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Neonatal Meningitis

Infection of meninges in infant <28 days old, often coexisting with bacteremia; requires immediate lumbar puncture and CNS-penetrating antibiotics; significant risk of neurodevelopmental sequelae

Written by: Saygı Hospital Health Guide Editorial Board
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This content is for general information; please consult your physician for diagnosis and treatment.

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What is Neonatal Meningitis?

Definition and anatomy: inflammation of meninges (dura, arachnoid, pia) and often underlying brain (meningoencephalitis); neonate's meninges have unique features — higher permeability, immature blood-brain barrier, relatively larger ventricular system, immature immune response; pathogens can gain CNS access via bacteremia, direct extension (omphalitis, otitis), or congenital malformations (spina bifida, dermal sinus).

Common pathogens — bacterial: early-onset — Group B Streptococcus (most common), E. coli (especially K1 capsular type), Listeria monocytogenes; late-onset — CoNS (with indwelling devices), S. aureus (including MRSA), gram-negatives (Klebsiella, Enterobacter, Pseudomonas, Citrobacter), Enterococci, Candida in preterm; less common — Haemophilus influenzae (after term), Salmonella, group A Streptococcus.

Viral pathogens: herpes simplex virus (HSV 1 and 2) — serious cause of devastating disease with high morbidity/mortality; enteroviruses (Coxsackie, echovirus) most common; parechoviruses (type 3 particularly associated with severe disease); other — CMV (congenital or acquired), adenovirus, lymphocytic choriomeningitis virus.

Fungal: Candida species in premature infants with prolonged NICU stay and central lines; cryptococcus rare.

Epidemiology: incidence ~0.25-1/1000 live births; preterm and VLBW infants higher risk (3-4 fold); 20-25 percent of neonatal sepsis cases have concomitant meningitis.

Symptoms

Nonspecific: temperature instability (hypothermia more common in neonates than fever), lethargy, poor feeding, irritability, apnea, tachypnea, jaundice, vomiting
More specific (often late): bulging fontanelle (increased intracranial pressure), neck stiffness (rare in neonate due to low muscle tone), seizures (common — up to 30-40 percent), high-pitched cry, abnormal posturing, decreased responsiveness
Cardiovascular: tachycardia or bradycardia, hypotension, poor perfusion
Focal neurological signs: asymmetric tone, asymmetric Moro reflex, focal seizures, cranial nerve palsies, gaze deviation
Signs of increased intracranial pressure: bulging fontanelle, widening sutures, sun-setting eyes, apnea, bradycardia, vomiting
HSV specific: vesicular skin lesions (may be absent especially in encephalitis alone), eye involvement (keratoconjunctivitis), severe disseminated disease with shock, hepatitis, seizures — mother may have no history of HSV

Risk Factors

Prematurity and low birth weight (strongest; risk 3-4 fold higher)
Early-onset: maternal GBS colonization without adequate intrapartum prophylaxis, chorioamnionitis, maternal fever, prolonged ROM, preterm labor; Listeria — maternal consumption of contaminated food (soft cheese, deli meats, unpasteurized dairy)
Late-onset: prolonged hospitalization, central venous lines, mechanical ventilation, neurosurgical procedures, myelomeningocele/spina bifida, dermal sinus tract, VP shunt
HSV: maternal genital HSV infection (especially primary at delivery — higher risk than recurrent), invasive fetal monitoring, vaginal delivery with active lesions, prolonged ROM
Community: delayed presentation, household contacts with recent infection (RSV, viral), daycare attendance (late LOS), socioeconomic barriers to care access
Congenital anomalies: open spinal dysraphism, dermal sinus, CSF fistula

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Any neonate with signs of sepsis or meningitis requires urgent evaluation including lumbar puncture (LP) — LP indicated for all infants <28 days with fever (rectal ≥38°C), positive blood culture, clinical suspicion of meningitis (seizures, bulging fontanelle, focal neurology, persistent lethargy), severe illness requiring broad-spectrum antibiotics; contraindications are relative (instability, coagulopathy, focal deficit with concern for increased ICP).
  • HSV suspicion (maternal history, vesicles on infant, seizures at any age with fever <6 weeks, severe systemic illness, elevated transaminases) — empirical acyclovir pending PCR results; delayed acyclovir increases mortality/morbidity.
  • Post-meningitis follow-up: hearing evaluation (auditory brainstem response) before discharge and at 6 months; neurodevelopmental assessment in high-risk infant clinic; neuroimaging (head ultrasound during illness, MRI at term or post-discharge) for hydrocephalus, abscess, infarct; developmental therapy and early intervention; family education on signs of hydrocephalus or delay.

Treatment Methods

01
Prevention: same as neonatal sepsis — GBS screening/intrapartum prophylaxis; hygiene; treatment of maternal infections (Listeria caution with contaminated foods); HSV prevention (cesarean for active genital lesions at delivery, antiviral suppression for recurrent maternal HSV from 36 weeks); strict NICU hand hygiene and device care; close surveillance for infant contacts.
02
Diagnostic evaluation: LP with CSF analysis (cell count, protein, glucose, Gram stain, culture — including blood culture simultaneously), blood culture and CBC/CRP/procalcitonin; urine culture; if HSV concern — CSF HSV PCR, skin/eye/mouth/rectal swabs for HSV culture/PCR, serum HSV PCR, LFTs; imaging (head ultrasound, CT if LP deferred, MRI later for detail); monitor clinically and with imaging for complications.
03
Empirical antibiotic therapy (CNS penetrating doses): ampicillin 300-400 mg/kg/day divided (high-dose for meningitis) + cefotaxime 200-300 mg/kg/day divided (or ceftriaxone with caution in jaundiced neonates), covering GBS, Listeria, and E. coli; add vancomycin for LOS (CoNS, S. aureus coverage); meropenem 120 mg/kg/day divided for resistant organisms (ESBL E. coli, Pseudomonas); add acyclovir 20 mg/kg/dose every 8 h if HSV concern pending PCR.
04
Targeted therapy: narrow based on CSF/blood culture and sensitivity; durations — GBS meningitis 14-21 days, Listeria 21 days, gram-negative meningitis 21 days (minimum, may extend per CSF clearance); CoNS 10-14 days + line removal; repeat LP at 48-72 hours to confirm CSF sterilization (especially gram-negative); extend treatment if CSF not sterile.
05
Acyclovir for HSV: duration 21 days for CNS/disseminated disease; 14 days for skin/eye/mouth (SEM); follow with oral suppressive acyclovir 300 mg/m² three times daily for 6 months (reduces recurrence and improves neurodevelopmental outcomes).
06
Supportive care and complications: seizure management (phenobarbital 20 mg/kg load, maintenance 3-5 mg/kg/day; add levetiracetam or fosphenytoin if refractory); increased intracranial pressure management (head elevation, avoid hypotonic fluids, hyperventilation for acute signs, consider mannitol/hypertonic saline); hydrocephalus surveillance with head ultrasound and head circumference (may require ventriculostomy or shunt); subdural collections; cerebral infarct or venous sinus thrombosis (consider anticoagulation with multidisciplinary input); long-term sequelae — hearing loss (audiologic follow-up essential), developmental delay, epilepsy, cerebral palsy — comprehensive follow-up in high-risk infant clinic with multidisciplinary team and early intervention services.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.