This case involves an 18-month-old child who was presented to her regular pediatrician with fever and vomiting. The pediatrician advised it was a viral infection and that the parents should let the infection run its course. After several days, the child’s symptoms began to worsen. The parents became concerned and took the child to the emergency room. The parents were once again assured that the child had a virus. The child was given over the counter painkillers and anti-vomiting medication and was discharged. Two days later, the child returned to the hospital again with continued vomiting and decreased urine output. The child was given an abdominal ultrasound that was essentially normal. She was also administered a bolus of saline and subsequently discharged. The child continued to decline hours after discharge and her parents decided to take her to a different hospital. At the second hospital, a lumbar puncture confirmed the child had a bacterial infection. The child was treated for bacterial meningitis but subsequently failed hearing tests and lost the level of language she had before the infection. The child required anti-seizure medication and feeding through an NG tube. Further intervention was later required to drain fluid from the child’s brain.
Question(s) For Expert Witness
- 1. How often do you treat patients with bacterial meningitis?
- 2. How important is a speedy diagnosis and administration of antibiotics?
- 3. Could the delayed diagnosis have led to a worse prognosis? Please explain.
Expert Witness Response E-042480
I am board-certified in pediatric infectious diseases and in general pediatrics. As the medical director of a pediatric antimicrobial stewardship program, I have considerable expertise in appropriate and timely antibiotic management. I serve on national committees and working groups in the overall field of pediatric infectious diseases as well as specifically on the optimal antibiotic management of bacterial infections. I performed lab research in fellowship on bacteriology and specifically participated in research on group B strep and pneumococcus, both of which are causes of bacterial meningitis. My current research is on the appropriate antibiotic management of bacterial infections.
I have treated many patients with bacterial meningitis. Thanks to vaccinations, it is not, overall, a common diagnosis. I also participate as a consultant in the evaluation of countless patients who we suspect of having bacterial meningitis but who ultimately do not. The absolutely most critical determinant of outcome in a bacterial meningitis case is time to antibiotics. This is known from research and is established as the standard of care. If you suspect bacterial meningitis, you promptly perform an LP and administer antibiotics–sometimes even giving empiric antibiotics without an LP if one cannot be done quickly enough or safely if the patient is severely ill (which at the initial presentation, it sounds like this patient was not). A delay in diagnosis and in treatment can absolutely lead to a worse prognosis and worse outcome in bacterial meningitis. It is hard to say how much this contributes, as the disease can have severe outcomes regardless of treatment, and without knowing more about the case, it may be that there was no reason to suspect the diagnosis early on (though it sounds, with vomiting, like increased intracranial pressure and an intracranial process may have been worth suspecting, or a bacterial process at the very least, prompting labs to be sent from the blood as a starting point). However, delaying dx and antibiotics absolutely hurts the chances of a good outcome.