the risk of death was 19.3% and the prob-
ability of survival without neurological sequelae was
36.7%. In a meta-analysis of 19 studies, 27 different
treatment regimens were used, with treatment dura-
tion varying. Duration and dosing of antituberculot-
ic drugs also varied, but corticosteroids were given
in every case. The most common findings at pre-
sentation were CSF pleocytosis, predominant CSF
lymphocytosis, fever, and hydrocephalus.85 Initial
treatment should be started immediately, and initial
therapy with rifampin, isoniazid, pyrazinamide, and
either ethambutol or streptomycin is appropriate.86
Given the high heterogeneity of treatment regimens,
we recommend consultation with infectious disease
specialists for any suspected tuberculosis infection.
Immunocompromised State
An empiric regimen of vancomycin plus a third-
generation cephalosporin is reasonable in most
children with immunocompromised status. If gram-
negative infection is suspected, especially with
gram-negative rods, an aminoglycoside such as gen-
tamicin (neonates, 5 mg/kg/dose IV; adolescents,
7.5 mg/kg/dose IV) can be added for double gram-
negative coverage.87 Based on the immunocompro-
mised state, specific bacterial regimens may need
to be tailored for each patient. While pseudomonas
meningitis is rare, if there is concern, cefepime 50
mg/kg/dose IV every 8 hours can be substituted
along with an aminoglycoside. In resistant gram-
negative infections, meropenem may also be used.88
Penetrating Trauma or Recent Neurosurgery
Recent neurosurgery or penetrating trauma places
patients at increased risk for MRSA infection. In ad-
dition, other pathogens can be introduced, includ-
ing Klebsiella sp and Pseudomonas sp. If the patient
has had penetrating trauma or recent neurosurgery,
broader spectrum antibiotics, such as cefepime,
should be considered to cover gram-negative bacte-
ria.89 Cefepime has broader coverage and excellent
CNS penetration in comparison to third-generation
cephalosporins.
Concurrent Urinary Tract Infection
Clinical research has helped define the risk of bac-
terial meningitis in the young infant with febrile
urinary tract infection (UTI). A large 23-center
study of infants aged < 60 days with febrile UTI
reported that the risk of concomitant bacterial
meningitis in infants aged 29 to 60 days who had
a lumbar puncture performed was 0.2%.90 The
low prevalence of concomitant acute bacterial
meningitis with febrile UTI in infants aged < 30
11 Copyright © 2018 EB Medicine. All rights reserved.
days has also been demonstrated in a 2017 single-
center retrospective study.91 When interpreting
these data, it is interesting to note that the preva-
lence of bacterial meningitis in recent research on
febrile infants with and without UTI has been low
in other retrospective cohorts. Research including
all patients undergoing lumbar puncture at one
center demonstrated positive CSF cultures in only
0.4%, while another study revisiting the Rochester
criteria reported a prevalence of bacterial meningitis
in 0.3% of patients who had a lumbar puncture.26,92
A 2018 study focusing on infants aged 29 to 60 days
found no difference in the rate of meningitis in pa-
tients with a positive urinalysis compared with those
in whom a negative urinalysis was returned. Overall,
the risk of meningitis in a febrile young infant with
a UTI is low, but the extent with which to pursue the
diagnosis remains controversial.93
Risk Management Pitfalls in the Management of
Pediatric Patients With Bacterial Meningitis (Continued on page 13)
1. “The patient is sleeping. I don’t want to wake
her up to perform a neurological examination.”
The neurologic assessment of the young
child can be difficult, even under optimal
circumstances. If you are performing this
evaluation when a child is fearful or when
they should be sleeping, it can be even more
challenging and requires patience and,
frequently, a dedicated period of observation
for reassessment. Efforts should also be made to
provide distraction to reduce the amount of fear
or inhibition caused by the hospital environment
to allow the most accurate examination possible.
This distraction can be provided by family
interaction with the child or by having the child
play independently with a toy.
2. “The patient has inflamed tympanic mem-
branes. The fever and irritability are likely due
to otitis media. It’s not meningitis.”
Many young children with bacterial meningitis
can have concomitant inflammation in other
areas on physical examination or diagnostic
study. Otitis media and upper respiratory tract
infections are common enough conditions
that their presence can lead the emergency
clinician to “explain away” the child’s more
serious symptoms as being due to those
pathophysiologic findings. Anchoring on a
simpler, less severe diagnosis can result in
missing or delaying the correct diagnosis.
Copyright © 2018 EB Medicine. All rights reserved.
Controversies and Cutting Edge
Corticosteroids
The use of corticosteroids as adjunct therapy in
patients with meningitis has been debated heavily.
In a 2015 Cochrane review that included 132 young
infants with bacterial meningitis, adjunctive ste-
roids for neonatal bacterial meningitis yielded some
reduction in death and hearing loss (low-quality
evidence). In recognition of the limited evidence,
the authors of that study do not recommend rou-
tine adjuvant steroids for the treatment of neonatal
meningitis.94 In another 2015 Cochrane review that
included 2511 children and 1517 adults, corticoste-
roids significantly reduced hearing loss and neuro-
logical sequelae, but did not reduce overall mortal-
ity. This analysis supported the use of corticosteroids
in patients with bacterial meningitis in high-income
countries but not low-income countries.95 Develop-
ing countries may have a longer delay in treatment
3. “The patient likely had a febrile seizure. I can’t
get a neurological examination in his postictal
state.”
Delay during decision-making can result in
harmful diagnostic or therapeutic delay. A high-
risk scenario can develop while waiting for a
postictal child to awaken from a febrile seizure
to perform a thorough neurologic examination
and determining the need for a lumbar puncture
or empiric antibiotics. The large majority of
patients with simple febrile seizure are going to
awaken to a baseline neurologic state within 1
to 2 hours after the seizure. Is the patient who
is still “sleeping” 2 to 3 hours after a febrile
seizure postictal, or is the patient progressing
to a state of unresponsiveness? Patients who
behave in this manner after a complex febrile
seizure can be particularly concerning, and a
lower threshold of lumbar puncture should be
considered.
4. “This patient’s neck stiffness or meningismus
is likely due to pharyngitis or ‘flu-like’ symp-
toms.”
Pharyngitis and other viral illnesses can also
give a clinical presentation of neck stiffness.
Meningismus is not specific to meningitis.
Emergency clinicians can be inundated
with patients presenting with neck stiffness
during the winter months, and it is important
to be vigilant for any other clues that seem
disproportionate to a normal viral illness.
12 Reprints: www.ebmedicine.net/pempissues
with empiric antibiotic coverage, which could have
affected outcomes. Further, children in developing
countries may seek care much later than those in
developed countries, causing further delays. This,
compounded with the lack of available vaccinations,
may also affect the causative agents and prevalence
in selected populations.96,97
The risks and benefits of adjunct corticoste-
roid treatment must be weighed with each clinical
scenario. In pediatric populations, dexamethasone
seems to be most beneficial in reducing hearing loss
in H influenzae type b meningitis, and its effect is
debated for other pathogens.95 In general, dexameth-
asone is not indicated for nonbacterial or gram-nega-
tive enteric meningitis. There is currently insufficient
research to recommend the use of corticosteroids in
the treatment of bacterial meningitis in infants aged
< 6 weeks or patients with congenital or acquired
CNS disorders. General dosing is dexamethasone
0.15 mg/kg/dose IV every 6 hours for 2 to 4 days.
Risk Management Pitfalls in the Management of
Pediatric Patients With Bacterial Meningitis (Continued from page 12)
5. “The patient has a normal WBC count, so I
don’t need to be worried about meningitis.”
In isolation, the absence of leukocytosis or
leukopenia is an inadequate tool by which
to make clinical management decisions. The
peripheral blood absolute neutrophil count can
be used in combination with other elements of
the bacterial meningitis score to guide initial
decision-making while awaiting results of CSF
culture.
6. “The patient likely has viral meningitis, so we
don't need to get a lumbar puncture.”
The notion that emergency clinicians can
distinguish the difference between viral and
bacterial meningitis based on the history and
physical examination is not supported by the
available evidence. The clinical overlap of these
conditions is substantial, particularly early in the
course of illness. Diagnosis should not be made
based on the history and physical examination
alone.
7. “I did not consider group B Strep in my differ-
ential for this perinatal infant.”
GBS infection must be considered in any febrile
infant in the first 2 months of life, even after
maternal treatment of colonization.
November 2018 • www.ebmedicine.net
Dexamethasone must be administered before or
concurrent with antibiotics to have maximal effect.89
Potential adverse effects of dexamethasone must be
monitored, which include gastrointestinal bleeding
and other adverse effects related to glucocorticoids.
For more information regarding the use of
corticosteroids to treat bacterial meningitis, see the
March 2018 issue of Pediatric Emergency Medicine
Practice, “Corticosteroid Use in Management of
Pediatric Emergency Conditions,” available at
www.ebmedicine.net/corticosteroids.
Disposition
All children with suspected bacterial meningitis
should be admitted. The morbidity and mortality
associated with bacterial meningitis warrants initial
management in the pediatric intensive care unit for
the majority of cases, such as those with persistent
abnormal vital signs, seizures, altered mental status,
8. “We need to wait for a CT scan and lumbar
puncture before we can give antibiotics, as
they can cause sterilization of CSF.”
When caring for a patient with a presumptive
diagnosis of bacterial meningitis, do not delay
administration of appropriate antibiotics
for the completion of a CT scan or lumbar
puncture or for the results of these studies.
Although antibiotics may obscure the ultimate
bacteriologic diagnosis, this is a small clinical
price to pay to prevent further bacterial
proliferation and inflammation within the CNS.
9. “We don’t need to consider tuberculosis or
fungal meningitis.”
Meningitis due to atypical pathogens such as
Mycobacterium tuberculosis can be notoriously
insidious and indolent in presentation. Consider
these pathogens, particularly in patients with
immunodeficiency, patients traveling from
high-risk parts of the world, or, in the case of
tuberculosis, those with prolonged contact with
an infected individual.
10. “My patient has a positive urinalysis. This is
clearly just a UTI. I don’t need to consider any
other diagnoses.”
While concomitant UTIs are rare, they do occur.
In a recent study involving 1737 infants aged
29 to 60 days, concomitant UTI with bacterial
meningitis occurred 0.2% of the time, and was
more prevalent in infants aged 0 to 28 days.90
13 Copyright © 2018 EB Medicine. All rights reserved.
or other comorbidities. The bacterial meningitis
mortality rate in resource-rich countries has been
reported to range from 0% to 15%, depending on the
setting and the organism. In the United States, mor-
tality from bacterial meningitis has been reported
to be 4.2%.98 Patients should be placed on contact
and droplet precautions for infection risk. Cardiac
monitoring and frequent neurological checks are ap-
propriate in the first 72 hours.
Summary
Bacterial meningitis is a devastating disease, with
significant morbidity and mortality, despite advances
in diagnosis and management. While children with
bacterial meningitis can present similarly to those
with other conditions, emergency clinicians must be
vigilant for concerning signs or symptoms. In addi-
tion to examination and traditional evaluation, new
inflammatory markers in serum or CSF (eg, procal-
citonin) have shown promise. Differentiation be-
tween bacterial and viral meningitis can be difficult,
although validated clinical prediction scores (eg, the
bacterial meningitis score) can be used to accurately
identify children at low risk for bacterial meningitis.
Appropriate early antibiotics are critical for improved
outcomes. Adjunct therapies such as corticosteroids
are still controversial, but may have some utility in se-
lect cases. Until better diagnostic tools and therapies
are established, emergency clinicians must remain
vigilant to ensure rapid identification of children with
this deadly disease.
Case Conclusions
Although the 9-year-old unvaccinated girl's symptoms
improved, a lumbar puncture was performed because
of the referring provider’s concerns, the quality of the
headache, the patient’s neck discomfort, the elevated WBC
count, and the girl’s vaccination status. The lumbar punc-
ture demonstrated turbid CSF with a Gram stain showing
gram-positive diplococci. A tentative diagnosis of pneu-
mococcal meningitis was made. The patient was admitted
to the pediatric floor and treated with IV dexamethasone
0.15 mg/kg, IV vancomycin 20 mg/kg, and IV ceftriax-
one 100 mg/kg. Her CSF culture grew S pneumoniae,
confirming the diagnosis. The pathogen was sensitive to
ceftriaxone, and the antibiotics were narrowed to ceftri-
axone alone. The patient suffered no signs of neurologic
deterioration and frank meningismus never developed.
Her symptoms and fever curve improved over the next
several days. The patient was hospitalized for a total of 10
days, and she made a complete recovery.
The 4-month-old boy with a history of cough, pallor,
fever, and decreased feeding was placed in a warmer on a
cardiorespiratory monitor with continuous pulse oxime-
try. His heart rate and respiratory rate rose and his degree
of responsiveness declined. You decided the patient needed
Copyright © 2018 EB Medicine. All rights reserved.
a lumbar puncture, knowing that vital sign abnormali-
ties and subtle neurologic changes can be the first signs
of bacterial meningitis in this age group. After obtaining
consent from the mother, CSF was obtained on the first
attempt, and was visibly purulent. The CSF WBC count
was 2257 with 85% polys. The CBC showed a peripheral
WBC of 9.9, Hb of 9, and platelets of 329,000. A CSF
Gram stain revealed gram-positive cocci in pairs and oc-
casional chains. You immediately suspected pneumococcal
meningitis and initiated IV dexamethasone 0.15 mg/kg
and IV cefotaxime 100 mg/kg and admitted the patient to
the PICU. The CSF grew S pneumoniae that was sensi-
tive to cefotaxime. Over the next 24 hours, the patient
developed respiratory failure and progressive cerebral
edema, the complication that you feared most. Over the
next several days, his cerebral edema was unresponsive to
therapy and the child died on the seventh day of hospital-
ization due to this complication.
Time- And Cost-Effective Strategies
• Once there is suspicion for bacterial meningitis,
aggressive and early management is important.
After initial resuscitation, a child with suspected
bacterial meningitis requires inpatient care.
• For children who present with severe symptoms,
an intensive care unit setting will allow more
frequent monitoring as well fluid balance.
• While treatment for each patient should be
individualized, electronic health record 1-click
order sets for suspected bacterial meningitis can
standardize the diagnostic evaluation and treat-
ment for children with meningitis.
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for increased awareness. Arch Virol Suppl. 1996;11:21-32.
(Review)
82. Petersen LR, Brault AC, Nasci RS. West Nile virus: review of
the literature. JAMA. 2013;310(3):308-315. (Review)
83. Abzug MJ. Viral Meningitis and Encephalitis. In: Current Pe-
diatric Therapy, 18th ed. Burg FD, Ingelfinger JR, Polin RA, et
al eds. Philadelphia, PA: Saunders. 2006. (Textbook chapter)
84. Shah SS, Zaoutis TE, Turnquist J, et al. Early differentiation
of Lyme from enteroviral meningitis. Pediatr Infect Dis J.
2005;24(6):542-545. (Cross-sectional study; 24 patients with
Lyme meningitis and 151 patients with enteroviral menin-
gitis)
85. Chiang SS, Khan FA, Milstein MB, et al. Treatment outcomes
of childhood tuberculous meningitis: a systematic review
and meta-analysis. Lancet Infect Dis. 2014;14(10):947-957.
(Syetematic review and meta-analysis; 19 studies)
86. Schoeman JF, Donald PR. Tuberculous meningitis. Handb
Clin Neurol. 2013;112:1135-1138. (Review)
87. Chavez-Bueno S, McCracken GH Jr. Bacterial meningitis in
children. Pediatr Clin North Am. 2005;52(3):795-810. (Review)
88. Fong IW, Tomkins KB. Review of Pseudomonas aeruginosa
meningitis with special emphasis on treatment with ceftazi-
dime. Rev Infect Dis. 1985;7(5):604-612. (Review)
89. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines
for the management of bacterial meningitis. Clin Infect Dis.
2004;39(9):1267-1284. (Practice guidelines)
90. Thomson J, Cruz AT, Nigrovic LE, et al. Concomitant bacterial
meningitis in infants with urinary tract infection. Pediatr Infect
Dis J. 2017;36(9):908-910. (Retrospective study; 1737 infants)
91. Wallace SS, Brown DN, Cruz AT. Prevalence of concomitant
acute bacterial meningitis in neonates with febrile urinary
tract infection: a retrospective cross-sectional study. J Pediatr.
2017;184:199-203. (Retrospective cross-sectional study; 236
patients)
92. Banniettis N, Joshi S, Kaushik S, et al. Diagnostic practices
for suspected community-acquired central nervous system
November 2018 • www.ebmedicine.net
infection in the post-conjugate vaccine era. Pediatr Emerg Care.
2017. DOI: http://dx.doi.org/10.1097/PEC.0000000000001147
(Observational retrospective; 940 patients)
93. Young BR, Nguyen THP, Alabaster A, et al. The prevalence
of bacterial meningitis in febrile infants 29-60 days with posi-
tive urinalysis. Hosp Pediatr. 2018;8(8):450-457. (Retrospec-
tive cohort study; 833 patients)
94.* Ogunlesi TA, Odigwe CC, Oladapo OT. Adjuvant cortico-
steroids for reducing death in neonatal bacterial meningitis.
Cochrane Database Syst Rev. 2015(11):CD010435. (Cochrane
review; 2 trials, 132 participants)
95. Brouwer MC, McIntyre P, Prasad K, et al. Corticosteroids
for acute bacterial meningitis. Cochrane Database Syst Rev.
2015(9):CD004405. (Cochrane review; 25 studies, 4121 par-
ticipants)
96. Molyneux E, Riordan FA, Walsh A. Acute bacterial meningi-
tis in children presenting to the Royal Liverpool Children’s
Hospital, Liverpool, UK and the Queen Elizabeth Central
Hospital in Blantyre, Malawi: a world of difference. Ann
Trop Paediatr. 2006;26(1):29-37. (Cross-sectional study; 24
patients)
97. McCracken GH Jr. Rich nations, poor nations, and bacterial
meningitis. Lancet. 2002;360(9328):183. (Review)
98. Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticoste-
roids and mortality in children with bacterial meningitis.
JAMA. 2008;299(17):2048-2055. (Multicenter observational
study; 2780 children)
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1. There has been a notable decline in the preva-
lence of pediatric bacterial meningitis beyond
the early newborn period in the United States
that is due to the most common pathogens,
with the exception of:
a. Haemophilus influenzae type b
b. Neisseria meningitidis
c. Group B Streptococcus
d. Streptococcus pneumoniae
17 Copyright © 2018 EB Medicine. All rights reserved.
2. The diagnostic sensitivity of an ED clinical
assessment for bacterial meningitis does not
approach 100% without which of the following
elements being obtained?
a. A history of seizure activity and a peripheral
absolute neutrophil count
b. A history of fever, a peripheral absolute
neutrophil count, and cerebrospinal fluid
(CSF) analysis for cell count, protein, and
Gram stain
c. A history of seizure activity, peripheral
absolute neutrophil count, and CSF analysis
for cell count, protein, and Gram stain
d. A peripheral absolute neutrophil count and
CSF analysis for cell count, protein, and
Gram stain
3. Which of the following statements regarding
CSF analysis and antibiotics is TRUE?
a. Antibiotics should be delayed until CSF is
collected to avoid sterilization.
b. Sterilization of CSF can occur as soon as 2
hours after antibiotics are administered.
c. Previous oral antibiotic use does not affect
cerebrospinal fluid.
d. Bacterial meningitis traditionally has a
larger proportion of mononuclear cells in
comparison to aseptic meningitis.
4. Which of the following best describes the evi-
dence on fluids in the management of bacterial
meningitis?
a. Fluid restriction should be implemented
after initial fluid resuscitation to prevent
cerebral edema.
b. There is no significant mortality evidence to
guide practice as to whether maintenance
fluid should be chosen over restricted
fluids in the treatment of acute bacterial
meningitis.
c. Hypertonic solution should be used for fluid
resuscitation, as the increased osmolarity
prevents cerebral edema.
d. An initial 60 mL/kg IV fluid bolus is
reasonable starting therapy.
5. A recent European multicenter study reported
that the prevalence of bacterial meningitis in
children presenting with complex febrile sei-
zures was:
a. < 1% b. 1%
c. 2% d. 4%
6. Which of the following is an appropriate
empiric antibiotic coverage in a 2-week-old
previously healthy boy with suspected bacte-
rial meningitis?
a. Ciprofloxacin + metronidazole
Copyright © 2018 EB Medicine. All rights reserved.
b. Vancomycin + ceftriaxone + ampicillin
c. Ampicillin + ceftriaxone
d. Ampicillin + cefotaxime
7. Which of the following statements regard-
ing appropriate empiric antibiotic overage in
patients aged > 1 month is TRUE?
a. Vancomycin should be added to cover for
increased incidence of penicillin-resistant
organisms.
b. There is strong evidence for routine rifampin
use as an adjunct to traditional antibiotic
therapies.
c. Vancomycin does not need to be part of an
empiric treatment regimen.
d. In previously healthy patients, monotherapy
with a single antibiotic can be an alternative
for initial empiric coverage.
8. Which of the following statements regarding
aseptic meningitis is TRUE?
a. Enterovirus is the most common cause of
viral meningitis.
b. Arbovirus infection has declined in recent
years.
c. HSV infections tend to be less virulent
and less likely to result in morbidity and
mortality.
d. The peak incidence is in the winter.
9. Multicenter research has clarified that the
prevalence of concomitant bacterial meningi-
tis in infants aged 29 to 60 days with febrile
urinary tract infection is:
a. 0.02%
b. 0.2%
c. 2%
d. 4%
10. Which of the following best describes the
evidence of corticosteroid use as adjunct treat-
ment for bacterial meningitis in neonates?
a. There is low-quality evidence that may
suggest some reduction in death and
hearing loss when adjunctive corticosteroids
are used in the treatment of bacterial
meningitis in infants and children. The
current literature is insufficient to support
its use in infants aged < 6 weeks.
b. Dexamethasone should be routinely used as
adjunct therapy in every bacterial meningitis
case.
c. Corticosteroids have never been shown to
have efficacy in improving morbidity or
neurological sequelae.
d. Corticosteroids have been shown to be most
efficacious when used on nonbacterial or
gram-negative enteric organism infections.
18 Reprints: www.ebmedicine.net/pempissues
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Calculated Decisions - Clinical Decision Tools to Help in Clinical Care

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Decisions
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Clinical Decision Support for Emergency Medicine Practice Subscribers

Assessment of Chest Pain Score

gives you how-to-use guidance and reviews of medical calculators. These formulas, algorithms, rules, and
scores will help you make informed decisions when caring for your patients.
(EDACS)

Calculators
Identifies chest pain patients with low risk of major
Click the thumbnail above to
access the calculator. adverse cardiac event
Introduction » ST-elevation or non-ST- elevation MI.
The Emergency Department Assessment of Chest Pain » Requiring an emergency revascularization
Score (EDACS) identifies chest pain patients with low procedure.
risk of major adverse cardiac event. It was developed » Death from cardiovascular causes.
by Dr. Martin Than and colleagues in Christchurch, New » Ventricular arrhythmia.
Zealand and published in Emergency Medicine Austral- » Cardiac arrest.
asia in 2014. » Cardiogenic shock.

Calculated
Why Use Management
Patients requiring serial blood testing (serial troponin For low-risk patients, consider other causes of
markers typically at 0 and 6 hours to rule out myocar- chest pain due to aortic, esophageal, pulmonary,
dial infarction) and further risk stratification require an cardiac, and abdominal, and musculoskeletal

Decisions
extended emergency department evaluation, or hos-

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sources prior to discharge.

next to the title

pital admissions, leading to crowding, bed allocation For non-low-risk patients, physicians should
problems, and exposure of patients to side effects of use their best judgment to workup and treat as
increased testing. The authors of this study were able per usual chest pain protocols, including but not
to find a low risk group of patients (~45%) that could limited to consideration of aspirin, nitroglycerin,
safely be discharged from the ED after two biomarkers and serial EKGs and biomarkers.
just two hours apart, EKG, history and physical exam.
Critical Actions
When to Use Patients deemed low risk are safe for discharge
Use in patients with chest pain or other anginal symp- to early outpatient follow-up investigation (or

of the issue.
toms requiring evaluation for possible acute coronary proceed to earlier inpatient testing). For patients
syndrome who may be potentially low risk and appropri- who are NOT low risk, physicians should use
ate for early discharge from the emergency department. their best judgment, as this “Rule Out” calculator
was not designed to “rule in” patients with ACS.
Pearls/Pitfalls Physicians cannot use EDACS to rule out ACS.
• The EDACS-ADP (accelerated diagnostic protocol)
study included any symptoms lasting longer than
five minutes that the attending physician thought CONTENT CONTRIBUTORS
were worth working up for possible acute coronary
syndrome (ACS). This is a broader definition than Graham Walker, MD
Department of Emergency Medicine
other studies like the Vancouver Chest Pain Score,
Kaiser Permanente San Francisco
which only included chest pain patients specifically.
Similar to other chest pain evaluation studies, the Joseph Habboushe, MD, MBA
primary outcome was MACE (major adverse cardiac Department of Emergency Medicine
events), as defined by any of the following: NYU Langone / Bellevue Medical Center

Volume 1 | Issue 1 • Calculated Decisions 1 Copyright © 2017 EB Medicine. All rights reserved.

Points & Pearls - A Digest That Reinforces What You Learn

Points & Pearls—a two-page online digest of each monthly journal article. Points & Pearls features:
POINTS & PEARLS
• Key points and clinical pearls from the full-length issue
200+
A Quick-Read Review of Key Points & Clinical Pearls, May 2018

Synthetic Drug Intoxication in Children: Recognition

and Management in the Emergency Department

• A key figure or table and relevant links

Points Pearls
• For older children and adolescents, use a conven-
tional screening tool such as HEADSS (Home; Edu- Avoid nonsteroidal anti-inflammatory drugs
cation/Employment; Activities; Drugs; Sexuality; and acetaminophen in patients with hyper-
and Suicide/depression) to elicit key historical infor- thermia due to synthetic cannabinoid use,
mation, as those who use synthetic cannabinoids are as hyperthermia in these cases is not due to

Points &
more likely to engage in risky behaviors involving hypothalamic regulatory set points.
substance use and sexual activity when compared
peers who use conventional marijuana only. Do not use beta-blockers as first- or second-

• A quick summary of the must-know recommendations from the full issue

• Assess patients for suicidality and common co-inges- line treatment for synthetic-drug induced
tions, as polysubstance abuse is common. In particu- hypertension, since beta-blockade precipitat-
lar, acetaminophen overdose is concerning given the ing unopposed alpha-agonism is a well-docu-
brief window of opportunity for intervention. mented concern with other drug overdoses.
• Conventional urine and serum laboratory studies In patients who have ingested synthetic cathi-
cannot reliably detect the presence of all synthetic nones, consider compartment syndrome in

Pearls
drugs and their metabolites. However, a urine toxi- unusual locations, such as the paraspinal and
cology screen that is positive for conventional mari- gluteal muscles.
juana should raise suspicion for synthetic marijuana
use.
• Provide supportive care for mild cases of synthetic • Patients with serotonin syndrome should be
cannabinoid intoxication. treated by discontinuing the inciting serotonergic
• More-significant complications of synthetic can- agent and providing supportive care. Cyprohep-
nabinoid use include myocardial infarction, dys- tadine, a serotonin antagonist, may be used for
rhythmias, rhabdomyolysis, and seizures. Although persistent symptoms.
not reported, there is a theoretical risk of serotonin • Order a basic metabolic profile for patients with
syndrome. synthetic cathinone or MDMA intoxications, as

DIGEST
• Hyperthermia is a known adverse effect from these patients are at risk for hyponatremia and
synthetic cannabinoid use. Patients who present cerebral edema. In most cases, it is acute hypona-

Get it now—absolutely free—at www.ebmedicine.net/topics by clicking next to the title of the

with hyperthermia should be cooled rapidly to 38°C tremia, and rapid correction is acceptable.
(100.4°F), at an aggressive cooling rate of 0.18°C to • Order a chest radiograph in patients who con-
0.28°C/min. sumed phenethylamines who present with chest
• Use benzodiazepines to treat the sympathomimetic pain, as aortic dissection and pneumomediasti-
toxidrome and seizures associated with synthetic num can occur.
cannabinoid and cathinone exposure.
• Bruxism may suggest toxicity in patients who have Issue Authors

ingested phenethylamines. In addition, patients Rahul Shah, MD

Department of Pediatrics, Yale New Haven Children’s Hospital, New Haven,
who have consumed phenethylamines are at risk for CT
rhabdomyolysis, seizures, and liver failure.

issue.
Carl R. Baum, MD, FAAP, FACMT
• Consider serotonin syndrome in patients who Professor of Pediatrics and Emergency Medicine, Yale University School of
have used synthetic cathinones (“bath salts”) Medicine, New Haven, CT

or phenethylamines (“MDMA,” “ecstasy,” “E,” Points & Pearls Contributor

“Adam,” “Molly”) and present with symptoms of Kathryn H. Pade, MD
fever, agitation, horizontal nystagmus, hyperreflexia, Pediatric Emergency Medicine Ultrasound Fellow, Department of Emergency
Medicine, Stanford University School of Medicine, Lucile Packard Children’s
flushed skin, clonus, and hyperactive bowel sounds. Hospital, Palo Alto, CA

May 2018 • Pediatric Emergency Medicine Practice 1 Copyright © 2018 EB Medicine. All rights reserved.

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Pediatric Emerge
March 2018
Number 3
Communication ncy Transport:
Volume 15,
Are Key to and Coordin April 2018
oid Use in Improving ation Volume 15,
Number 4

Corticoster nt of Pediatric Outcomes

Authors & Pediatrics, Authors
Medicine
MD of Emergency
Asalim Thabet,
Professor,
Departments Syracuse, NY
University,
Abstract Abraham
Attending
Gallegos,
MD
Assistant

Manageme Conditions
Medical University Physician,
Upstate Department
SUNY Upstate DO Department & Pediatrics SUNY
Children’s
Hospital of Emergency
Pediatric Los Angeles,
Tyler Greenfield, Pediatric Emergency Medicine
patients who
Vijay Prasad,
MD, MPH Los Angeles, and Transport Medicine,
Director, of Emergency Attending CA
Medical Professor NY subspecialty are critically

Emergency
Assistant Physician,
Syracuse, Department
or proceduresevaluation or specialized ill or who Children’s
Hospital; University, Chief, Pediatric Hospital Los of Emergency
Upstate
Medical FACEP
MD, FAAP, and Pediatrics;
Section Upstate require urgent Calvin G. Angeles,
Los Angeles, and Transport Medicine,
Poison Center, must often Lowe,
Richard
M. Cantor,
of Emergency
Medicine Upstate ters. The
safe be transferredimaging, equipment, Medical Director, MD, FAAP CA
coordination execution of interfacility to tertiary care
Director, Physician, Alan Purwin
Professor Medicine; Medical Division of Emergency
to NY
Synthetic Drug Intoxication in Children:
Transport
May end 2018
Emergency
transfer requires cen-
between the Hospital Los
half a centuryuse
Emergency Syracuse, Program;
Abstract for over their
Medical
University, of the transfer facility healthcare the
Medicine
Angeles; Assistant and Transport
at the University Professor Medicine, Attending
Children’s
been used Volume 15, Number 5 as well as of Pediatrics,
discusses the transport teams at each
Recognition and Management in the
of Southern
however, Peer Reviewers Emergency Peer Reviewers Keck School
oids have disorders; ial. This FACEP
MD, FAAP, Children’s Hospital
Oakland
and Emergency
the
services, the process of interfacility
California,
Los Angeles, of
Corticoster inflammatory remains controvers in acute J. Saulys,
UCSF Benioff of Pediatrics Authors
role of the
team. This
issue Stephen CA

Emergency Department emergency transfer, the required

Augusta Patterson,
treat various pediatric
Departments
conditions id treatment Associate
Director,
Clinical Professor, Rahul Shah, MD transport
Assistant MD, FACEP
Medical Director/EMS
in many
pediatric on corticostero s, anaphy- Department;
UCSF School
of Medicine
of Medicine; at studies
Department of Pediatrics, Yale New team, and CT clinician, the role
Haven Children’s Hospital,
Medicine,
Director, Department
evidence acute pharyngiti . While Medicine, MD College Hospital
and treatmentNew Haven, the commonly of the Riverside
Kristy Williamson, Community Hospital/UCR of Emergency
issue reviews ns, croup, meningitis nt of Sellinger,
of Pediatrics,
Albert Einstein Children’s
Services, Abstract
Carl R. Baum, MD, FAAP, FACMT of pediatric needed used
Yale University School of during interfacility diagnostic
Professor of Pediatrics and Emergency Medicine,patients.
Assistant MD, FAAP EM Residency,
and bacterial
Catherine Professor,
exacerbatio Professor Emergency Riverside,
asthma spinal injury, for manageme Assistant
Director,
Pediatric Medicine, New Haven, CT transfers Children's Department
Medical Center of Pediatric CA

laxis, acute ids are clearly indicated not universally Associate Bronx, NY CME Information”
Emergency of New York,
they are

If there are 5 or more clinicians at your hospital or group that are interested in subscribing, you can get
New Hyde Medicine,
croup, Due to Montefiore, see “Physician When children and adolescents present to the emergency Peer Reviewers Prior to beginning Park, NY Cohen
corticostero ns and cord injury. ids may be this activity,
on the back
page.
department with agitation or mental status changes, intoxi-
this activity,
exacerbatio spinal Prior to beginning Michael Levine, MD see
on the back “Physician CME Information”
asthma s,
ed for potential data, corticostero
s, anaphylaxi cation from synthetic drug use should be in the differential Associate Professor of Emergency Medicine, University of Southern California,
Editors-in-Chie page.
recommend data or conflicting Los Angeles, CA f
acute pharyngiti Vella, MD,
FAAP diagnosis. Identifying the responsible compound(s) may be Ilene Claudius, Ari Cohen,
insufficient in children with Adam E.
Associate
of Emergency
Professor and Medical
difficult, so asking the patient broad questions and utilizing
Dan Quan, DO Associate
Department of Emergency Medicine,
MD
Professor,
MaricopaDepartment
Integrated Health System;
MD, FAAP
Chief of Pediatric

considered meningitis. MD Pediatrics, of Emergency Medicine, Emergency Joseph Habboushe,

Robert Luten,Pediatrics and Medicine, Director Of Pediatric Clinical Associate Professor,Pediatrics,
Emergency Medicine ArizonaMassachusetts General
USCMedicine, andUniversity ofHospital; MD, MBA
of
Education, Medicine, Icahn appropriate diagnostic studies, when indicated, will aid in
School
Keck Instructor
Assistant
Professor
and bacterial MD, MBA Professor, Medicine, University New College of Medicine, Phoenix,Medicine,
AZ Los Angeles,School of Harvard Medical in Pediatrics, Medicine, of Emergency Robert Luten,
Habboushe, FL Emergency at Mount Sinai, NYU/Langone Professor, MD
Emergency Joseph Professor
of
and
Emergency
Florida,
Jacksonville, of Medicine making the diagnosis and help identify more-serious compli- CME Objectives
Tim Horeczko, CA
MD, MSCR,
Jay D. Fisher,
School, Boston,
MA
Bellevue Medical and
Centers, New Emergency
Pediatrics
and Adam E. Vella,
Assistant FAAP MD, York, NY;
MD, FAAP MD, MSHS York, NY FACEP, Clinical ProfessorFAAP Associate MD, FAAP
Ari Cohen, Emergency Medicine,
NYU/Langone New
Medical
Centers, Garth Meckler, of Pediatrics, MD, FACEP,cations. This issue discusses the challenges presented by the
FAAP
Associate Emergency of Pediatric Alson S.
CEO, MD
Aware LLC
Medicine,
Florida, Jacksonville, University
of Professor
Chief of Pediatric General Bellevue Aware LLC Professor Walker,
David M. Pediatric Emergency Upon completion of this article,
Professor
you should be able to: Medicine, and Inaba, MD, FL Medicine,
Pediatrics, Emergency
of
ief Massachusetts CEO, MD Associate
of British
Columbia;
changing chemical formulations of synthetic cannabinoids, Emergency of Clinical of Nevada, University Pediatric FAAP Garth Meckler,
Medicine, in Pediatrics, MA York, NY; University Emergency Director, Director, Medicine,
School of with synthetic Las Vegas Emergency MD, MSHS Education, and Medical
Editors-in-Ch Instructor Inaba, MD,
FAAP Head, Pediatric Hospital, Associate
Medicine; of Emergency Medicine,
1. Identify toxidromes associated Medicine, David Geffen
cannabinoids, cathinones,
Medicine, School of Specialist, Medicine Associate
Professor Emergency
Director Of
Pediatric
MD Hospital; School, Boston, Alson S. Emergency MedicineCenter Division
BC Children's cathinones, and phenethylamines; outlines common presenta- and phenethylamines. Faculty and UCLA ; Core Las Vegas,
NV for Women
Kapiolani
Medical Center University of Pediatrics, Medicine,
Ilene Claudius,Professor,
Department Harvard Medical Pediatric Kapiolani Medical Medicine, BC, Canada Department ueens, Senior Physician,
Angeles County-Harbor-UCLA Marianne
Gausche-Hill, Professor
& Children; of British
Division Head, Columbia;
of Medicine
at Mount
Icahn School
Associate Medicine
and MD, FAAP and New York-Presbyterian/Q tions of intoxication from these substances; and summarizes 2. Determine when diagnostic studies are warranted Los for patients who have MD, FACEP,
FAAP, FAEMS of Pediatrics, Associate Pediatric York, NY Sinai, New
School of Jay D. Fisher, of Pediatric Specialist, & Children; Associate Vancouver, Medical Center, of Hawaii Medicine, Emergency
MHPEd NY John A. Burns University

even bigger discounts with a group subscription. Visit www.ebmedicine.net/groups to learn more.
of Emergency BC
Nagler, MD, of Pediatrics and
USC Keck CA Flushing, been exposed to these synthetic drugs.
Torrance, Medical Director, Vancouver, Children's Hospital, David M.
Clinical Professor University for Women Pediatrics, University MD, MHAbest practices for evaluating and managing patients who Editorial with toxicityCA Medicine, School of Walker, MD,
Pediatrics,
Los Angeles,
Medicine, of of School of Joshua Professor Medical J. Wang, Keck 3. Manage patients who present Board County
associated with synthetic
Los
EMS Agency; Angeles Honolulu, BC, Canada Director, Pediatric FACEP, FAAP
Medicine, Emergency Las Vegas School Professor
John A. Burns Assistant Medicine, Harvard Vincent of Pediatrics,the Madeline HI Joshua Nagler,
MD, MSCR,
FACEP,
of Nevada, NV of Hawaii HI Division Professor present with intoxication after consumption of these synthetic
of Jeffrey R. and/or phenethylamines. Clinical Emergency Professor of
cannabinoids, cathinones, Matar Joseph, MD, MHPEd Medicine;
Associate
Emergency
Las Vegas, Honolulu, Emergency Director, Medicine Avner, Pediatrics, Medicine FAAP MD, Assistant
Tim Horeczko, Medicine, MD, FACEP, Medicine, MD, FACEP, School; Fellowship Boston School of of Southern California; Chairman, MD, FAAP David Geffen and FACEP,
Emergency
Professor
of Pediatrics Department Director,
of Emergency
FAAP
Professor
of Clinical
Geffen Marianne Gausche-Hill, Madeline
Matar Joseph, of Emergency
Medicine,
Boston, MA drugs of abuse.
University Division Head, Division
Prior to beginning
Pediatrics,
Department
this activity, of
seeof“Physician
Professor CMEDirector,
Medicine
Information”UCLA; EMSat School of Professor
of Emergency
and Pediatrics, Medicine
Medicine,
School; Fellowship
and
Harvard Medical
New York-Presbyterian/Que Medicine,
Associate Medicine, David Hospital, Associate Children's Pediatrics, Harbor-UCLA Fellowship Flushing, ens,
UCLA ; Core FAAP, FAEMS Los Angeles of FAAP Medicine Children’s Medicine, Maimonides Clinical Chief and
Director, Pediatric of Emergency Director, Division NY
Hospital on the back page.
of Emergency Center, Department Medical Medical
Emergency Director, Medical MD of EmergencyAngeles, Los Children's Emergency Medicine, Vincent J.
Medicine,
School of Senior Physician,
Los Medical Agency;
Professor
and
Professor Chief and James Naprawa, Emergency Los of Brooklyn,
Brooklyn, Medicine, of
Los Angeles,Emergency
Medicine
Division, University
Children’s Boston
Hospital, Boston, Wang, MD,
Hospital MHA
Faculty and
LA County EMS Medicine and Pediatrics, Emergency Physician, CA Steven Bin, NY CA of Florida James Naprawa, MA Professor
School of Pediatric Attending USCF Benioff CA Angeles, MD Michael J. College of of Pediatrics,
Angeles
County-Harbor-UCCA Clinical Emergency
David Geffen
Director, University
Division, Medicine- Department Oakland, Editors-in-Chief
Editor
Ari Cohen, MD, FAAP Joseph Habboushe, MD, MBA Robert Luten, Associate
MD Adam E. Vella, MD, FAAP
Clinical Professor, Associate Professor
FACEP, of
Gerardi, MD, Jacksonville, Medicine- Attending MD School of
Medicine Keck
Center, Torrance, Pediatrics, UCLA; EMS Fellowship
Hospital, Chief of Pediatric Emergency Assistant Professor of Emergency Professor, Pediatrics
School of and Emergency FAAP, Jacksonville, Physician, University of
Medical at
Medicine
College
of
FL Children's International FAAP, IleneFACEP,
Claudius, MD Medicine; UCSF President
Associateand Medical Stephanie FL Department Emergency of Southern the
Medical of Florida MD Medicine, Massachusetts General Medicine, NYU/Langone and Emergency Pediatric
Medicine, University Medical
of Medicine, Pediatrics, Kennebeck, Associate California;
Board Medicine Jacksonville, Rocker, Medical
MD, Associate Professor, Department Emergency Director, Medicine,
Professor
of Emergency Associate MD Children's USCF Benioff Division Head,
Harbor-UCLA of Emergency Jacksonville, Joshua Chief and Lara Zibners, Hospital; Instructor in Pediatrics, Bellevue Medical Centers, New Florida, Jacksonville, FL
Benioff Children's Medicine, Education, Director OfIcahn
Pediatric Professor, Hospital, of Emergency Division
Editorial FAAP
Director, MD Associate of Pediatric ofPaediatric
Emergency Medicine and UCSF at Mount Sinai; School of Cincinnati University Joshua Rocker, Oakland,
Hospital Los Medicine, Children's
Avner, MD, Center, Department CA Kennebeck,
Stephanie Professor, University
of
Division
MMed
Consultant,Pediatrics, Harvard Medical School, Boston, MA York, NY; CEO, MD Aware LLC
Garth Meckler, Francisco,
MD, MSHS
Hospital, SanEmergency Medicine, School Medicine
IcahnDirector, Department of CA
Jeffrey R. Department
of
Medicine,
Los Angeles,
of Pediatrics,
Director, Medicine,
Assistant Honorary Medicine,
St. Mary'sUSC Keck School of CA
of MedicineEmergency
at Mount Sinai, New
Medicine, Pediatric Cincinnati,
OH
of Pediatrics, Associate MD Angeles, Angeles,
Los
Chairman, Professor of Clinical MD, FAAP, Associate Emergency Pediatrics and Trust,
Medicine, Los Angeles, CA Jay D. Fisher, MD, FAAP Alson S. Inaba, MD, FAAP Associate Richard
Professor of Pediatrics, Children's Chief CA
Department Emergency College M. Cantor, Goryeb Anupam Director, Divisionand Medical
Pediatrics, Maimonides Children's J. Gerardi, Cincinnati OH of Imperial Instructor Clinical Professor of Pediatric and Pediatric Emergency Medicine University FACEP
of British Columbia; MD, FAAP, York, NY Medical Hospital, Morristown Kharbanda, International
Michael President Professor Medicine, Cohen Hospital Tim Horeczko, MD, MSCR, FACEP, Center, FAAP Chief, Critical MD, MS Emergency of Pediatric
Pediatrics, Brooklyn, Brooklyn,
NY
FACEP, of Emergency Cincinnati, MD, MS Emergency Center of
New
London,
UK; Nonclinical Icahn Emergency Medicine, University Specialist, Kapiolani Medical Center Division Head, Pediatric Emergency David M. Walker, MD, FACEP,Morristown,
Professor Care Services Professor
Medicine,
Lara Zibners,
Editor
of Professor Medical FAAP
Medicine, of Emergency Sandip Godambe, NJ Children's Assistant
of Medicine Zucker Sinai, of Nevada, Las Vegas School of for Women & Children; Associate Medicine, and
BC Children's
Pediatrics; Hospital, Medicine Director, Pediatric Emergency Hospitals of
Hospital Associate
Icahn School Pediatric Anupam
Kharbanda, Services Children's and Barbara of Emergency at Mount MD, PhD Minnesota, and Emergency Pediatrics and MMed
MD, FAAP,
Care of MedicineAssociate Professor of Clinical BC, Canada Director, Pediatric Chief Quality
Minneapolis, Clinics of FACEP,
MD UCSF Medicine,
Sinai; Director, Chief, Critical and Clinics York, Donald at Hofstra/ School of Medicine, Las Vegas, NV Professor of Pediatrics, University Vancouver, Emergency Medicine; Associate Director,
and Patient Medicine,
Steven Bin, Clinical Professor, Director, Medicine Emergency Medicine, David Geffen Department; Officer, MN Children's Cohen Honorary
at Mount Goryeb Hospitals School of New Hyde Park,
NY NY of Hawaii John A. Burns School of Director, Department ProfessorMedicine,Safety
of Emergency Tommy Y. Medical Center Consultant,
Medicine, Children's Minneapolis, MN New York, School of Medicine, UCLA ; Core Marianne Gausche-Hill, MD, FACEP, Joshua Nagler, MD,Central
MHPEdNew Medical Emergency of Pediatrics Kim, MD, York, Donald Emergency Paediatric
Associate
Medicine;
Medical UCSF Emergency Morristown Editor
yFaculty Medicine, Honolulu, HI
Assistant Control York PoisonNew York-Presbyterian/Queens,
Medicine, and Associate FAAP, FACEP and Barbara of New Medicine,
School of Medicine, Hospital, NJ Minnesota,
FAAP, FACEP
Northwell, and Senior Physician, Los FAAP, FAEMS Center,
Professor of Pediatrics and
Golisano Flushing,Physician, Attending Professor of
Pediatric
School of
Medicine Zucker Hospital Imperial St. Mary's
Emergency San Children's Morristown, Y. Kim, MD, MD of Pharmacolog BCPS Hospital, Children's NY Children's Emergency at Hofstra/ College Trust,
Steven Rogers, Madeline Matar Joseph, MD, FACEP,
Pediatric Center, University Angeles
PharmD, County-Harbor-UCLA Medical Director, Los Angeles Emergency Medicine, Harvard Medical
Syracuse, King's Daughters Hospital of Medicine, Northwell, London, UK;
Hospital, Tommy of Pediatric of NY California Riverside University of New Hyde
Benioff Children's
Medical
MD, PhD Professor Professor,
Associate School of Medicine, Aimee Mishler,MedicineMedical Pharmacist,
Center, Torrance, CA County EMS Agency; Professor of FAAP Steven
School; Fellowship
Choi,Director, Division Wang, MD, MHA Health System, the
Vincent J. Norfolk, School of Medicine, Steven Rogers, Park, NY of EmergencyNonclinical Instructor
CA Associate Medicine, University MD, FAAP VA Riverside Community Medicine,
Godambe, Patient Safety Medicine, Emergency Center, Clinical Emergency Medicine and Professor of Emergency Medicine Assistant
of Emergency Medicine, Boston Professor of Pediatrics, Keck MD
Francisco,
MD, FAAP, Sandip and and Emergency School of Connecticut Medicine Medical Vice President, Ran Goldman, Department Hospital, Associate School of
Medicine Icahn
M. Cantor, Chief Quality of Pediatrics California
Riverside Hospital, Emergency
Attending Connecticut Children's Maricopa Editorial Board Pediatrics, David Geffen School of and Pediatrics, Chief and Medical Montefiore
Children’s Hospital, Boston, MA School of D.Medicine of theMD Riverside,
of Emergency Connecticut
Professor,
University New York, at Mount
Sinai,
AZ Health System; Professor, Medicine, NY
Richard
Medicine Officer, Professor Attending Community
Riverside of Emergency Medicine, Physician, CT Phoenix, Jeffrey R. Avner, MD, FAAP Medicine at UCLA; EMS Fellowship Director, Pediatric Emergency Montefiore University of Southern
Director, California;
Department CA
Attending School of of
FACEP
of Emergency Pediatric
Medicine,
EmergencyChildren's Hospital
of the Center, Hartford, Director, Harbor-UCLA Medical Medicine Division, University
James Naprawa, MDNetwork
Improvement; Performance Associate University
Divisionof Head, of Pediatrics, Melissa
British Division Langhan, Emergency Medicine, Pharmacology
CME Editor MD
Professor Department Medical MD Chairman, Department of Attending Physician, Executive
Emergency Research Columbia; MD, MHS Physician, Medicine Editor
Director, Physician, Health System, CA Strother, Center, Department of Emergency of Florida College of Medicine- Montefiore Director, of Emergency Medicine,
Director, Children's Associate Connecticut Aimee Mishler,
and Pediatrics; Medical Riverside, Emergency Pediatrics, Professor of Clinical Department USCF Benioff
Institute Emergency Pediatric Professor Medical Center, Children's
Department; Poison King's Daughters MD, MHS and ChristopherProfessor, and Medical R. Liu, of Pediatrics, Medicine, Los Angeles, CA Jacksonville, Jacksonville, FL Improvement; for PerformanceHospital Los Angeles, Los
Medicine, Emergency of Pediatrics Hartford, Emergency PharmD, BCPS
Emergency York Langhan, Pediatrics Deborah Pediatrics,
Professor Maimonides Children's Children's Hospital, Oakland, CA Hospital, BC Medicine; and Christopher CT
Central New Norfolk,
VA Melissa of Assistant
Pediatrics, Associate of USC; of Pediatrics, Associate
Professor Angeles, CA Vancouver, BC, Children's Director, Director Fellowship Maricopa Medicine Pharmacist,
Director, Children's Professor Medicine, Director, Undergraduate of Medicine
Hospital of Brooklyn, Brooklyn, NY
Michael J. Gerardi, MD, FAAP, Stephanie Kennebeck, MD Strother,
Golisano MD
of Pediatrics,
Associate Medicine; Fellowship Keck SchoolEmergency Medicine, Joshua of
Rocker, MD Albert Einstein College
Medicine, Canada Pediatric Emergency of Education, Assistant MD Medical Center,
Control Center, NY Ran D. Goldman, Education; of FACEP, President Associate Professor, University of Bronx, International Editor Professor,
Emergency
Phoenix,
AZ
Syracuse, Department Emergency Education,
Director of Medicine, Yale
DepartmentMedicine
of Division Steven Bin,
LosMD
Angeles, Associate Chief and NY
Medical University
School of
Medicine,
Yale
Medicine,
Pediatrics,
Hospital, Professor, Columbia; Director, and Emergency Icahn School NY
Hospital Associate Professor of Emergency Cincinnati Department of Pediatrics, Medicine, Education; and Medical CME Editor
MD, FAAP University
of British
Pediatric Emergency Medicine, New York, Children's Associate
CA
Clinical Professor, UCSF
Medicine, Icahn School of Medicine Cincinnati, OH
Director, Assistant Professor Lara Zibners, MD, FAAP, FACEP, Haven, CT New Director, Undergraduate
Simulation;
Steven Choi,Vice President, Director, Director,
Research Medicine, BC Children's
Pediatric
School of Sinai, New Los Angeles,School of Medicine; Medical Director, at Mount Sinai; Director, Pediatric
of Pediatrics and Emergency MMed and Emergency
Deborah
Assistant Health System; University at Mount Pediatric Emergency Medicine, UCSF Anupam Kharbanda, MD, MS Medicine, Cohen Children's Medical Simulation; Department R. Liu, MD
Emergency BC, Canada Haven, CT Benioff Children's Hospital, San Emergency Medicine, Goryeb Honorary Consultant, Paediatric Icahn
at Mount Sinai, School of Medicine Associate
Professor
Montefiore Network Performance Vancouver, Chief, Critical Care Services Center of New York, Donald and Emergency Medicine, St. Mary's Keck School of Pediatrics,
Director, Hospital, Francisco, CA Children's Hospital, Morristown New York,
Montefiore Executive Children's Hospitals and Clinics of Barbara Zucker School of Medicine Hospital Imperial College Trust, NY Division of of Medicine of USC;
Medical Center, Morristown, NJ
Improvement; for Performance Richard M. Cantor, MD, FAAP, Minnesota, Minneapolis, MN at Hofstra/Northwell, New Hyde London, UK; Nonclinical Instructor Children's
Emergency
Institute Professor Hospital Los Medicine,
Montefiore Associate FACEP Sandip Godambe, MD, PhD Park, NY of Emergency Medicine, Icahn
College Tommy Y. Kim, MD, FAAP, FACEP Los Angeles, Angeles,
Improvement; Albert Einstein Professor of Emergency Medicine Chief Quality and Patient Safety
Associate Professor of Pediatric Steven Rogers, MD School of Medicine at Mount Sinai, CA
of Pediatrics, Bronx, NY and Pediatrics; Director, Pediatric Officer, Professor of Pediatrics and
Emergency Medicine, University of Associate Professor, University of New York, NY
of Medicine, Emergency Department; Medical Emergency Medicine, Attending
California Riverside School of Medicine, Connecticut School of Medicine,
Director, Central New York Poison Physician, Children's Hospital of the
Riverside Community Hospital, Attending Emergency Medicine
Pharmacology Editor
Control Center, Golisano Children's King's Daughters Health System, Aimee Mishler, PharmD, BCPS
Department of Emergency Medicine, Physician, Connecticut Children's
Hospital, Syracuse, NY Norfolk, VA Emergency Medicine Pharmacist,
Riverside, CA Medical Center, Hartford, CT
Steven Choi, MD, FAAP Ran D. Goldman, MD Maricopa Medical Center,
Melissa Langhan, MD, MHS Christopher Strother, MD
Assistant Vice President, Professor, Department of Pediatrics, Phoenix, AZ
Associate Professor of Pediatrics and Assistant Professor, Emergency
Montefiore Health System; Director, University of British Columbia;
Research Director, Pediatric
Emergency Medicine; Fellowship Medicine, Pediatrics, and Medical CME Editor
Montefiore Network Performance Director, Director of Education, Education; Director, Undergraduate
Improvement; Executive Director, Emergency Medicine, BC Children's Deborah R. Liu, MD
Pediatric Emergency Medicine, Yale and Emergency Department
Montefiore Institute for Performance Hospital, Vancouver, BC, Canada Associate Professor of Pediatrics,
University School of Medicine, New Simulation; Icahn School of Medicine
Improvement; Associate Professor Haven, CT at Mount Sinai, New York, NY Keck School of Medicine of USC;
of Pediatrics, Albert Einstein College Division of Emergency Medicine,
of Medicine, Bronx, NY Children's Hospital Los Angeles,
Los Angeles, CA

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 Physician CME Information
Date of Original Release: November 1, 2018. Date of most recent review: October 15, 2018.
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Number 9
Volume 14,

thopedic Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA
Pediatric Or ence-Based
Author San Diego
,
of California

id
Jamie Lien,
MD, FAAP
Physician,
University
PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the
Injuries: Ev t in the
ce; Associate , CA
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en’s Hospital,
Rady Childr

extent of their participation in the activity.

ManagemenDepartment
Revie wers
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Boston Childr Harvard
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and Emergency
NY
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disease CME credits.
Assistant Profes at Moun
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Abstract mon in chil
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ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the
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year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and
hief UCLA; EMS Matar Josep Children’s Hospita Angeles, CA
Editor-in-C Medicine at Medica l Madeline
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AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American

Jeffrey R. at Mount Sinai; Goryeb Stephanie University Cohen Childre sor of Emergency
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FAAP, FACEP Volume 14, Number 8
Connecticut
Attending
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Steven Bin, l Professor, Tommy Y. Pediatric Connecticut CT r
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Needs Assessment: The need for this educational activity was determined by a survey of
or of
Authors
Associate Clinica Medical King's Daugh Associate Profess e, Physician,

Prevention and Management l of Medicine; University of e, l Center, Hartfo

rd,
UCSF Schoo Pediatric Norfolk , VA Emerg ency Medicin of Medicin Medica Choi, MD, FAAP
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School
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Medicine, UCSF co, CA Ran D. Goldm tment of Pediat de Comm Assistant e, Health System ance
Emergency Francis sor, Depar Riversi ency Medicin
Clinical nt Profes l fiore

medical staff, including the editorial board of this publication; review of morbidity and mortality
l, San Profes bia; of Emerg Professor
Assista of Emergency Medica
and Medicine, Monte rk Perform
Children's Hospita of British Columric Department Riverside School of Medicine, Medicine,
Pediatrics, raduate UniversityMontefiore of Netwo r,
University California tive Directo
Cantor, MD,
FAAP, Director, Pediat Children's Riverside, CA Director, Underg
tion; Riverside Community Hospital, ement; Execu Performance
Abstract Richard M.
FACEP Medicine
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data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency
Professor r, MBA New York,
NY
rics; Directo Medical ushe, MD, MediciAssociate Mount Sinai,
Professor ofatPediatric of Pediatrics,
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of Emerg ency of Mediciof California
s are at increased risk for heat-relate
Director, Centra, Golisano Children's
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NYU/Langon s, New Pediatric EmergEmergency ne, Professor Community
Associate CA rics, and Medical Hospital, Editor
illness due to their inability to Medicine,
d School of Medici Medicine, Riverside, CME Department of

physicians.
Control Center se, NY Medica l Center sity Pediat
remove themselves from dangerous
Hospital, Syracu
Bellev ue
MD Aware
LLC Univer
Haven, CT Peer Reviewers
Medici ne,
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l ah R. Liu,
MD rics,
environments. Evidence shows York, NY; CEO, , FACEP,
Education, Icahn Schoo Debor iate Professor of Pediat
Medicine, of USC;
Ari Cohen
, MD, that morbidity and mortality
FAAP
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Robert Luten , MD Emerg ency
at Mount Sinai,
New Assoc
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heat illness is related to the length
Chief of Pediatr chusetts General from
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sityFAAP of Medicine Keck Schoo
Emergency
Medicine,
of time core temperature is elevat-
FAAP of Clinical Medicine,
Univer Division of Angeles,
Medicine, Massator in Pediatrics,
ed, so rapid reduction and accurate Associate
Professor
David Geffen Emergency Chief of Pediatric Emergency
nville, FL
York, NY
Medicine, FACEP, FAAPs General Hospital Los
Children's

Target Audience: This enduring material is designed for emergency medicine physicians,
Medicine, MD, Massachusett
Hospital; Instruc l School, Boston, MA
serial measurements are crucial Emergency Florida, Jackso Instructor in Pediatrics,David M. Walker, Hospital; s, CA
UCLA ; Core Harvard Emergency Angele
prevention of organ system
Harvard Medica to
School of
Medicine, ian, Los er, MD, MSHS r,Medical
Pediatric School, Boston, MA Los
Garth Meckl Seansor M.ofFox, rics,
FACEP,Directo Director,
damage and death. The primary
Jay D. Fisher
, MD, FAAP ric and Faculty and
Senior Physic A Profes
Associate Associate
PediatMD, FAAP ne; Associate ency Medicine,
of patient cooling are conduction
Clinical Profes
sor of Pediat sity methods y-Harbor-UCL
Angeles Count , Torrance, CA of British Colum
University Department
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Professor, ency
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Associate tment of Emerg
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(ice-water immersion, cold packs)
physician assistants, nurse practitioners, and residents.
Medicine,
Univer Pediatric Emerg Medicine
rian/Q Director,
Medical Center Division Head,Children's of Emergency York-Presbyte
and convection (moisture and
Emergency Vegas Schoo
l of Hospit al, Medicine,
New
NY Carolinas Medical Center,
figures.
of Nevad moving air). The choice of method
a, Las
, NV MD, FAAP
Alson S. Inaba, ency Medicine
Medicine,
BC
BC, Canad
a Flushin g, Charlotte, NC
at tables and
used may depend on availability
Medicine,
Las Vegas
l, MD, FACEP
, Pediatric Emerg ani Medical Center Vancouver, Prior to beginning this activity,
see “Physician closer look
for a Information”
of equipment, but there is evidence
Gausche-Hil Specialist,
Kapiol
Associate the icon CME
that can guide optimal use of
Marianne S & Children;
on
Clickthe onback page.
resources. This issue presents for Women

Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
FAAP, FAEM r, Los Angeles
based recommendations and Medical Directo Agency; Profes
evidence-
sor of
best practices in heat-illness
County EMS
tion, including managing children resuscita-
who are obese, have special
making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the
or take medications, and advocacy needs
for prevention strategies.

Editor-in-Chief
Ilene Claudius, MD
Associate Professor, Department
of Emergency Medicine and
Pediatrics, USC Keck School
of
Medicine, Los Angeles, CA
Editorial Board
Clinical Emergency Medicine
Pediatrics, David Geffen School
Medicine at UCLA; EMS Fellowship
and
of
Director, Harbor-UCLA Medical
Center, Department of Emergency
Medicine, Los Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Professor of Pediatrics, University
of Hawaii John A. Burns School
of
Joshua Nagler, MD, MHPEd
Vincent J. Wang, MD, MHA
most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each
topic covered.
Medicine, Honolulu, HI Assistant Professor of Pediatrics
and Professor of Pediatrics, Keck
Emergency Medicine, Harvard
Madeline Matar Joseph, Medical School of Medicine of the
MD, FACEP, School; Fellowship Director,
FAAP Division University of Southern California;
of Emergency Medicine, Boston
Professor of Emergency Medicine Associate Division Head,
and Pediatrics, Chief and Medical
Children’s Hospital, Boston,
MA Division
of Emergency Medicine, Children's

CME Objectives: Upon completion of this article you should be able to: (1) Identify the
Jeffrey R. Avner, MD, FAAP Director, James Naprawa, MD Hospital Los Angeles, Los
Associate Professor of Emergency Pediatric Emergency
Chairman, Department of Medicine Division, University Attending Physician, Emergency Angeles, CA
Medicine, Icahn School of Department USCF Benioff
Pediatrics, Maimonides Infants Medicine of Florida College of Medicine-
Children’s Hospital of Brooklyn;
& at Mount Sinai; Director, Pediatric
Jacksonville, Jacksonville, Children's Hospital, Oakland, International Editor
Emergency Medicine, Goryeb CA

populations that are at high risk for bacterial meningitis, (2) recognize the variable clinical
FL
Professor of Clinical Pediatrics, Children's Hospital, Morristown Stephanie Kennebeck, MD Joshua Rocker, MD Lara Zibners, MD, FAAP, FACEP
Albert Einstein College of Medical Center, Morristown, Associate Chief, Division of Honorary Consultant, Paediatric
Medicine, NJ Associate Professor, University
Children's Hospital at Montefiore, of Pediatric Emergency Medicine, Emergency Medicine,
Sandip Godambe, MD, PhD Cincinnati Department of Pediatrics, St. Mary's
Bronx, NY Cohen Children's Medical Hospital Imperial College Trust,

Steven Bin, MD
Associate Clinical Professor,
UCSF School of Medicine; Medical
Chief Quality and Patient Safety
Officer, Professor of Pediatrics
and
Emergency Medicine, Attending
Physician, Children's Hospital
presentations of patients with bacterial meningitis, (3) discuss the challenges in making a
Cincinnati, OH Center;
Assistant Professor of Emergency London, UK; Nonclinical Instructor
Anupam Kharbanda, MD, Medicine and Pediatrics, Hofstra of Emergency Medicine, Icahn
MS
Chief, Critical Care Services Northwell School of Medicine, School of Medicine at Mount
New Sinai,
Children's Hospitals and Clinics New York, NY

Director and Interim Chief, Pediatric
Emergency Medicine, UCSF
Benioff
Children's Hospital, San Francisco,
CA Ran D. Goldman,
Richard M. Cantor, MD, FAAP,
FACEP
prompt diagnosis, and (4) diagnose and manage patients with bacterial meningitis.
of the of Hyde Park, NY
King's Daughters Health System, Minnesota, Minneapolis, MN
Norfolk, VA Steven Rogers, MD Pharmacology Editor
Tommy Y. Kim, MD, FAAP,
FACEP Associate Professor, University
Associate Professor of Pediatric of Aimee Mishler, PharmD,
MD Connecticut School of Medicine, BCPS
Professor, Department of Pediatrics, Emergency Medicine, University Attending Emergency Medicine Emergency Medicine Pharmacist,
University of British Columbia; of Maricopa Medical Center,
California Riverside School of

Discussion of Investigational Information: As part of the journal, faculty may be presenting

Professor of Emergency Medicine
and Pediatrics; Director, Pediatric
Emergency Department; Medical
Director, Central New York
Research Director, Pediatric
Emergency Medicine, BC
Children's
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 Calculated
Decisions
Clinical Decision Support for Pediatric Emergency Medicine Practice Subscribers
Bacterial Meningitis Score for Children
Introduction: The bacterial meningitis score for children rules
out bacterial meningitis in pediatric patients with suspected
Click the thumbnail above meningitis.
to access the calculator.
Points & Pearls
• The bacterial meningitis score (BMS) predicts
bacterial versus aseptic etiology of meningitis in
patients aged 29 days to 19 years with suspected
meningitis.
• The BMS can help determine if the patient will
require admission for parenteral antibiotics while
awaiting cerebrospinal fluid (CSF) culture results.
• A higher BMS indicates a higher likelihood of
bacterial meningitis.
• Although the score was derived and validated
in a population of children aged 29 days to 19
years, the sensitivity, specificity, and negative
predictive value (NPV) of the BMS decrease
significantly for children aged < 2 months.
Therefore, the creators of the BMS advise against
using it for children who are aged < 2 months,
as well as for children who have already received
antibiotics prior to the lumbar puncture, are ill-
appearing, or have examination findings that are
indicative of an invasive bacterial infection (eg,
petechiae and purpura).
• The BMS is not effective at ruling out potentially
harmful nervous system infections (eg, herpes
encephalitis, Lyme meningitis, tuberculous men-
ingitis) that would require antibiotics.
• Meningococcal meningitis can present
without CSF pleocytosis; thus, patients
with meningococcal meningitis could be
misclassified as not having inclusion criteria
CALCULATOR REVIEW AUTHOR
Cullen Clark, MD
Departments of Emergency Medicine and Pediatrics
Louisiana State University Health Sciences Center
New Orleans, LA
CD1
POWERED BY
for use of the BMS. It is important to perform
a thorough physical examination to assess for
petechiae or purpura if there is suspicion for
meningococcemia or meningococcal meningitis,
as the CSF culture may have a false normal result
in these cases.
Critical Actions
The clinician’s gestalt and the patient’s severity of ill-
ness and clinical presentation supersede the applica-
tion of the BMS. If there is significant suspicion for
bacterial meningitis, clinicians should err on the side
of caution and admit the patient for observation and
empiric antibiotics.
Instructions
The BMS should be used in patients aged 29 days to
19 years who have a CSF white blood cell count of
≥ 10 cells/μL. Do not use the BMS if the patient is criti-
cally ill, has recently received antibiotics, has a ventric-
uloperitoneal shunt or has recently had neurosurgery,
is immunosuppressed, or has another bacterial infec-
tion that requires antibiotics (including Lyme disease).
Evidence Appraisal
The original BMS was derived from a multicenter
retrospective cohort study published by Nigrovic
et al in 2007. Data were collected from 20 participat-
ing emergency departments at academic medical
centers over a 3-year period. The study used the
BMS to classify 3295 patients aged 29 days to 19
years who had CSF pleocytosis. Among the 1714 pa-
tients who were categorized as very low risk, 2 were
found to have bacterial meningitis. Both of the mis-
categorized patients were aged < 2 months and had
E coli meningitis with an E coli urinary tract infection
www.ebmedicine.net
but a negative urinalysis. The sensitivity of the BMS
for bacterial meningitis was 98.3% (95% confidence
interval [CI], 94.2%-99.8%) and the NPV was 99.9%
(95% CI, 99.6%-100%). The investigators attempted
to refine the score using recursive partitioning, which
led to a simpler model with only 3 variables, but also
led to 1 additional patient with meningitis being
misclassified as very low risk.
Given that the 2 misclassified patients were aged
< 2 months, the investigators analyzed the BMS for a
subgroup of all patients aged < 2 months and found
that the sensitivity was 92.3% (95% CI, 74.9%-99.4%)
and the NPV was 99.5% (95% CI, 98.3%-99.9%).
The BMS was validated by Nigrovic et al in 2012,
in a meta-analysis of studies published between 2002
and 2012 that included 4896 patients aged 29 days
to 19 years. The sensitivity for bacterial meningitis
was 99.3% (95% CI, 98.7%-99.7%) and the NPV was
98.3% (95% CI, 96.6%-99.3%).
In 2013, Kulik et al published a systematic review
of several bacterial meningitis predictive rules.
Among the studies reviewed, the authors found

Why to Use
The incidence of bacterial meningitis has dramatically declined since the advent of highly effective vaccines
against some of the more common causes (eg, Haemophilus influenzae type b, Streptococcus pneumoniae).
This has made it more challenging to determine which patients should be admitted for observation while await-
ing CSF culture results.
The BMS helps identify patients who do not necessarily require observation due to the higher likelihood
that they have aseptic (ie, spontaneously resolving) meningitis. It also helps avoid the financial burden and
health risk that are associated with hospitalization for observation and administration of parenteral antibiotics.

When to Use
• The BMS can be used in pediatric patients aged 29 days to 19 years with suspected meningitis.
• Do NOT use the BMS if the patient:
» Is critically ill, requiring respiratory or vasopressor support
» Received antibiotics < 72 hours prior to the lumbar puncture
» Has a ventriculoperitoneal shunt or has recently had neurosurgery
» Is immunosuppressed
» Has proof of another bacterial infection (eg, urinary tract infection, bone infection, or known bactere-
mia) that warrants inpatient antibiotic therapy
» Has known active Lyme disease

Next Steps
For patients at very low risk for bacterial meningitis (BMS = 0):
• Consider discharging the patient with close follow-up (ideally within 24-48 hours) and return precautions
explained to the caregiver, including new seizure activity, altered mental status, purpuric rash, or other
concerning symptoms.
• Patients may have received a dose of empiric antibiotics after a lumbar puncture was performed if there
is concern for bacterial meningitis. If no antibiotics were administered, consider giving a single dose of a
long-acting antibiotic with good CSF penetration (eg, ceftriaxone) prior to discharge.

For patients with at least 1 risk factor or high clinical suspicion for bacterial meningitis (BMS > 0):
• Consider admitting the patient for observation and administration of parenteral antibiotics while awaiting
CSF culture results.
• Make sure the CSF is sent for culture.
• Consider continuous monitoring of the patient’s vital signs, along with performing regular neurologic
examinations.
• Start administration of empiric broad-spectrum antibiotics if these were not previously administered.
• Consider expanding the antimicrobial coverage.
» If there is concern for herpes encephalitis, add acyclovir.
» If there is high clinical suspicion for tuberculous meningitis, consult with an infectious disease special-
ist and consider rifampin, isoniazid, pyrazinamide, and a fluoroquinolone or aminoglycoside.
• Consider steroid administration based on the patient’s clinical presentation, the geographic area, and
any potential risk factors.

Abbreviations: BMS, bacterial meningitis score; CSF, cerebrospinal fluid.

Pediatric Emergency Medicine Practice • November 2018 CD2 Copyright © 2018 EB Medicine. All rights reserved.
that the BMS had the highest quality of evidence Other References
• Nigrovic LE, Kuppermann N, Malley R. Development and
and the best performance to date, but they still
validation of a multivariate predictive model to distinguish
recommended that the score be further evaluated bacterial from aseptic meningitis in children in the post-Hae-
with prospective trials. mophilus influenza era. Pediatrics. 2002;110(4):712-719.
https://www.ncbi.nlm.nih.gov/pubmed/12359784
Use the Calculator Now • Kulik DM, Uleryk EM, Maguire JL. Does this child have bac-
Click here to access the calculator. terial meningitis? A systematic review of clinical prediction
rules for children with suspected bacterial meningitis.
Calculator Creator J Emerg Med. 2013;45(4):508-519.
Lise Nigrovic, MD, MPH DOI: https://doi.org/10.1016/j.jemermed.2013.03.042
Click here to read more about Dr. Nigrovic.
Copyright © MDCalc • Reprinted with permission.
References
Original/Primary Reference
• Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical pre- Additional Reading
diction rule for identifying children with cerebrospinal fluid Click here to access a Pediatric Emergency
pleocytosis at very low risk of bacterial meningitis. JAMA. Medicine Practice issue reviewing tick-borne
2007;297(1):52-60. illnesses.
DOI: https://doi.org/10.1001/jama.297.1.52
Validation Reference Click here to access a Calculated Decisions issue
• Nigrovic LE, Malley R, Kuppermann N. Meta-analysis of reviewing the Rule of 7s for Lyme meningitis.
bacterial meningitis score validation studies. Arch Dis Child.
2012;97(9):799-805.
DOI: https://doi.org/10.1136/archdischild-2012-301798

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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway,
Suite 150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication
is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used
for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2018 EB Medicine. All rights
reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only
and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission.

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