Meningitis in Children - I.V. Bogadelnikov 2005

Treatment of Meningitis in Children
General Principles of Meningitis Treatment

Hospital Treatment approaches for patients with meningitis have certain specific features depending on the Etiology, severity, and clinical course of Purulent meningitis; however, General Principles can be outlined. These include:

- hospitalization;

- bed rest regimen;

- medical Nutrition;

- etiotropic therapy;

- pathogenetic treatment;

- symptomatic treatment;

- Prevention of complications.

Hospitalization. All patients with purulent meningitis, regardless of the clinical form and severity of the disease, must be hospitalized. A patient is discharged home after recovery, which is confirmed by clinical and laboratory examinations (no less than 21 days). Hospitalization is also mandatory for any form of serous meningitis, regardless of the patient's well-being. If serous meningitis is mild—confirmed by clinical and laboratory findings, shows steady positive dynamics, and does not require intensive care (infusion therapy, daily consultations with a neurologist, ophthalmologist, etc.)—then after inpatient evaluation and Diagnosis, completing treatment at home may be permitted. However, inpatient treatment, particularly during the diagnostic phase, is mandatory.

Regimen. Strict bed rest is prescribed for all meningitis patients until their general condition improves, body Temperature steadily normalizes, and CEREBROSPINAL FLUID parameters significantly improve (on average, for at least 10 days; for Mumps Meningitis, 12-14 days; for lymphocytic choriomeningitis, up to 3 weeks). Afterwards, the patient is transferred to a semi-bed rest regimen for 5-7 days, followed by an unrestricted activity regimen until discharge from the hospital.

Nutrition. During the initial stage of patient care (days 3-5 of the illness), when pronounced symptoms of toxemia and impaired consciousness are present, meeting the body's plastic metabolic needs and compensating for the Energy balance are achieved primarily through adequate infusion therapy. Once hemodynamics stabilize, infants under one year of age are given expressed breast milk or adapted formula. Feeding volume is reduced to 1/2 - 1/3 of the age-appropriate norm on the first day, followed by a rapid increase to the normal volume over 2-3 days. If swallowing is impaired, tube feeding is performed.

Older children are prescribed a mechanically, chemically, and thermally sparing diet. Cold dishes must have a temperature of no lower than 15°C, and hot dishes no higher than 60⁰C. Food preparation Methods are limited to boiling in Water or steaming. Meals should be fractional, 5-6 times a day, in small portions per feeding. The diet corresponds to Pevzner's Diet No. 5. Often, children themselves indicate the dishes they would like to eat, and their preferences should be accommodated in the absence of specific contraindications.

During the convalescence period, Diet No. 2 or No. 15 is prescribed (depending on the patient's age), but with restrictions on foods that stimulate the Central Nervous system (strong coffee, tea, strong broths, spices, chocolate). The feeding schedule should be 3-4 times a day.

The fluid intake regimen corresponds to the child's daily fluid requirements, taking into account intravenously administered solutions. Juices, fruit drinks, and mineral water are typically used for drinking.

Antibacterial therapy is the cornerstone of purulent meningitis treatment. Its efficacy depends on the pathogen's susceptibility to the chosen antibiotic, the drug's ability to cross the Blood-Brain barrier, and its capacity to achieve a sufficient concentration at the site of inflammation.

Empirical antibacterial therapy

Empirical antibiotic Selection is used when the etiology of meningitis cannot be established During the first 24 hours of hospitalization, lumbar puncture has to be delayed, or Gram-stained cerebrospinal fluid smear results are uninformative. In such cases, clinicians must be guided by current epidemiological data on the prevalence of The most significant pathogens, taking into account the child's age.

Table 17

Antibiotics Recommended for Empirical Therapy of Purulent Meningitis

Note:

Vancomycin is added to empirical therapy when pneumococcal or staphylococcal resistance to penicillin or Cephalosporins is suspected.

Etiotropic Therapy Based on Pathogen Specifics

Once cerebrospinal fluid culture results are available, therapy is prescribed based on the specific pathogen, its susceptibility, or resistance to antibacterial drugs.

Table 18

Recommended antibiotic selection for specific etiological therapy of purulent meningitis

* Recently, there has been an urgent need to account for the increasing penicillin resistance of pneumococci, as well as their resistance to chloramphenicol. Consequently, in severe cases of Pneumococcal meningitis or when there is evidence of pneumococcal resistance to penicillin and levomycetin, The Use of vancomycin in combination with 3rd-generation cephalosporins is recommended.

For patients who do not respond to treatment, intraventricular administration of vancomycin is recommended.

An alternative therapy for pneumococcal meningitis may involve the use of a combination of a 3rd-generation cephalosporin and rifampicin.

In cases of moderately expressed pneumococcal resistance, chloramphenicol (levomycetin succinate) may also be used.

Encouraging results in the treatment of pneumococcal meningitis have been achieved with the use of meropenem.

Table 19

Antibiotic dosages for Purulent meningitis in children

* The use of ceftriaxone in children under 1 month of age should be restricted due to its high plasma protein binding.

The duration of antibacterial therapy depends on the pathogen type and the clinical and microbiological response to treatment.

Table 20

Guidelines for the duration of antimicrobial therapy in purulent meningitis in children

Adjuvant therapy

Given The Role of pro-inflammatory cytokines in the Pathogenesis of bacterial meningitis, elevated intracranial pressure (ICP), and The Development of brain edema, initiating meningitis therapy with dexamethasone is recommended. The efficacy of dexamethasone is higher in children than in adults. Dexamethasone must be administered concurrently with the first antibiotic dose (ideally immediately prior to it).

Indications for prescribing dexamethasone in meningitis include:

1. Meningitis in children under 2 months of age.

2. Children in whom gram-negative bacilli are detected in the CSF smear.

3. Patients with elevated ICP.

4. Patients with cerebral edema.

5. Dexamethasone is prescribed at a dose of 0.15 mg/kg every 6 hours for 4 days.

Reduction of intracranial pressure

In patients with signs of elevated ICP (impaired consciousness, extraocular movement disorders), monitoring is indicated, and if pressure exceeds 200 mm H₂O, therapy aimed at reducing it is warranted.

In cases of elevated intracranial pressure, the patient should be positioned in bed with the head elevated by 30 cm to improve venous drainage.

Diuretics can be used to increase fluid drainage from the brain into the intravascular space. The administration of diuretics in meningitis is indicated only after correcting hypovolemia and in patients with stable hemodynamics. Among diuretics, mannitol is prescribed at a dose of 0.25-0.5 g/kg of body weight every 6-8 hours, administered as 10-15-20% solutions. The specified dose of the drug is infused over 10-20 minutes. The administration rate must not exceed 1.5 g/kg of body weight per day. Combining mannitol with furosemide at a dose of 1-2 mg/kg of body weight per day, administered immediately before THE START OF infusion therapy, is well justified.

The risks associated with diuretic use include severe fluid and electrolyte imbalances, hypovolemia, and hemodynamic instability. The use of mannitol in the presence of high plasma osmolarity may trigger a rebound phenomenon and osmotic nephrosis.

To prevent the "rebound" phenomenon after discontinuing mannitol infusions, administering albumin is recommended.

Every child with purulent meningitis requires continuous monitoring of pulse, respiratory rate, body temperature, fluid and electrolyte balance, acid-base status, plasma osmolarity, and urinary output.

The optimal fluid intake is 80-100 mL/kg per day, taking into account physiological fluid requirements and ongoing losses. The risk of fluid overload must be considered, and fluids should be administered under careful monitoring.

No specific etiological therapy has been developed for Viral serous meningitis. Acyclovir is indicated only for confirmed herpetic meningitis at a single dose of 10 mg/kg of body weight 3 times daily for 7-10 days. Appropriate targeted therapy is also prescribed for toxoplasmic, brucellar, borrelial, tuberculous, and certain other specific forms of serous meningitis.

Lumbar puncture is the primary therapeutic intervention for serous meningitis. Subsequent management is symptomatic and includes antipyretic medications (paracetamol, ibuprofen, nimesulide), agents that normalize cerebrospinal fluid dynamics (diacarb), and strict bed rest.

Patients with serous meningitis typically recover within 1-3 weeks. Only in rare cases can Meningitis caused by mumps virus, cytomegalovirus, herpesvirus, or HIV exhibit a protracted or recurrent course.