How to write orders for a pediatric meningitis patient?

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Despite advances in antimicrobial and general supportive therapies, central nervous system (CNS) infections remain a significant cause of morbidity and mortality in children. As classical signs and symptoms often are not present, especially in the younger children, diagnosing CNS infections is a challenge to the emergency department. Many residents and interns have to write ward orders for these meningitic patients. Here is a quick example of a sample ward order for meningitis pediatrics patient.

1. Admit the child to ward

2. Write the diagnosis: Meningitis.

3. Explain the condition: Guarded.

4. Vital Signs: Call MD if: (any problem you suspect would be important for calling an MD)

5. Activity of the child:

6. Nursing:Strict isolation precautions. Inputs and outputs, daily weights; cooling measures prn temp >38?C; consent for lumbar puncture.

7. Diet: Regular

8. IV Fluids: Isotonic fluids at maintenance rate.

9. Special Medications:

Term Newborns <1 months old (Group B strep, E coli, gram negatives, Listeria):

-Ampicillin, 0-7 days: 150 mg/kg/day IV/IM q8h; >7days: 200 mg/kg/day IV/IM q6h AND

-Cefotaxime (Claforan): <7days: 100 mg/kg/day IV/IM q12h; >7 days: 150 mg/kg/day q8h IV/IM.

Infants 1-3 months old (H. flu, strep pneumonia, N. Meningitidis, group B strep, E coli):

-Cefotaxime (Claforan) 200 mg/kg/day IV/IM q6h OR

-Ceftriaxone (Rocephin) 100 mg/kg/day IV/IM q12-24h AND

-Vancomycin (Vancocin) 40-60 mg/kg/day IV q6h.

-Dexamethasone 0.6 mg/kg/day IV q6h x 4 days. Initiate before or with the first dose of parenteral antibiotic.

Children 3 months to 18 years old (S pneumonia, H flu, N. meningitidis):

-Cefotaxime (Claforan) 200 mg/kg/day IV/IM q6h, max 12 gm/day or ceftriaxone (Rocephin) 100 mg/kg/day IV/IM q12-24h, max 4 gm/day AND

-Vancomycin (Vancocin) 60 mg/kg/day IV q6h, max 4gm/day.

-Dexamethasone 0.6 mg/kg/day IV q6h x 4 days. Initiate before or with the first dose of parenteral antibiotic.

10. Symptomatic Medications:

-Ibuprofen (Advil) 5-10 mg/kg/dose PO q6-8h prn OR

-Acetaminophen (Tylenol) 15 mg/kg PO/PR q4h prn temp >38?C or pain.

11. Extras and X-rays: CXR.

12. Labs: CBC, SMA 7. Blood culture and sensitivity x 2. UA, urine culture and sensitivity; urine specific gravity. Antibiotic levels. Urine and blood antigen testing.

Lumbar Puncture:

CSF Tube 1 – Gram stain, culture and sensitivity, bacterial antigen screen (1-2 mL).

CSF Tube 2 – Glucose, protein (1-2 mL).

CSF Tube 3 – Cell count and differential (1-2 mL).