This document discusses the management of bacterial meningitis in children. It defines bacterial meningitis and related terms. The most common causes are Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae type b. Risk factors include age and immune deficiencies. Diagnosis involves lumbar puncture and cerebrospinal fluid analysis showing pleocytosis, low glucose, and high protein. Treatment involves intravenous antibiotics and management of increased intracranial pressure. Outcomes depend on early diagnosis and treatment.

1. MANAGEMENT OF BACTERIAL
MENINGITIS in children.
Dr. Arun K. M
JR III
IMS.BHU
VARANASI
Page 1

2. DEFINITIONS:
• BACTERIAL MENINGITIS (BM): An acute purulent
infection of the cranial and spinal leptomeninges due to
bacterial etiology.
• ENCEPHALITIS: Inflammation of the brain parenchyma.
• MENINGOENCEPHALITIS: Inflammation of the
leptomeninges and the brain parenchyma.
• ASEPTIC MENINGITIS: Refers to CSF findings consistent
with leptomeningeal inflammation but routine bacterial culture
are negative.
Page 2

3. INTRODUCTION:
• Bacterial meningitis remains a major cause of mortality and neurological
sequelae worldwide. In India and other developing countries the
mortality rate ranges from 16-32%.
• The community incidence of acute BM in India is not known. The exact
etiological diagnosis is often not possible. There are limited studies from
India regarding the etiology and epidemiological factors associated with
BM.
• Delay in diagnosis and initiation of antimicrobial therapy can result in
poor outcome. Since clinical signs of meningitis cannot always be relied
upon, laboratory support is imperative to achieve an early diagnosis.
• Due to emergence of antimicrobial resistance recommendations for
therapy are changing.
• Laboratory surveillance of isolates is crucial to identify for
immunization, chart preventive strategies and to help formulate rational
empirical treatment for potentially fatal BM.
Page 3

4. ETIOLOGY: The etiology of BM is affected most by the age of
the patient.
Neonate:Early-onset acquisition S.
agalactiae, E.coli, K.pneumoniae, Enterococci,
L. monocytogenes
Neonate:Late-onset infection S. aureus, Gram-negative enteric bacilli,
P. aeruginosa
Age: 1–3 months Same as early-onset in neonate + S.pneumoniae,
N. meningitidis, and H.influenzae type b.
Age: 3 months to 5 years S. pneumoniae, N. meningitidis and H.
influenzae type b.
Age: >5 years children and adults S. pneumoniae and N. meningitidis.
Page 4

5. RISK FACTORS:
A major risk factor for BM is the lack of immunity to specific
pathogens associated with young age.
PRECIPATING FACTORS ORGANISMS
Defects of complement system(C5- Meningococcus
C8) and properdin system
Splenic dysfunction or asplenia Pneumococcus, H.influenzae type b.
T-Lymphocyte defect(aids, cancer, Listeria monocytogenes
chemotherapy and congenital)
CSF leak and cochlear implants Pneumococcus
Lumbosacral dermal sinus and Staph. aureus, Gram negative entric
meningomyelocele bacilli e.g: E.coli, Klebsiella etc.
CSF shunts Coagulase negative Staphylococci,
Staph. aureus.
Page 5

6. PATHOGENISIS AND PATHOPHYSIOLOGY:
• Bacteria reach the CNS either by hematogenous spread or by
direct extension from a contiguous site.
• In neonates, pathogens are acquired from non- sterile maternal
genital and intestinal secretions.
• Direct inoculation of bacteria into the CNS can result from
trauma, skull defects with CSF leaks, congenital dura defects
such as a dermal sinuses or meningomyelocele, or extension
from a suppurative parameningeal focus.
Page 6

7. Bacteraemia Endothelial damage Bacteria in CSF
Pro-inflammatory cytokines
Permeability of Leucocyte attraction and CSF Cerebral
blood-brain barrier entrance: meningeal inflammation vasculitis
Vasogenic edema Interstitial edema Cytotoxic edema Cerebral blood
flow: Ischaemia
Intracranial
pressure
Bloodstream Global perfusion Release of
volaemia excitatory amino
acidsaminoacids
Neuronal injury
apoptosis
Page 7

8. CLINICAL FEATURES:
• Manifestations of BM depend on the age of the patient and
duration of disease.
• In general, the younger the patient the more subtle and atypical
are the signs and symptoms.
• Onset of acute BM has two forms :
i. The sudden onset rapidly progressive manifestation of shock,
purpura, DIC, reduced level of consciousness leading to death
in 24hrs.
ii. Common form with-
a. Non specific findings- fever(84%),
headache(76%),vomiting(70%), anorexia(19%) , poor
feeding, symptoms of URTI, myalgia, arthralgia,
tachycardia, petechiae, rash etc.
b. Alteration in mental status like irritability, lethargy,
stupor or coma(5%). Page 8

9. c. Seizure (20-30%): focal or generalised and as result of cerebritis,
infarction or electrolyte disturbance.
d. Signs of meningeal irritation(59%)- neck stiffness(65%),
kernigs sign(27%) and brudzinski sign(51%).
e. Signs of increased ICT include headache, projectile vomiting,
reduced (GCS≤8) or fluctuating level of conciousness, abducent
nerve palsy, cushing’s reflex, un-equal dilated pupils,
papilloedema, decorticate or decerebrate posturing, stupor, coma,
signs of herniation.
g. Cranial neuropathy- Most common cranial nerves involved
include 3rd, 6th, 7th and 8th.
h. Focal cerebral signs (20%) - due to cortical necrosis, occlusive
vasculitis, cerebritis, abscess.
Page 9

10. NEONATES
a) Neonates and infants have nonspecific signs like
fever, hypothermia, irritability, lethargy and feeding difficulty.
b) Neurologic signs- Excited or depressed and bulging
fontanel. Minor convulsions present as blinking eyes, fixed
stare, facial twitching and sucking.
 No clinical feature is diagnostic in isolation, and the most
accurate combination of clinical features to rise or lower suspicion
of meningitis is still unclear.
Pediatrics 2010; 126:952-960.
Page 10

11. MANAGEMENT OF BACTERIAL MENINGITIS:
Symptoms and signs of BM
YES
Check airway, breathing &circulation; gain vascular access
YES
Manage accordingly
Signs of shock and raised ICP
NO
Perform diagnostic tests
NO
Contraindication to LP Perform LP
YES
YES
<3 months old ? CSF s/o meningitis
YES NO
Empiric antibiotics for suspected Empiric antibiotic for suspected
meningitis: Do not delay antibiotic meningitis : i.v Cefetriaxone.
i.v Cefotaxime + iv ampicillin No role of steroids.
Add vancomycin, if prolonged Or multiple antibiotic exposure within last 3
months
If HSV meningoencephalitis in differential diagnosis give i.v acyclovir
Cont’d Page 11

12. Reduced or fluctuating conscious level or focal neurological signs
NO YES
Full volume maintenance fluid [Isotonic fluid-DNS or NS]. Perform CT scan
Do not restrict fluid unless there is SIADH or raised ICT.
Monitor fluid administration, urine output,electrolytes and blood
glucose.
Close monitoring for signs of raised ICP ,shock and repeated review.
If LP contra-indicated, perform delayed LP when no longer contra-
indicated.
Specific pathogen identified
YES NO
Antibiotics for confirmed meningitis. Antibiotics for unconfirmed
meningitis.
<3 months old?
NO
YES
i.v cefotaxime + ampicillin i.v for ≥14 days Ceftriaxone ≥ 10 days
Page 12

13. Initial management:
• Check airway, breathing, circulation, disability (level of
consciousness) and environment (presence of rash, temperature
control).
• Elective intubation and ventilation if necessary.
• If signs of shock present manage accordingly with normal
saline boluses and vasopressor support.
• Seizures managed with anticonvulsants like phenytoin and
midazolam.
• After the patient has been stabilised further examination and
diagnostic tests performed.
Page 13

14. Management of raised ICP.
• Early intubation if; GCS <8, Evidence of herniation, Apnea,
Inability to maintain airway.
• Mild head elevation of 15–30 (Ensure that the child is
euvolemic).
• Hyperventilation: Target PaCO2: 30–35 mm Hg (suited for acute,
sharp increases in ICP or signs of impending herniation).
• Mannitol: Initial bolus: 0.25–1 g/kg, then 0.25–0.5 g/kg, q 2–6 h
as per requirement, up to 48 hrs.
• Hypertonic Saline: Preferable in presence of Hypotension,
Hypovolemia, Serum osmolality >320 mOsm/kg, Renal failure,
Dose: 0.1–1 ml/kg/hr infusion, Target Na+−145–155 meq/L.
Page 14

15. • Adequate sedation and analgesia.
• Prevention and treatment of seizures: use Lorazepam or
midazolam followed by phenytoin as initial choice.
• Avoid noxious stimuli: use lignocaine prior to ET suctioning
[nebulized (4% lidocaine mixed in 0.9% saline) or intravenous
(1–2 mg/kg as 1% solution) given 90 sec prior to suctioning].
• Control fever: antipyretics, cooling measures.
• Maintenance IV Fluids: Only isotonic or hypertonic fluids
(Ringer lactate, 0.9% Saline, 5% D in 0.9% NS), No
Hypotonic fluids.
• Maintain blood sugar: 80–120 mg/dL.
• Refractory raised ICP - Barbiturate coma, Hypothermia and
Decompressive craniectomy.
Page 15

16. Routine investigations:
• Complete blood count: Neutrophilia suggestive of bacterial
infection.
• Serum glucose: Often low; allows interpretation of CSF glucose.
• Electrolytes, urea, and creatinine :To assess for complications and
fluid management.
• Coagulation studies: To assess for complications.
• Blood cultures: Positive in 40–90% depending on the organism.
• Inflammatory markers(CRP and procalcitonin): Elevation
suggestive of bacterial infection; procalcitonin(≥5ng/mL) of more
value; neither can establish nor exclude diagnosis.
Page 16

17. CEREBROSPINAL FLUID EXAMINATION.
• CSF analysis and culture remains the definitive method for
diagnosis of BM.
• Lumbar puncture (LP) should be performed when BM is
suspected. In neonates, meningitis accompanies sepsis in 20-25%
of cases so procedure to be considered.
• If LP is delayed empirical antibiotic should be started within 1hr.
• Contraindications to LP:
a. Absolute (lumbar puncture is not to be done)
i. Signs of raised intracranial pressure (papilloedema, decrebrate
posturing)
ii. Local skin infection at the LP site.
iii. Evidence of obstructive hydrocephalus, cerebral oedema or
herniation in CT (or MR) scan of brain
Page 17

18. b. Relative (appropriate therapeutic measures and/or investigations
are indicated before lumbar puncture)
i. Shock or hypotension
ii. Coagulation disorder
iii. Presence of focal neurological deficit, especially when
posterior fossa lesion is suspected.
iv. Glasgow coma score of 8 or less.
v. Continuing seizure activity.
NORMAL CSF VALUES
Neonate Child
Total WBC (mm3) ≤20 <5
DLC-NEUTROPHILS Up to 5% none
Protein (mg/dL) <100 10-40
Glucose (mmol/L) ≥2.1 ≥2.5
CSF/serum glucose ≥0.6 ≥0.6
Page 18

19. Typical CSF Parameters in Patients with Meningitis
Pathogen White blood Percentage Glucose Protein level Positive CSF stain
cells per μL of level in mg per dL
neutrophils
Pyogenic > 500 > 85-90 Low > 100-200 ~70 percent
L. monocytogenes > 100 >50 Normal > 50 ~30 percent
Partially treated > 100 >80 Normal > 70 ~60 percent
pyogenic
Aseptic, often 10 to 1,000 Early: > 50 Normal Normal or < Not applicable
viral Late: < 20 100
Tubercular 50 to 500 < 30 Low > 100 Rare
Fungal 50 to 500 < 30 Low Varies High in
cryptococcus
CSF = cerebrospinal fluid.
Page 19

20. • Early in illness, CSF cell count can be normal despite a
positive CSF culture.
• Glucose concentration usually is decreased with a CSF to
serum glucose ratio of 0.6 or less in neonates and 0.4 or less in
children older than 2 months of age.
• Gram stain is positive in 80-90% of untreated cases with lower
limit of detection of about 105 CFU/mL.
• CSF culture not routinely recommended because the yield
decreases (80 to <50%) soon after antibiotic therapy (except
gram negative Enteric bacilli) and isolates recovered are
frequently contaminants.
Page 20

21. • CSF cell count and glucose and protein concentrations generally
remain abnormal for several days even after initiating appropriate
antibiotic therapy.
• Latex agglutination tests and PCR to detect bacterial capsular
antigens is useful in some patients with prior antibiotic therapy.
• Traumatic LP makes interpretation difficult. Leukocytes and
protein are affected; gram stain, culture and glucose are not
affected. A more accurate method is to calculate the predicted
CSF WBC count by this formula.
Peripheral WBC/RBC count× CSF RBC count = CSF WBC count
Page 21

22. Other tests on CSF:
• Latex agglutination : Rapid; not 100% specific or diagnostic.
Latex agglutination depends on laboratory availability; including
N. meningitidis, S. pneumoniae, H. influenzae type
b, Escherichia coli and group B streptococci.
• PCR: Rapid; good sensitivity, techniques improving. PCR
depends on laboratory availability; including N.
meningitidis, S. pneumoniae, H. influenzae type b, L.
monocytogenes, HSV, CMV, Enterovirus and Mycobacterium
tuberculosis.
• Lactate : Routine use not currently recommended
Page 22

23. INDICATION FOR REPEAT LP:
• Lack of clinical improvement in 48-72 hrs.
• Meningitis caused by resistant S. pneumonia strains or by
gram negative enteric bacilli.
• In neonate with gram negative bacillary
meningitis, examination of CSF during treatment after 48-72
hrs of initiation of treatment is necessary to verify that culture
are sterile.
DO NOT PERFORM REPEAT LP IF:
 Who are receiving appropriate antibiotics and making good
clinical recovery.
 Before stopping antibiotic therapy if patient is clinically well.
Page 23

24. RADIALOGICAL DIAGNOSIS:
• Cranial computed tomography (CT) is of limited use in acute
BM. CT in cerebral oedema may show slit-like lateral ventricle
and areas of low attenuation.
• Diffuse meningial enhancement may be seen.
• The main indications for a CT scan in meningitis when it is
preferred as a first line investigation prior to LP are:
a. Signs of ↑ICT (e.g. papilloedema)
b. Suspecting malignancy( focal neurological deficits).
c. Deteriorating neurological status.
d. Previous neurosurgical procedure or trauma.
e. Immunocompromised.
• Normal CT scan does not exclude the risk of raised ICT.
Page 24

25. Page 25

26. DIFFERENTIAL DIAGNOSIS OF ACUTE BACTERIAL
MENINGITIS:
• Other infective meningitis or meningoencephalitis
(viral, tuberculous, fungal and parasitic).
• Focal infection (Brain abscess, subdural emphysema, cranial
and spinal epidural abscess).
• Non infective illness ( malignancy, collagen vascular
syndrome and exposure to toxins).
Page 26

27. Clinical Decision Rules to Distinguish Bacterial from Aseptic Meningitis in Children with CSF Pleocytosis*
Rule Bacterial Meningitis Score Meningitest
Exclusion criteria 1. Neurosurgical history 1. Neurosurgical history
2. Immunosuppression 2. Immunosuppression
3. CSF red blood cell count ≥ 0.01 × 106 3. CSF red blood cell count ≥ 0.01 ×
per μL 106 per μL
4. Antibiotic use in the previous 48 4. Antibiotic use in the previous 48
hours hours
5. Purpura
Criteria (further evaluation, 1. Positive CSF Gram stain 1. Positive CSF Gram stain
including lumbar puncture, is needed 2. Seizure 2. Seizure
in patients with one or more 3. Blood neutrophil count ≥ 10,000 per 3. Purpura
findings) μL 4. Toxic appearance (irritability,
4. CSF neutrophil count ≥ 1,000 per μL lethargy, or low capillary refill)
5. CSF protein level ≥ 80 mg per dL 5. CSF protein level ≥ 50 mg per dL
6. Serum procalcitonin level ≥ 0.5
ng per mL
Sensitivity (95% confidence 99 percent (99 to 100) 100 percent (96 to 100)
interval)
CSF = cerebrospinal fluid. Curr Opin Neurol. 2009;22(3):292
*—White blood cell count ≥ 10 per μL Page 27

28. Antibiotic management:
i. Key is to start promptly.
ii. Antibiotic choice is based on
-Ability of CSF penetration and its concentration.
-Bactericidal property.
Page 28

29. Penetration and estimated bactericidal power of antibiotics
used for treatment of bacterial meningitis:
Antibiotic CSF penetration Bactericidal power* against
β- lactam β- lactam
susceptible resistant
pathogens pathogens
Penicillin/ampicillin 5–15% 1–10 <1
Chloramphenicol >20% >10 NA
Cefotaxime/ceftriaxone 5–15% >10 1–10
Cefepime/meropenem 5–15% >10 1–10
Vancomycin <5% 1–10 1–10
Fluoroquinolones >20% >10 >10
Rifampicin >20%
*concentration in CSF over the minimal bactericidal concentration against the isolated pathogen. Page 29

30. Recommended initial empiric selection of antibiotics for previously
healthy children with suspected bacterial meningitis, by age and
epidemiological situation
Patients Likely pathogens Antibiotic
Neonate- S agalactiae, E. coli, Ampicillin+cefotaxime/amikacin
Early-onset acquisition
K pneumoniae, enterococci,
L monocytogenes
Neonate- S aureus, gram-negative Nafcillin (flucloxacillin) or
Late-onset infection
enteric bacilli, P aeruginosa Vancomycin+ceftazidime ± amikacin
Age: 1–3 months Same as early-onset in neonate Ampicillin+cefotaxime or
+ S pneumoniae, ceftriaxone
N meningitidis,and H influenza
Age: 3 months to 5 S pneumoniae, N meningitidis, Cefotaxime or ceftriaxone
years
and H influenzae
Age: >5 years children S pneumoniae and N Cefotaxime or ceftriaxone
and adults meningitidis.
In areas with moderate Multi-resistant pneumococci Cefotaxime or ceftriaxone
or greater prevalence + vancomycin(consider
of resistant S addition of rifampicin)
pneumonia
Page 30

31. Suggested pathogen-specific antimicrobial therapy for children
with bacterial meningitis
Bacteria Antibiotic of choice Other useful antibiotics
N. meningitidis Penicillin G or ampicillin Cefotaxime or ceftriaxone
H. Influenzae type b Cefotaxime or ceftriaxone Ampicillin, chloramphenicol
S. pneumoniae:
Penicillin-susceptible Penicillin G, ampicillin Cefotaxime or ceftriaxone
(MIC<0·1 mcg/mL)
Penicillin-intermediate Cefotaxime or ceftriaxone Cefepime or meropenem
(MIC=0·1–1·0 mcg/mL) plus vancomycin when
MIC >0·5 mcg/mL
Penicillin-resistant Cefotaxime or ceftriaxone Cefepime or meropenem
(MIC>1·0 mcg/mL) plus vancomycin plus vancomycin
Cephalosporin-resistant Cefotaxime or ceftriaxone Adding rifampicin
(MIC>0·5 mcg/mL) plus vancomycin New fluoroquinolones?
L. monocytogenes Ampicillin+gentamicin Trimethoprim-sulfamethoxazole
S. agalactiae Penicillin G+gentamicin Ampicillin+gentamicin
Enterococcus species Ampicillin+aminoglycoside Vancomycin+aminoglycoside
Enterobacteriaceae Cefotaxime or ceftriaxone Cefepime or meropenem
P. aeruginosa Ceftazidime+aminoglycoside Cefepime or meropenem
MIC=minimum inhibiting concentration.
Page 31

32. Guidelines for the duration of antibiotic therapy.
Pathogen Suggested duration
Of therapy(days)
H. influenza 5-7
N. meningitides 7-10
S. pneumonia 10-14
L. monocytogenes ≥21
Group B streptococci 14-21
Gram-negative bacilli (other than 21or 2 wks beyond 1st sterile culture
H. influenzae) (whichever is longer)
Page 32

33. Adjunctive and supportive treatment:
1. Fluid management:
{NICE clinical guidelines 2012 and Starship children’s health clinical
guidelines 2009}
i. Resuscitation with normal saline bolus if required.
ii. Fluid therapy should focus on avoiding hypovolemia and hypo-
osmolality.
iii. Fluid type should be 0.9% NaCl with 5% dextrose (10% may require in
infants).
iv. Give full volume maintenance fluids with appropriate adjustment for
ongoing losses unless there is SIADH or raised ICT.
v. Hyponatremia at presentation can usually be assumed to be dilutional
, on the basis of elevated level of ADH. Increased ADH is due to
• Appropriate secretion to compensate for hypovolemia or to
maintain cerebral perfusion in the presence of cerebral edema →
Full volume maintenance fluid.
• Inappropriate secretion due to brain damage and which might
contribute to further brain damage → Restriction of fluid may be
needed.
Page 33

34. vi. Ongoing management
• Frequent clinical review, including a careful assessment of
volume status.
• Check serum sodium 6-12hrly depending on the initial sodium
level, ongoing fluid losses, clinical status and whether there is
fluid restriction in place.
• In hyponatremia child on fluid restriction, fluid can be
increased slowly as condition improves and serum sodium
normalises.
There is evidence to support not restricting fluid for children in
developing countries where death rate are high and disease is
often advanced at presentation.
{The Cochrane Library 2011, issue 2}
Page 34

35. 2. Role of steroids and glycerol:
1. Corticosteroids significantly reduced hearing loss and
neurological sequelae, but did not reduce overall mortality.
Data support the use of corticosteroids in patients with
bacterial meningitis in high-income countries, but no
beneficial effect in low-income countries.
{Cochrane database sys rev. 2010 sep;8(9).
2. Adjunctive dexamethasone in the treatment of acute bacterial
meningitis does not seem to significantly reduce death or
neurological disability. The benefit of adjunctive
dexamethasone for all or any subgroup of patients with
bacterial meningitis thus remains unproven.
{Lancet Neurol. 2010 Mar;9(3)}
Page 35

36. 3. No significant difference was seen in neurological or hearing
outcome with use of either glycerol or dexamethasone in
children with acute bacterial meningitis.
{Indian Pediatr. 2007 Sep;44(9) }
4. With bacterial meningitis, the child's presenting status and
young age are the most important predictors of hearing
impairment. Little relief is obtained from current adjuvant
medications like dexamethasone and glycerol.
{Pediatrics. 2010 Jan;125(1)}
Page 36

37. COMPLICATIONS:
1.Early complications:
• Ventriculitis.
• Fluid and electrolyte disturbance.
• SIADH.
• Seizures.
• Increased ICP.
• Cranial nerve palsies.
• Stroke.
• Cerebral or cerebellar herniation.
• Thrombosis of the dural venous sinuses.
• Sub-dural effusion and empyema.
• Prolonged fever or secondary fever.
Page 37

38. 2. Late complications:
• Hearing loss.
• Mental retardation.
• Recurrent seizures.
• Delaying accusation of language.
• Visual impairment.
• Behavioural problems.
• Hydrocephalous.
Page 38

39. PROGNOSIS:
Factors affecting the outcome
1) Age.
2) Etiology.
3) CSF findings at the time of diagnosis- concentration of
bacteria or its products, WBC count and glucose
concentration (<20mg/dL).
4) Time to sterilization of CSF after start of therapy.
5) Decreased level of consciousness.
6) Seizures occurring during hospitalization.
7) Presence of comorbid conditions
Page 39

40. PREVENTION:
1.VACCINATION-
• Immunisation is the most effective means of prevention BM in
children.
• IAP recommends routine use of Hib vaccine in children with
efficacy rate against invasive infection ranges from 70-100%.
• IAP recommends pnemococcal and meningococcal vaccination
for high risk children as vaccines under special circumstances.
• Only meningococcal polysaccharide (MPSV) is avalaible.
Minimal age- 2 yrs. Revaccination only once after 3yrs in those
at continued high risk.
• Minimum age for administration- 6wks for pnemococcal
conjugate vaccine(PCV) and 2yrs for polysaccharide
vaccine(PPSV). Administer 1 dose of PCV to all children aged
24 through 59mts who are not immunised for age. PPSV
revaccination only once after 35yrs only in certain high risk
patients.
• PCV must be offered to premature and low birth weight infants.
• S.agalactiae vaccinaton for pregnant women in future.
Page 40

41. Chemoprophylaxis for Bacterial Meningitis
Pathogen Indication Antimicrobial agent Dosage Comments
Neisseria meningitidis Close contact (for more Rifampin Adults: 600 mg every 12 hours Not fully effective and
(postexposure than eight hours) with Or for two days rare resistant isolates
prophylaxis)
someone with N. Children one month or older:
meningitidis infection 10 mg per kg every 12 hours
Contact with oral for two days
secretions of someone Children younger than one
with N. meningitidis month: 5 mg per kg every 12
infection hours for two days
Ciprofloxacin (Cipro) Adults: single dose of 500 mg Rare resistant isolates
Or
Ceftriaxone (Rocephin) Single intramuscular dose of __
250 mg (125 mg if younger
than 15 years)
Haemophilus influenzae Living in a household Rifampin 20 mg per kg per day, up to 600 ___
(postexposure with one or more mg per day, for four days
prophylaxis) unvaccinated or
incompletely vaccinated
children younger than 48
months
Streptococcus agalactiae Previous birth to an infant Penicillin G Initial dose of 5 million units Clindamycin
(group B streptococcus; with invasive S. Or intravenously, then 2.5 to 3 susceptibility must be
women in the intrapartum million units every four hours confirmed by
period) agalactiae infection during the intrapartum period antimicrobial
Colonization at 35 to 37 susceptibility test
weeks’ gestation If allergic to penicillin: 2 g followed by 1 g every eight
hours
Bacteriuria during Cefazolin
pregnancy or
High risk because of
fever, amniotic fluid Clindamycin (Cleocin) 900 mg every eight hours
rupture for more than 18 or
hours, or delivery before
37 weeks’ gestation Vancomycin 15 to 20 mg per kg every 12
hours Page 41
Am Fam Physician. 2010;82(12):1491-1498.

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