On this page
Referral and warning signs
When to refer
ALL suspected cases of neonatal meningitis require IMMEDIATE referral and admission to a hospital (H) with neonatal intensive care capabilities for diagnosis, treatment, and monitoring.
Red flags
- Lethargy or poor feeding in a neonate
- Irritability or excessive crying
- Temperature instability (fever or hypothermia)
- Seizures
- Bulging fontanelle
- Apnea or respiratory distress
- Signs of sepsis
Signs and symptoms
- Often non-specific, may mimic neonatal sepsis:
- Temperature instability (fever or hypothermia)
- Lethargy, poor feeding, decreased activity
- Irritability, excessive crying
- Vomiting
- Respiratory distress (apnea, tachypnea, grunting)
- Seizures
- Bulging fontanelle (late or inconsistent sign)
- Poor tone (hypotonia)
- Jaundice
- Diarrhoea
Risk factors
- Prematurity
- Low birth weight
- Maternal factors: Prolonged rupture of membranes (>18 hours), Maternal fever during labor, Maternal Group B Streptococcus (GBS) colonization or infection, Chorioamnionitis.
- Neonatal sepsis.
- Invasive procedures (e.g., central lines).
Diagnosis
Clinical assessment
High index of suspicion in any neonate presenting with signs of sepsis or neurological abnormality (lethargy, irritability, seizures, bulging fontanelle). Clinical signs are often subtle and non-specific.
Investigations
- Lumbar Puncture (LP) and CSF Analysis: Essential for diagnosis. Should be performed in any neonate evaluated for sepsis, unless critically unstable or contraindicated. Send CSF for cell count/differential, glucose, protein, Gram stain, culture & sensitivity.
- Blood Culture: Obtain before starting antibiotics.
- Complete Blood Count (CBC) with differential, Platelet count.
- C-Reactive Protein (CRP).
- Blood Glucose.
- Consider urine culture.
Diagnostic criteria
Clinical suspicion of sepsis/meningitis in a neonate + Confirmatory CSF findings (pleocytosis, low glucose, high protein, positive Gram stain/culture).
Management
Non-pharmacological management
- Immediate referral to hospital (H).
- Supportive Care (Essential):
- - Maintain Temperature: Keep baby warm (incubator, skin-to-skin).
- - Respiratory Support: Oxygen if needed (maintain SpO2 >92%), CPAP or mechanical ventilation if respiratory failure.
- - Cardiovascular Support: IV fluids for hydration/shock.
- - Glucose Management: Prevent/treat hypoglycemia (IV glucose if needed, encourage breastfeeding/NGT feeding when stable).
- - Nutrition: Support feeding (breast milk preferred via NGT if unable to suck).
- - Seizure Management: Treat seizures with Phenobarbital primarily (preferred over benzodiazepines in neonates).
Pharmacological treatment
- Empirical Antibiotics: Start IMMEDIATELY after obtaining LP and blood cultures. Cover common neonatal pathogens (Group B Strep, E. coli, Listeria).
- - UCG Recommended Regimen: Ampicillin + Gentamicin.
- - Ampicillin IV: Neonate <7 days: 50-100mg/kg/dose q12h; Neonate >7 days: 50-100mg/kg/dose q8h.
- - Gentamicin IV: 2.5mg/kg/dose q12h (Adjust dosing interval based on gestational age/weight/renal function if possible).
- - Duration: Typically 21 days for Gram-negative meningitis, 14 days for GBS, longer if complications.
- Specific Antibiotics (Based on culture results):
- - Group B Streptococcus (GBS): High-dose Benzylpenicillin (Neonate <7d: 50k-100k IU/kg/dose q8h; Neonate >7d: 100k-150k IU/kg/dose q4-6h) PLUS Gentamicin (synergy, esp. initially). Duration 14-21 days.
- - Gram-negative bacilli (E. coli, Klebsiella): Third-generation cephalosporin (e.g., Cefotaxime - preferred over Ceftriaxone in neonates due to bilirubin displacement risk) often used instead of/in addition to Aminoglycoside based on sensitivity. Duration 21 days.
- - Listeria monocytogenes: Ampicillin + Gentamicin.
- Adjunctive Dexamethasone: Generally NOT recommended in neonatal meningitis.
Monitoring
Closely monitor: Vital signs (HR, RR, Temp, BP, SpO2), Neurological status (level of activity, tone, fontanelle tension, seizures), Feeding tolerance, Urine output, Glucose levels. Monitor response to antibiotics. Repeat LP may be considered if poor clinical response or for Gram-negative meningitis.
Complications
- Neurological sequelae (high risk): Hearing loss, vision impairment, cognitive impairment, learning disabilities, epilepsy, cerebral palsy, hydrocephalus.
- Ventriculitis
- Subdural effusion/empyema
- Brain abscess
- Sepsis / Septic shock
- Death (mortality remains significant)
Prevention
- Maternal screening and intrapartum antibiotic prophylaxis (IAP) for Group B Streptococcus (GBS) colonization.
- Good obstetric care (avoid prolonged rupture of membranes).
- Aseptic techniques during delivery and neonatal care.
- Prompt recognition and treatment of neonatal sepsis.
Patient education
- Explain the seriousness of the infection to parents.
- Discuss the need for hospitalization, investigations (LP), and prolonged IV antibiotics.
- Explain potential complications and the importance of follow-up (hearing tests, developmental assessment).
- Provide emotional support to parents.
Uganda-specific notes
Neonatal meningitis carries high morbidity and mortality. Common pathogens include GBS, E. coli, Klebsiella, S. pneumoniae. Empirical treatment with Ampicillin and Gentamicin is standard per UCG. Access to advanced neonatal care, including respiratory support and specific CSF analysis, is limited outside major hospitals. GBS screening/IAP may not be widely implemented.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.1.5.1