Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Bacterial Meningitis & Septic Shock

Comprehensive emergency evaluation and protocolized resuscitation of acute bacterial meningitis and septic shock in pediatric patients: age-stratified microbiology (GBS, E. coli, Listeria in neonates; Streptococcus pneumoniae, Neisseria meningitidis in older infants/children), purpura fulminans/Waterhouse-Friderichsen syndrome, CSF analysis and opening pressure interpretation, immediate empiric IV antibiotic dosing within 60 minutes, Dexamethasone prior to or with the first antibiotic dose for Hib/pneumococcal hearing loss prevention, and ACCM vasoactive resuscitation pathways (epinephrine for cold shock, norepinephrine for warm shock).

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

First Dose Antibiotic (60 min)

Never delay antibiotics for lumbar puncture or head CT! Vancomycin 15 mg/kg IV + Ceftriaxone 100 mg/kg IV within 60 min of arrival

Dexamethasone Timing

0.15 mg/kg IV administered PRIOR TO or SIMULTANEOUSLY with the first dose of antibiotics; reduces sensorineural hearing loss

Neonatal Meningitis Regimen

Infants < 28 days: Ampicillin 100 mg/kg IV q8h + Cefotaxime 50 mg/kg IV q6h (or Gentamicin); avoid ceftriaxone (kernicterus)

Purpura Fulminans Warning

Rapidly spreading petechial/purpuric rash = Meningococcemia; high risk of Waterhouse-Friderichsen adrenal hemorrhage and circulatory collapse

Pediatric Cold Shock

Cold extremities, delayed capillary refill > 3s, weak pulses: first-line vasoactive is EPINEPHRINE (0.05–0.3 mcg/kg/min)

Pediatric Warm Shock

Bounding pulses, flash capillary refill < 1s, wide pulse pressure: first-line vasoactive is NOREPINEPHRINE (0.05–0.3 mcg/kg/min)

Bottom-Line Clinical Pearl

Pediatric bacterial meningitis and septic shock are hyperacute medical emergencies with high mortality and devastating neurologic sequelae. In older infants and children, Streptococcus pneumoniae and Neisseria meningitidis dominate. Classic signs (Kernig, Brudzinski, nuchal rigidity) are notoriously ABSENT in infants < 12–18 months; look for bulging fontanelle, paradoxical irritability (crying more when held), high-pitched cry, and purpuric rash. Administer IV antibiotics within 60 minutes of triage: Vancomycin (15 mg/kg IV) + Ceftriaxone (100 mg/kg IV, or Cefotaxime in neonates) + Dexamethasone (0.15 mg/kg IV prior to or with first antibiotic dose to reduce sensorineural hearing loss). For pediatric septic shock, prioritize rapid isotonic crystalloid boluses (10–20 mL/kg up to 40–60 mL/kg) and start early Epinephrine infusion (0.05–0.3 mcg/kg/min) for cold shock with poor perfusion.

1. Age-Stratified Microbiology & Empiric Antimicrobial Regimens

Bacterial pathogens penetrate the nasopharyngeal mucosa, invade the bloodstream, and seed the choroid plexus and subarachnoid space. Bacterial cell wall breakdown releases endotoxins, peptidoglycans, and teichoic acid, triggering massive microglial and astrocytic production of TNF-alpha, IL-1beta, and IL-6, resulting in cerebral endothelial breakdown, vasogenic and cytotoxic cerebral edema, raised intracranial pressure (ICP), and cortical neuronal apoptosis.

Patient Age Tier	Dominant Bacterial Pathogens	Empiric Intravenous Antimicrobial Regimen
0 to 28 Days (Neonates)	Group B Streptococcus (GBS), Escherichia coli (K1 capsular strain), Listeria monocytogenes, Klebsiella pneumoniae	Ampicillin (100 mg/kg IV q8h) + Cefotaxime (50 mg/kg IV q6h) OR Gentamicin (2.5 mg/kg IV q8h). (Avoid ceftriaxone in neonates).
1 to 3 Months (Infants)	Group B Streptococcus, Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes	Ampicillin (100 mg/kg IV q6h) + Ceftriaxone (100 mg/kg IV q12h; max 4g/day) + Vancomycin (15 mg/kg IV q6h).
> 3 Months to 18 Years	Streptococcus pneumoniae (#1 cause of mortality), Neisseria meningitidis (#1 epidemic cause), Haemophilus influenzae type b (unvaccinated)	Ceftriaxone (100 mg/kg IV q12h; max 4g/day) + Vancomycin (15 mg/kg IV q6h; target trough 15–20 mcg/mL) + Dexamethasone (0.15 mg/kg IV q6h x 2–4 days).

2. Dexamethasone Hearing Loss Prevention Protocol

Bacterial lysis caused by bactericidal antibiotics triggers a massive secondary surge in subarachnoid cytokine release within the first 4–6 hours of therapy. In Haemophilus influenzae and Streptococcus pneumoniae meningitis, this inflammatory surge damages the cochlear duct and auditory nerve fibers. Administering Dexamethasone 0.15 mg/kg IV (max 10 mg) prior to or simultaneously with the first dose of antibiotics significantly reduces the incidence of severe sensorineural hearing loss and long-term neurocognitive impairment. If antibiotics have already been administered, dexamethasone is unlikely to provide benefit.

3. Pediatric Septic Shock: Cold Shock vs. Warm Shock Resuscitation

Unlike adult septic shock (which is almost universally distributive 'warm shock' with low SVR and high cardiac output), pediatric septic shock is characterized by 'cold shock' (low cardiac output, high systemic vascular resistance) in $> 60\%$ of cases:

Hemodynamic Shock Phenotype	Clinical Examination Findings	First-Line Vasoactive Infusion
Cold Shock (Most Common in Peds: Low Output, High SVR)	Cold, mottled extremities; delayed capillary refill $> 3\text{ seconds}$; narrow pulse pressure; weak, thready peripheral pulses; tachycardia	Epinephrine Infusion: 0.05 to 0.3 mcg/kg/min IV/IO. Provides potent beta-1 inotropy and chronotropy to augment stroke volume and cardiac index.
Warm Shock (Distributive: High Output, Low SVR)	Warm, flushed extremities; 'flash' capillary refill $< 1\text{ second}$; wide pulse pressure; bounding peripheral pulses; water-hammer carotid pulse	Norepinephrine Infusion: 0.05 to 0.3 mcg/kg/min IV/IO. Provides potent alpha-1 vasoconstriction to restore systemic vascular resistance and diastolic organ perfusion pressure.

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