by identifying a subset of patients at very low risk of bac-
terial meningitis who could, in the appropriate clinical
context, be managed as outpatients after strong consid-
eration of administration of a long-acting parenteral
antibiotic (Dubos et al., 2006b, 2008). Meningitis clinical
prediction rules should be applied cautiously to the youn-
gest infants (2 months of age), who are most likely to
be misclassified and who are the most difficult to eval-
uate clinically. Clinicians also need to be aware that these
prediction models do not identify patients at risk of other
treatable types of central nervous system infections such
as Lyme meningitis or herpes encephalitis.
PRETREATED MENINGITIS
Administration of antibiotics prior to lumbar puncture
may render CSF culture results falsely negative, making
the determination of the appropriate duration of antibi-
otics more difficult (Kanegaye et al., 2001). When bacte-
rial meningitis is clinically suspected, however, empirical
antibiotics should be started without delay even if
the diagnostic lumbar puncture is to be deferred. Antibi-
otic pretreatment has also been shown to affect CSF
profiles by decreasing CSF protein and increasing CSF
glucose without significant effects on CSF cell counts
(Nigrovic et al., 2008). Therefore, clinical prediction
rules for bacterial meningitis should not be applied to
patients pretreated with antibiotics. CSF latex agglutina-
tion tests detect the presence of bacterial antigens in the
CSF but have low sensitivity and limited clinical utility.
TREATMENT
Viral meningitis is treated with supportive measures
alone. Inpatient care is required only for intravenous
hydration and pain control. No currently available anti-
viral agents have activity against enteroviruses. Defini-
tive exclusion of bacterial infections depends on
bacterial culture results, which take several days to reli-
ably exclude bacterial growth. Empirical antibiotics
should be initiated early for all patients with a clinical
concern for bacterial meningitis. For these patients, anti-
biotics should be selected to have a broad antimicrobial
spectrum that covers the likely bacterial pathogens and
known resistance patterns. The duration of antibiotics
should be determined by a combination of clinical pre-
sentation, viral diagnostics, and bacterial culture results.
MENINGOENCEPHALITIS
Children with meningoencephalitis present with acute
onset of altered mental status, focal neurological defi-
cits, ataxia, aphasia, or focal seizures. Most children will
also have an associated fever. Examination of the CSF
typically reveals a mild pleocytosis with a lymphocytic
predominance.
Herpes simplex virus (HSV) is the most commonly
identified cause of encephalitis and occurs in patients
of all ages. Neonates are particularly susceptible to
HSV infection, with most cases transmitted peripartum
(although in utero and postnatal transmission are also
reported). Neonatal HSV meningitis often occurs without
cutaneous findings and typically presents within the first 2
weeks of life. If HSV infection is suspected, CSF should
be obtained for PCR detection as well as routine studies.
Abnormalities in the temporal lobe region on neuroimag-
ing suggest HSV encephalitis, although the viral tropism is
not specific enough to enable definite identification of the
infecting virus. Aciclovir therapy should be initiated pend-
ing diagnostic test results. Children with proven HSV
encephalitis should be treated with intravenous aciclovir
for 21 days as well as long-term suppressive therapy
(Kimberlin et al., 2011). Even after appropriate diagnosis
and treatment, children with HSV encephalitis can have
significant associated morbidity and mortality.
Arthropod-borne viruses cause epidemic encephali-
tis. Because the mosquito is the most common vector,
most cases occur during the summer months when insect
activity is the highest. West Nile encephalitis was first
reported in the West Nile district of Uganda in the
1930s. Now, West Nile virus has been detected in 46
of the states (concentrated in the East and South) as
well as throughout Europe. Other causes of arborviral
encephalitis in the USA include: eastern equine,
La Crosse, St. Louis, and western equine viruses. Ther-
apy for arborvirus infection is largely supportive,
although empirical acyclovir should be considered until
HSV infection can be definitely excluded. Most patients
make a complete recovery, although some patients with
arborviral encephalitis are left with seizure disorder or
persistent neurological deficits.
Influenza virus infection (particularly type A)
has also been rarely associated with encephalitis. The
incidence of neurological complications is highest in
children under 5 years of age. Viral transmission occurs
person to person through respiratory secretions with a
peak incidence during the winter months (January
through February).
Table 119.1
Bacterial Meningitis Score: five high-risk criteria
Positive CSF Gram stain
CSF absolute neutrophil count (ANC) 1000 cells/mm
3
CSF protein 80 mg/dL
Peripheral blood ANC 10 000 cells/mm
3
Presence of a seizure at or prior to presentation
From Nigrovic et al. (2007a).
ASEPTIC MENINGITIS 1155