Complications of bacterial meningitis vary according to the etiological organism, the duration of symptoms prior to initiation of appropriate therapy, and the age and immune status of the patient.

Temporary problems include development of hemodynamic instability and disseminated intravascular coagulopathy, particularly in meningococcal infection, SIADH or other dysregulation of the hypothalamic-pituitary axis (e.g. diabetes insipidus), and an acute increase in ICP.

Focal neurological signs may develop in the early stages of meningitis, but are more common later. Although the mechanisms described above, including vasculitis and thrombosis, may explain these clinical findings, awareness of conditions that may require neurosurgical intervention is necessary. These include development of subdural empyema, brain abscess, and acute hydrocephalus. Subdural effusions are more common after Hib meningitis, but can occur with any organism. They usually resolve spontaneously, but the presence of significant and persistent neurological symptoms, including seizures, paresis, raised ICP, and development of empyema, are indications for drainage.

Cerebral abscess must also be considered in any child who deteriorates neurologically, usually following the acute phase of bacterial meningitis, and is often accompanied by persistent fever. Other causes of focal neurology include the development of ischemic areas or infarction, caused by vasculitis, vascular spasm, or venous thrombosis.

Duration of fever varies. Fever persisting beyond day 10 is considered prolonged, whereas a new fever following defervescence for 24 h is considered to be secondary or recurrent. Duration of fever depends on the etiological agent. After 5 days of appropriate therapy, more than 85 per cent of patients with pneumococcal or meningococcal meningitis will be afebrile, whereas only 68 per cent will be afebrile with Hib meningitis. In addition, about 80 per cent of the latter will develop secondary fever. Most commonly, recurrent fever is due to a nosocomial infection such as thrombophlebitis, but subdural empyema, disseminated sepsis such as osteomyelitis, pericarditis, and endocarditis must be considered. It is unusual for fever to be caused by persistence of the organism within the meninges. However, with the emergence of drug-resistant organisms it cannot be assumed that persistent or recurrent fever is not due to continued presence of live bacteria within the cerebrospinal fluid.

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