Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Bacterial meningitis in children older than one month: Treatment and prognosis

Sheldon L Kaplan, MD
Section Editors
Morven S Edwards, MD
Douglas R Nordli, Jr, MD
Deputy Editor
Carrie Armsby, MD, MPH


Suspected bacterial meningitis is a medical emergency, and immediate diagnostic steps must be taken to establish the specific cause so that appropriate antimicrobial therapy can be initiated. The mortality rate of untreated bacterial meningitis approaches 100 percent and, even with optimal therapy, morbidity and mortality may occur. Neurologic sequelae are common among survivors.

The treatment and prognosis of bacterial meningitis in infants and children older than one month will be reviewed here. The pathogenesis, epidemiology, clinical features and diagnosis of acute bacterial meningitis and the treatment and prognosis of bacterial meningitis in neonates (<1 month of age) and adults are discussed separately. (See "Pathogenesis and pathophysiology of bacterial meningitis" and "Bacterial meningitis in children older than one month: Clinical features and diagnosis" and "Bacterial meningitis in the neonate: Treatment and outcome" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults".)


There are a number of general principles of antibiotic therapy in patients with bacterial meningitis. The most important initial issues are avoidance of delay in administering therapy and the choice of drug regimen.

Avoidance of delay — Antibiotic therapy should be initiated immediately after lumbar puncture (LP) is performed if the clinical suspicion for meningitis is high (algorithm 1). Delay in the administration of appropriate antibiotics can have a deleterious effect on outcome for patients who are deteriorating rapidly.

If computed tomography (CT) scan is to be performed before LP, antibiotic therapy should be initiated immediately after blood cultures are obtained, before the CT is performed. Although the administration of antimicrobial therapy before LP may affect the yield of cerebrospinal fluid (CSF) Gram stain and culture, pathogens other than meningococcus usually can be identified in the CSF up to several hours after the administration of antibiotics [1-3]. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis", section on 'Interpretation of CSF in pretreated patients'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Jul 26, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Geiseler PJ, Nelson KE, Levin S, et al. Community-acquired purulent meningitis: a review of 1,316 cases during the antibiotic era, 1954-1976. Rev Infect Dis 1980; 2:725.
  2. Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
  3. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics 2001; 108:1169.
  4. Lutsar I, McCracken GH Jr, Friedland IR. Antibiotic pharmacodynamics in cerebrospinal fluid. Clin Infect Dis 1998; 27:1117.
  5. Finberg RW, Moellering RC, Tally FP, et al. The importance of bactericidal drugs: future directions in infectious disease. Clin Infect Dis 2004; 39:1314.
  6. Friedland IR, Paris M, Ehrett S, et al. Evaluation of antimicrobial regimens for treatment of experimental penicillin- and cephalosporin-resistant pneumococcal meningitis. Antimicrob Agents Chemother 1993; 37:1630.
  7. Cherubin CE, Marr JS, Sierra MF, Becker S. Listeria and gram-negative bacillary meningitis in New York City, 1972-1979. Frequent causes of meningitis in adults. Am J Med 1981; 71:199.
  8. Scheld WM, Sande MA. Bactericidal versus bacteriostatic antibiotic therapy of experimental pneumococcal meningitis in rabbits. J Clin Invest 1983; 71:411.
  9. Hieber JP, Nelson JD. A pharmacologic evaluation of penicillin in children with purulent meningitis. N Engl J Med 1977; 297:410.
  10. Tuomanen EI, Powell KR, Marks MI, et al. Oral chloramphenicol in the treatment of Haemophilus influenzae meningitis. J Pediatr 1981; 99:968.
  11. Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.
  12. Maconochie IK, Bhaumik S. Fluid therapy for acute bacterial meningitis. Cochrane Database Syst Rev 2014; :CD004786.
  13. Kim KS. Bacterial meningitis beyond the neonatal period. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.425.
  14. Feigin RD, McCracken GH Jr, Klein JO. Diagnosis and management of meningitis. Pediatr Infect Dis J 1992; 11:785.
  15. Outpatient management of bacterial meningitis. Pediatr Infect Dis J 1989; 8:258.
  16. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial meningitis in the United States, 1998-2007. N Engl J Med 2011; 364:2016.
  17. Peltola H. Worldwide Haemophilus influenzae type b disease at the beginning of the 21st century: global analysis of the disease burden 25 years after the use of the polysaccharide vaccine and a decade after the advent of conjugates. Clin Microbiol Rev 2000; 13:302.
  18. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
  19. Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics 1998; 102:1087.
  20. Chávez-Bueno S, McCracken GH Jr. Bacterial meningitis in children. Pediatr Clin North Am 2005; 52:795.
  21. Sommers LM, Hawkins DS. Meningitis in pediatric cancer patients: a review of forty cases from a single institution. Pediatr Infect Dis J 1999; 18:902.
  22. Kollmann T, Bortolussi R, MailmanT. Listeriosis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.1329.
  23. Mylonakis E, Hohmann EL, Calderwood SB. Central nervous system infection with Listeria monocytogenes. 33 years' experience at a general hospital and review of 776 episodes from the literature. Medicine (Baltimore) 1998; 77:313.
  24. Marhoum el Filali K, Noun M, Chakib A, et al. Ceftriaxone versus penicillin G in the short-term treatment of meningococcal meningitis in adults. Eur J Clin Microbiol Infect Dis 1993; 12:766.
  25. American Academy of Pediatrics. Meningococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.547.
  26. Jackson LA, Tenover FC, Baker C, et al. Prevalence of Neisseria meningitidis relatively resistant to penicillin in the United States, 1991. Meningococcal Disease Study Group. J Infect Dis 1994; 169:438.
  27. Brown EM, Fisman DN, Drews SJ, et al. Epidemiology of invasive meningococcal disease with decreased susceptibility to penicillin in Ontario, Canada, 2000 to 2006. Antimicrob Agents Chemother 2010; 54:1016.
  28. Lebel MH, Freij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis. Results of two double-blind, placebo-controlled trials. N Engl J Med 1988; 319:964.
  29. Schaad UB, Suter S, Gianella-Borradori A, et al. A comparison of ceftriaxone and cefuroxime for the treatment of bacterial meningitis in children. N Engl J Med 1990; 322:141.
  30. Vallejo JG, Kaplan SL, Mason EO Jr. Treatment of meningitis and other infections due to ampicillin-resistant Haemophilus influenzae type b in children. Rev Infect Dis 1991; 13:197.
  31. American Academy of Pediatrics. Haemophilus influenzae infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.368.
  32. American Academy of Pediatrics Committee on Infectious Diseases: Treatment of bacterial meningitis. Pediatrics 1988; 81:904.
  33. Charpentier E, Gerbaud G, Jacquet C, et al. Incidence of antibiotic resistance in Listeria species. J Infect Dis 1995; 172:277.
  34. Cherubin CE, Appleman MD, Heseltine PN, et al. Epidemiological spectrum and current treatment of listeriosis. Rev Infect Dis 1991; 13:1108.
  35. Spitzer PG, Hammer SM, Karchmer AW. Treatment of Listeria monocytogenes infection with trimethoprim-sulfamethoxazole: case report and review of the literature. Rev Infect Dis 1986; 8:427.
  36. Aguilar J, Urday-Cornejo V, Donabedian S, et al. Staphylococcus aureus meningitis: case series and literature review. Medicine (Baltimore) 2010; 89:117.
  37. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
  38. Beer R, Engelhardt KW, Pfausler B, et al. Pharmacokinetics of intravenous linezolid in cerebrospinal fluid and plasma in neurointensive care patients with staphylococcal ventriculitis associated with external ventricular drains. Antimicrob Agents Chemother 2007; 51:379.
  39. Myrianthefs P, Markantonis SL, Vlachos K, et al. Serum and cerebrospinal fluid concentrations of linezolid in neurosurgical patients. Antimicrob Agents Chemother 2006; 50:3971.
  40. Villani P, Regazzi MB, Marubbi F, et al. Cerebrospinal fluid linezolid concentrations in postneurosurgical central nervous system infections. Antimicrob Agents Chemother 2002; 46:936.
  41. Yogev R, Damle B, Levy G, Nachman S. Pharmacokinetics and distribution of linezolid in cerebrospinal fluid in children and adolescents. Pediatr Infect Dis J 2010; 29:827.
  42. Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007; 41:296.
  43. Kaplan SL, Patrick CC. Cefotaxime and aminoglycoside treatment of meningitis caused by gram-negative enteric organisms. Pediatr Infect Dis J 1990; 9:810.
  44. Fong IW, Tomkins KB. Review of Pseudomonas aeruginosa meningitis with special emphasis on treatment with ceftazidime. Rev Infect Dis 1985; 7:604.
  45. Klugman KP, Dagan R. Randomized comparison of meropenem with cefotaxime for treatment of bacterial meningitis. Meropenem Meningitis Study Group. Antimicrob Agents Chemother 1995; 39:1140.
  46. Sáez-Llorens X, McCracken GH Jr. Antimicrobial and anti-inflammatory treatment of bacterial meningitis. Infect Dis Clin North Am 1999; 13:619.
  47. Paterson DL, Ko WC, Von Gottberg A, et al. Outcome of cephalosporin treatment for serious infections due to apparently susceptible organisms producing extended-spectrum beta-lactamases: implications for the clinical microbiology laboratory. J Clin Microbiol 2001; 39:2206.
  48. Molyneux E, Nizami SQ, Saha S, et al. 5 versus 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Lancet 2011; 377:1837.
  49. Snape MD, Kelly DF. Fine with five? Shorter antibiotic courses for childhood meningitis. Lancet 2011; 377:1809.
  50. Feigin RD, Dodge PR. Personal experience: Unpublished data for prospective studies of bacterial meningitis, 1974-1979.
  51. Waler JA, Rathore MH. Outpatient management of pediatric bacterial meningitis. Pediatr Infect Dis J 1995; 14:89.
  52. Tice AD, Strait K, Ramey R, Hoaglund PA. Outpatient parenteral antimicrobial therapy for central nervous system infections. Clin Infect Dis 1999; 29:1394.
  53. Bradley JS, Ching DK, Phillips SE. Outpatient therapy of serious pediatric infections with ceftriaxone. Pediatr Infect Dis J 1988; 7:160.
  54. Klein JO, Feigin RD, McCracken GH Jr. Report of the Task Force on Diagnosis and Management of Meningitis. Pediatrics 1986; 78:959.
  55. Arditi M, Herold BC, Yogev R. Cefuroxime treatment failure and Haemophilus influenzae meningitis: case report and review of literature. Pediatrics 1989; 84:132.
  56. Lin TY, Nelson JD, McCracken GH Jr. Fever during treatment for bacterial meningitis. Pediatr Infect Dis 1984; 3:319.
  57. Oliveira CR, Morriss MC, Mistrot JG, et al. Brain magnetic resonance imaging of infants with bacterial meningitis. J Pediatr 2014; 165:134.
  58. Steele RW, McConnell JR, Jacobs RF, Mawk JR. Recurrent bacterial meningitis: coronal thin-section cranial computed tomography to delineate anatomic defects. Pediatrics 1985; 76:950.
  59. Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am 1999; 13:711.
  60. Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med 1997; 337:970.
  61. Baraff LJ, Lee SI, Schriger DL. Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J 1993; 12:389.
  62. Mongelluzzo J, Mohamad Z, Ten Have TR, Shah SS. Corticosteroids and mortality in children with bacterial meningitis. JAMA 2008; 299:2048.
  63. Nigrovic LE, Kuppermann N, Malley R, Bacterial Meningitis Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era. Acad Emerg Med 2008; 15:522.
  64. Husain E, Chawla R, Dobson S, et al. Epidemiology and outcome of bacterial meningitis in Canadian children: 1998-1999. Clin Invest Med 2006; 29:131.
  65. Roine I, Peltola H, Fernández J, et al. Influence of admission findings on death and neurological outcome from childhood bacterial meningitis. Clin Infect Dis 2008; 46:1248.
  66. Fortnum HM. Hearing impairment after bacterial meningitis: a review. Arch Dis Child 1992; 67:1128.
  67. Wald ER, Kaplan SL, Mason EO Jr, et al. Dexamethasone therapy for children with bacterial meningitis. Meningitis Study Group. Pediatrics 1995; 95:21.
  68. Dodge PR, Davis H, Feigin RD, et al. Prospective evaluation of hearing impairment as a sequela of acute bacterial meningitis. N Engl J Med 1984; 311:869.
  69. Pelkonen T, Roine I, Monteiro L, et al. Risk factors for death and severe neurological sequelae in childhood bacterial meningitis in sub-Saharan Africa. Clin Infect Dis 2009; 48:1107.
  70. Roine I, Weisstaub G, Peltola H, LatAm Bacterial Meningitis Study Group. Influence of malnutrition on the course of childhood bacterial meningitis. Pediatr Infect Dis J 2010; 29:122.
  71. Kornelisse RF, Westerbeek CM, Spoor AB, et al. Pneumococcal meningitis in children: prognostic indicators and outcome. Clin Infect Dis 1995; 21:1390.
  72. Kaplan SL, Schutze GE, Leake JA, et al. Multicenter surveillance of invasive meningococcal infections in children. Pediatrics 2006; 118:e979.
  73. Taylor HG, Schatschneider C, Watters GV, et al. Acute-phase neurologic complications of Haemophilus influenzae type b meningitis: association with developmental problems at school age. J Child Neurol 1998; 13:113.
  74. Lebel MH, McCracken GH Jr. Delayed cerebrospinal fluid sterilization and adverse outcome of bacterial meningitis in infants and children. Pediatrics 1989; 83:161.
  75. American Academy of Pediatrics. Pneumococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.626.
  76. Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2006; :CD004884.