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A 4-week-old baby presented to the emergency department with apparent septic shock. She required 60 mL/kg of fluid boluses prior to transfer to intensive care for inotropes and ventilation. She was given intravenous cefotaxime and intravenous amoxicillin as per local protocol. There were no risk factors for sepsis. Forty-eight hours later, when clinically stable, she had a lumbar puncture (LP). This showed white cells 45 x 106/L, red cells 14 000 x 106/L and glucose 2.2 mmol/L. Protein count was unavailable due to blood-stained sample. Cytospin showed a neutrophil predominance of 73%. Gram stain and culture were negative, as were blood cultures. Meningococcal and pneumococcal PCR were also negative. Following discussion, we concluded that bacterial meningitis was likely despite no identified organism, especially given she had 48 hours of antibiotics prior to performing LP. Decision for a prolonged course of intravenous antibiotics was therefore necessary.
Structured clinical question
In (patient) infants, children and adolescents with presumed meningitis, how does (intervention) antibiotic pretreatment compared with (comparison) no antibiotic pretreatment affect the diagnostic value of (outcome) cerebrospinal fluid?
Search strategy and outcome
MEDLINE (1946–2016) and EMBASE (1974–2016) were searched using the search strings: (adolescent OR child OR infant OR paediatric OR pediatric) AND (meningitis) AND (antibiotic OR antibiotic agent OR antibiotic therapy OR anti-bacterial agents) AND (empiric OR pre treat OR pretreat OR time interval OR time to treatment) AND (cerebrospinal fluid OR CSF OR lumbar puncture OR spinal fluid). The search was then limited to English language. This identified 253 articles in MEDLINE and 295 in EMBASE. A total of four articles were then reviewed (table 1). The references of these articles were reviewed and no additional studies were identified.
Bacterial meningitis in childhood carries a significant morbidity and mortality, which worsens with delayed treatment. Accurate and rapid diagnosis is important to enable appropriate treatment. Clinical prediction …
Contributors MM: review of literature and writing of manuscript. IDW: review of literature and editing of manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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