Pediatrics: Meningitis Nursing Guide

Content Creator: Stephanie Smith, MS, BSN, RN, CPN.

Overview: Meningitis

This content is intended as a Quick Reference for Meningitis and will cover an overview as well as nursing considerations utilizing the nursing process.

Meningitis Etiology and Epidemiology

Meningitis is inflammation of the protective membranous layers overlaying the brain and spinal cord. Bacterial meningitis is caused by bacteria (DynaMed, 2018). It is a life-threatening medical emergency requiring immediate treatment with antibiotics to prevent serious neurologic sequalae. Meningitis caused by viruses, fungi, parasites, autoimmune disorders, or drugs without bacterial infection is aseptic meningitis (DynaMed, 2019). Aseptic meningitis treatment consists of treating the underlying cause and managing symptoms.

Bacterial meningitis is noted with the following (DynaMed, 2018; Hockenberry et al., 2021b):

• Presenting symptoms are often non-specific and include:
  • Sick appearance
  • Headache
  • Fever
  • Lethargy
  • Nausea
  • Vomiting
• More specific signs include:
  • Stiff neck or back
  • Non-blanchable rash
  • Light sensitivity
• Neonates and young children may have:
  • Hypothermia
  • Seizures
  • Irritability
  • Bulging fontanelle
  • Poor tone and oral feeding
  • Apnea
  • Weak cry
• Highest incidence in neonates (< 1 month of age)
• Low fatality rate with most deaths from pneumococcal meningitis
• May cause the following serious conditions:
  • Sepsis, shock
  • Disseminated intravascular coagulation
  • Extremity weakness
  • Hydrocephalus
  • Brain abscess
  • Increased intracranial pressure (ICP)
  • Joint invasion
  • Kidney failure
• Children may experience hearing loss, cognitive impairment, and developmental delays.
• Primary pathogens vary by age. Most common pathogens include:
  • S. pneumoniae
  • Group B Streptococcus
  • H. influenzae type B
  • N. meningitidis
  • E. coli
• Highest risk includes:
  • Group B Streptococcus exposure at birth
  • Cochlear implants
  • Prematurity or low birth weight
  • Immunodeficiency
  • Lack of vaccination or bactericidal antibodies
• Vaccines for H. influenzae type B, meningococcal, and pneumococcal have significantly reduced the incidence of meningitis.
• Typical route is bacterial colonization in the upper respiratory tract traveling into the bloodstream.
• Other routes include exposure to bacteria during the birthing process or bacterial contamination of the cerebrospinal fluid through surgery, trauma, shunts, or congenital defects.

Aseptic meningitis is noted with the following (DynaMed, 2019; Hockenberry et al., 2021a):

• Presenting symptoms similar to bacterial meningitis
• Highest incidence in infants (< 1 year of age)
• Higher prevalence than bacterial meningitis
• Most individuals fully recover from viral meningitis within 2 weeks.
• Prolonged headaches may occur after enteroviral infection.
• Enterovirus is the most common pathogen.
• Fungal and parasitic pathogens are rare.
• Autoimmune causes include neurosarcoidosis, rheumatoid arthritis, and Kawasaki disease.
• Drug-induced causes include nonsteroidal anti-inflammatory drugs, intravenous immunoglobulin, antibiotics, anticonvulsants, and vaccines.
• Partially treated bacterial meningitis or bacteria difficult to culture may have similar presentation.

Meningitis Diagnosis

The diagnosis of meningitis is based on recent medical history, physical examination, and diagnostic testing. Clinical suspicion prompts a lumbar puncture and cerebrospinal fluid (CFS) testing. If possible, obtain cultures before administering antibiotics.

Testing for meningitis includes:

• CSF culture or polymerase chain reaction (PCR) to isolate bacteria
• Additional CSF testing
  • Grain stain
  • White blood cell count
  • Glucose
  • Protein
• Complete blood count (CBC)
• Blood cultures
• Glucose
• C-reactive protein

Signs of bacterial meningitis during lumbar puncture testing reveal a high opening pressure, elevated CSF white blood cell count and protein, positive Gram stain, cloudy fluid, and glucose less than 40 mg/dL. Serum blood test results often reveal elevated C-reactive protein and white blood cell count. Individuals with elevated intracranial pressure are at an increased risk of brain herniation if they receive a lumbar puncture.

Aseptic meningitis is suspected when there is an elevated white blood cell count in the CSF combined with fever, headache, stiff neck, and light sensitivity combined with negative bacterial cultures.

Computerized tomography (CT) and magnetic resonance imaging (MRI) may be indicated in specific patients. CT and MRI may be used to rule out masses or lesions, evaluate illness unresponsive to antibiotics, or worsening signs and symptoms.

Management

Bacterial meningitis is a medical emergency and antibiotic treatment must be administered as quickly as possible after suspected diagnosis. The following empiric treatments are recommended for bacterial meningitis:

• Neonates ≤ 7 days of age options:
  • Ampicillin 150mg/kg/day IV divided every 8 hours plus cefotaxime (Claforan®) 100-150mg/kg/day IV divided every 8-12 hours
  • Gentamicin (Garamycin®) 5mg/kg/day divided every 12 hours
• Neonates ≥ 8 days of age options:
  • Ampicillin 200 mg/kg/day IV divided every 6-8 hours plus cefotaxime (Claforan®) 200 mg/kg/day divided every 6-8 hours
  • Gentamicin (Garamycin®) 7.5mg/kg/day divided every 12 hours
• Infants and children ≥ 1 month of age options:
  • Vancomycin (Vancor®, Vancocin®) 60 mg/kg/day in divided doses every 6 hours plus ceftriaxone (Rocephin®) 80-100 mg/kg/day divided every 12-24 hours
  • Cefotaxime (Claforan®) 225-300 mg/kg/day divided every 6-8 hours

Further antibiotic treatment is determined by the results of culture and sensitivity testing. Treatment with IV antibiotics may continue up to 14 days. Individuals may finish antibiotic therapy at home if they have:

• Received ≥ 6 days of inpatient IV antibiotics
• No fever in the prior 24 to 48 hours
• Found to be neurologically intact
• Reliable IV access
• Safe home environment
• Plan for proper medical follow-up

Treat aseptic meningitis with empiric antibiotic coverage until bacterial meningitis has been ruled out or there is not a clear distinction. Treatment of aseptic meningitis includes identifying the underlying cause. Treatment is primarily supportive care with IV fluids and analgesic medication. There are no antiviral medications indicated for the treatment of aseptic meningitis, except for in the case of herpesvirus. Immediately stop administration of a drug if it suspected of causing aseptic meningitis.

Meningitis Nursing Care Plan

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for meningitis are listed below.

Assessment

• Sick appearance
• Headache
• Fever
• Lethargy
• Nausea and vomiting
• Poor feeding or oral intake
• Vomiting
• Stiff neck or back
• Non-blanchable rash
• Light sensitivity
• Hypothermia
• Seizures
• Irritability
• Bulging fontanelle
• Poor tone
• Apnea
• Weak cry
• Severe
  • Sepsis
  • Shock
  • Disseminated intravascular coagulation
  • Extremity weakness
  • Hydrocephalus
  • Brain abscess
  • Increased intracranial pressure
  • Joint invasion
  • Kidney failure

Meningitis Nursing Diagnosis/Risk For

• Acute pain related to meningeal irritation or elevated intracranial pressure as evidenced by:
  • Verbalization
  • Irritability
  • Stiff neck
• Hyperthermia related to altered thermoregulation secondary to infection as evidenced by elevated body temperature
• Ineffective tissue perfusion related to elevated intracranial pressure as evidenced by:
  • Lethargy
  • Decreased level of consciousness
  • Seizures

Interventions

• Administer IV medications and IV fluids, per order.
• Apply LMX or EMLA cream to site prior to lumbar puncture, if appropriate.
• Droplet precautions for first 24 hours of antimicrobial therapy
• Contact precautions for viral meningitis
• Airborne precautions for M. tuberculosis meningitis
• Assist with diagnostic testing.
• Seizure precautions, if necessary
• Provide psychosocial support to the parent/caregiver.
• Assess, treat, and reassess pain.
• Prophylactic antibiotics for family and close contacts for N. meningitidis
• Monitor:
  • Vital signs
  • Neurologic status
  • Respiratory status
  • Signs of elevated ICP
  • Lab and test results
  • Intake and output
  • Pain

Expected Outcomes

• Verbalize or demonstrate decrease in pain levels
• Maintain normal body temperature
• Maintain fluid volume balance
• Restore normal mental status

Individual/Caregiver Education

• Disease process, treatment, and expected outcomes
• Recommended vaccinations, especially Hib, meningococcal, and pneumococcal
• Proper handwashing technique and hand hygiene
• Clean and disinfect contaminated surfaces
• Avoid close contact with infected individuals
• Home health follow-up instructions
• Medication dosing administration instructions
• Proper care of intravenous line, if applicable
• Prophylactic medication instructions for family and close contacts
• Hearing evaluation follow-up after bacterial meningitis
• Recommended follow-up with medical provider(s)
• Notify medical provider(s) or seek immediate care for return of symptoms or development of:
  • Stiff neck
  • Headache
  • Fever
  • Nausea or vomiting
  • Poor feeding
  • Lethargy

Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2024

Content Contributor

The content was created by Relias staff writer Stephanie Smith, MS, BSN, RN, CPN. She has been a clinical nurse for 25 years. Stephanie was educated and trained in New York State as a Licensed Practical Nurse where she practiced pediatric hematology/oncology nursing at the Children’s Hospital of Buffalo. She earned her Associate in Science in Nursing, Bachelor of Science in Nursing, and Master of Science in Nursing with a concentration in Nursing Leadership and Administration from Excelsior College. She is a Certified Pediatric Nurse (CPN), Pediatric Advanced Life Support (PALS) certified, and is a former PALS instructor. Her clinical expertise is in acute pediatric medical surgical nursing and case management for children with medical complexity. She most recently worked at Duke Children’s Hospital as a Nurse Clinician before coming to Relias.

Resources

• American Academy of Pediatrics- Meningococcal Vaccines https://www.healthychildren.org/english/safety-prevention/immunizations/pages/Meningococcal-Vaccines-What-You-Need-to-Know.aspx
• Centers for Disease Control and Prevention-Bacterial Meningitis https://www.cdc.gov/meningitis/bacterial.html
• Centers for Disease Control and Prevention- Viral Meningitis https://www.cdc.gov/meningitis/viral.html
• Centers for Disease Control and Prevention-The Pink Book: Meningococcal Disease https://www.cdc.gov/vaccines/pubs/pinkbook/mening.html
• Centers for Disease Control and Prevention- Transmission Based Precautions https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/transmission-precautions.html

References

• DynaMed. (2018). Bacterial meningitis in children. EBSCO Information Services. https://www.dynamed.com/condition/bacterial-meningitis-in-children/about
• DynaMed. (2019). Aseptic meningitis. EBSCO Information Services. https://www.dynamed.com/condition/aseptic-meningitis
• Hockenberry, M.J., Rodgers, C.C., & Wilson, D. (2021a). Nonbacterial (aseptic) meningitis. In Wong’s Essentials of Pediatric Nursing (11th ed., pp. 3557). Mosby.
• Hockenberry, M.J., Rodgers, C.C., & Wilson, D. (2021b). Bacterial meningitis. In Wong’s Essentials of Pediatric Nursing (11th ed., pp. 3540-3555). Mosby.
• Schub, T. & Schiebel, D.A. (2018). Meningitis, bacterial, in children. CINAHL Nursing Guide. EBSCO Information Services.
   

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