Meningitis in neonates and children younger than 2 months

Neonates and children younger than 2 months with meningitis often present with nonspecific signs of sepsis rather than the classical signs of meningitis. Early consultation with an experienced clinician is required for all cases of suspected meningitis in neonates and infants.

The following recommendations apply to neonates and children younger than 2 months who are being treated in hospital. For neonates and children younger than 2 months presenting with meningitis in the community, see Prehospital management of suspected meningitis.

Ideally obtain microbiological samples (eg cerebrospinal fluid [CSF], blood) before starting empirical antimicrobial therapy. However, if there is a significant delay in performing investigations, do not withhold empirical treatment.

Note: Do not withhold empirical treatment for suspected bacterial meningitis if there is a significant delay in performing investigations.

If the pathogen or susceptibility is unknown, start empirical antimicrobials as soon as possible, ideally within 1 hour of presentation to hospital, regardless of whether a prehospital dose of ceftriaxone or benzylpenicillin was given.

Note: Start empirical therapy as soon as possible, regardless of whether the neonate or child received a prehospital dose of ceftriaxone or benzylpenicillin.

For neonates and children younger than 2 months, the most likely pathogens are Streptococcus agalactiae (group B streptococcus), enteric gram-negative bacilli. Rarely, and generally only in children up to 1 month of age, Listeria monocytogenes is also seen.

For neonates and children younger than 2 months, treat as for sepsis or septic shock, using the regimens for children in whom meningitis has not been excluded. For children 1 month to younger than 2 months, choice of empirical therapy depends on whether the child has been in hospital or is presenting from the community; use either:

For neonates, choice of empirical therapy depends on the neonate’s age and whether the neonate has been in the community since birth.

For neonates who develop meningitis within 72 hours of birth, see Neonates with early onset sepsis or septic shock who are severely unwell and may have meningitis.
For neonates who develop meningitis 72 hours or more after birth, if the neonate has remained in hospital since birth, see here, and if the neonate was admitted from the community, see here.

Complications during therapy, such as ventriculitis or abscess, are not infrequent – seek expert advice.

Dexamethasone is not indicated in neonates and children younger than 2 months because there is insufficient evidence to support its use.