This is a very common senario and, we too, are experiencing a mini-epidem=
of meningitis in children this summer.
A patient with a predominance of segmented cells in the CSF, as in this
case, should be assumed to have bacterial meningitis. To rely upon such
weak epidemiologic features, as the time of year, to exclude serious
disease is mental masturbation.
I will grant you that with only mild pleocytosis (few hundred cells),
normal glucose and benign clinical appearance the likelihood that this
represents an aseptic meningitis is high, but not invariable. Unless you
have an observation unit and more time on your hands than most of us, the=
strategy of repeating the tap to confirm a conversion to mononuclear cell=
in the ED, is not a viable one. The only rational alternative, in my
opinion is to treat for the possibility of bacterial disease until 1) a
repeat LP confirms a viral etiology or 2) CSF cultures are negative.
Having said that, does this mandate hospital admission? A few studies hav=
demonstrated the safety of once daily ceftrioxone administered on an
outpatient basis for serious pediatric infections including meningitis. B=
this, by no means, is the standard of care. In my opinion, the potential
risk of an adverse outcome in such a serious disease process is simply to=
great to sucumb to the whims of the managed care organizations. We
routinely admit patients to the hospital with conditions that are
potentially far less lethal than bacterial meningitis.
Even if, the CSF is consistant with a viral process, it has been my
practice to admit them for observation. This is not uniformly accepted a=
many clinicians mange these uneqivacol cases on an outpatient basis. I
would point out, however, that aseptic meningitis is NOT synonymous with
viral meningitis and the presence of a lymhocytic pleocytosis, alone, dos=
not establish the latter diagnosis. If, and when, CSF PCR testing becomes=
routinely available, we can have this discussion once again.
As to whether vancomycin should be added routinely I would suggest that y=
look at your hospital's antibiogram. If pneumoccocal resistance is
confirmed in your community then yes, otherwise, no.
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