Untimely Diagnosis of Meningitis in a Neonate
Infection of infants presents serious challenge for the healthcare provider. The younger the child, the less feedback to the clinician. The presentation of a neonate with sepsis often times cannot be distinguished from a neonate with meningitis.
Systemic bacterial infections in the neonate affect 1 to 5 in 1,000 live births. Neonatal sepsis is, by definition, a clinical syndrome characterized by systemic signs of infection accompanied by bacteremia and occurring in the first month of life. The survival of very low birth weight infants (1500 grams or less) is a necessitated extension of this definition to include infants requiring prolonged hospitalization or complications of prematurity. (Principles and Practice of Pediatric Infectious Disease, 2nd Edition), Epidemiology shows that in the last several decades mortality rates have declined from a level of 30-40% to approximately 5-10%, and the incidence of meningitis as a complication of early/onset sepsis has declined from approximately 25-30% to approximately 3-10%.
Certain viral infections in the neonate can, as well, present with similar symptomatology.
With respect to viral infections and, specifically, herpes simplex viral infections (HSV), overall the United States, with approximately four million deliveries each year, has an estimated 11 to 33 cases of neonatal HSV infection for 100,000 live births. Infectious Diseases of the Fetus and Newborn Infant, 6th Edition, Elsevier & Saunders (2006).
Because meningitis can accompany sepsis with no clinical signs to differentiate between bacteremia with meningitis or viral meningitis, a lumbar puncture should be considered for examination of the cerebral spinal fluid (CSF) in any neonate before initiation of therapy. Up to 15% of infants with sepsis have accompanying meningitis.
If the maternal history or infant clinical signs suggests the possibility of neonatal sepsis (hence: fever in child under 28 days of age), admission for a rule-out sepsis work-up including blood, CSF (all infants), cultures of urine and other clinically evident focal sites should be collected and a radiographic chest should be considered/performed. Clinical manifestation of sepsis can be subtle and progression of disease can be rapid. Because of that, the mortality rate remains high when compared with that for older infants with serious bacterial infection. Thus, empirical treatment should be initiated promptly in a neonate where there is a suspicion of sepsis and/or meningitis. Bacterial responsible for bacterial meningitis are largely the same of those that cause neonatal sepsis and thus both initial and subsequent therapy are similar.
The only way to rule in or rule out the existence of either bacterial or viral meningitis is an evaluation of the CSF. Presence of pleocytosis (and other circumstance) recommend application of empiric antiviral therapy for herpes simplex virus. Acyclovir is the drug of choice.
Current information available indicates that the earlier application of an anti-viral agent or anti-bacterial agent, whichever the case may be, the better the outcome.
Often times healthcare professionals are not attentive enough to the symptomatology or fail to follow those guidelines which would assist in evaluation and treatment. Consequences for failure to timely diagnose and treat such illness can be devastating, including both mortality and severe neurological morbidity.
This office has experience evaluating and prosecuting claims arising out of a failure to timely diagnose and treat possible meningeal infection. If you believe you have such a claim, please contact our office.
