Recommendations
Key Recommendations
Escalate early. Consult a senior doctor in emergency medicine or paediatrics if you suspect bacterial meningitis. Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care if you suspect meningococcal meningitis (or there are other signs of meningococcal disease), or if there are features of shock or raised intracranial pressure.[26] Bacterial meningitis is life-threatening and requires urgent intervention and possible critical care input.
Features of meningococcal disease other than meningococcal meningitis are not covered in this topic - see Meningococcal disease.
If you suspect bacterial meningitis, take the following immediate actions:
Isolate the patient and take droplet precautions, including wearing a surgical mask, if likely to be in close contact with respiratory secretions or droplets[16][51][52]
Give supportive care as needed, which may include:
Fluid resuscitation
Respiratory support
Management of shock, metabolic disturbances, seizures, and raised intracranial pressure.[2]
In the community, arrange urgent transfer by blue-light ambulance if you suspect bacterial meningitis.[2][39]
If the patient does not have a non-blanching rash, transfer them directly to hospital without giving parenteral antibiotics.[2]
Give parenteral antibiotics if urgent transfer to hospital is not possible, or the patient has:[2]
Signs of meningococcal disease such as a rash in combination with signs of meningism or sepsis - see Meningococcal disease
Signs of sepsis such as hypotension, poor capillary refill time, or altered mental state - see Sepsis in children
Suspected meningitis and urgent transfer to hospital is not possible. In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics specifically if there will be a delay of more than 1 hour in getting to hospital.[2] Check your local protocol.
Urgently notify the relevant public health authority and microbiology if you have a patient with suspected meningitis (regardless of the aetiology).[2]
Monitor the patient closely after admission to hospital for signs of deterioration.[2]
Adjust antibiotic therapy to target the causative organism as soon as it is identified, taking account of antibiotic sensitivities.
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice, and suggest follow-up within a specified period if you consider this to be appropriate.[53]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.
Isolate all patients with suspected meningitis until meningococcal meningitis is excluded (or considered unlikely) or empirical antibiotics have been given for 24 hours.[16][51] Always follow your local protocols, which may vary in practice.
Take droplet precautions, including wearing a surgical mask, if likely to be in close contact with respiratory secretions or droplets, until the patient has had 24 hours of antibiotics.[51][52]
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Urgently notify the relevant public health authority and microbiology if you have a patient with suspected meningitis (regardless of the aetiology).[2]
In the UK, the doctor who suspects a diagnosis of meningitis has a legal duty to notify the case to the local health protection team or the on-call Public Health Specialist. This is usually done by the hospital doctor, but general practitioners may wish to check that it has been done.[53] National Archives (UK): The Health Protection (Notification) Regulations 2010 Opens in new window
Age <3 months
Without delay, give infants aged <3 months with suspected bacterial meningitis either:[2]
Intravenous cefotaxime plus ampicillin or amoxicillin, or[2]
Intravenous ceftriaxone with or without ampicillin or amoxicillin (as long as there are no contraindications - see below).[2]
Amoxicillin is used to cover Listeria monocytogenes, which is rare in the UK.[54] Therefore, amoxicillin is not commonly used in UK practice for suspected bacterial meningitis, unless the patient has specific risk factors for listeria meningitis.
Do not give ceftriaxone:[2]
In premature babies
In babies with jaundice, hypoalbuminaemia, or acidosis because it may exacerbate hyperbilirubinaemia
If giving calcium-containing infusions.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends adding vancomycin if a child has recently travelled outside the UK or had prolonged or multiple exposure to antibiotics within the previous 3 months.[2] However, in practice, discuss these patients with an infectious disease or microbiology specialist because vancomycin may not be needed for infants <3 months.
Age 3 months to 15 years
Give children and young people aged 3 months to 15 years with suspected bacterial meningitis intravenous ceftriaxone without delay.[2]
Do not give ceftriaxone if giving calcium-containing infusions (use cefotaxime).[2]
Add vancomycin if the patient has recently travelled outside the UK or had prolonged or multiple exposure to antibiotics within the previous 3 months.[2] Also take this approach if MRSA is identified. Discuss these patients with an infectious disease or microbiology specialist.
Antibiotic allergy or immunocompromise
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
More info: Empirical antibiotics
Choice of empirical antibiotics is determined by the epidemiology of causative organisms for specific age groups. The introduction of widespread immunisation programmes in the UK and other developed countries, particularly the use of Haemophilus influenzae type b (Hib) and conjugate pneumococcal vaccines, has significantly changed the epidemiology of bacterial meningitis in children.[2][3][6][8][9][10][11]
In children and young people aged ≥3 months, the most common pathogens are Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae (pneumococcus).[2][3] H influenzae is no longer a major cause of bacterial meningitis following widespread introduction of the H influenzae type b (Hib) vaccine.[3] Meningitis due to H influenzae may occur incidentally in unvaccinated children or may be due to serotypes other than type b.[3][14]
In neonates, the most common pathogens are Streptococcus agalactiae (group B streptococcus), and Escherichia coli.[1] S pneumoniae and L monocytogenes account for a smaller proportion of cases.[1]
Escalate early. Consult a senior doctor in emergency medicine or paediatrics if you suspect bacterial meningitis. Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care if you suspect meningococcal meningitis (or there are other signs of meningococcal disease), or if there are features of shock or raised intracranial pressure.[26] See Meningococcal disease.
If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.[2][26]
Fluid resuscitation
Assess children and young people with suspected bacterial meningitis for all of the following:[2]
If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions.[2][26] See Shock and Raised intracranial pressure below.
Correct dehydration (if present) in children and young people with suspected bacterial meningitis using enteral fluids or feeds, or intravenous isotonic fluids.[2] Follow your local protocols
Do not restrict fluids unless there is evidence of increased intracranial pressure or increased antidiuretic hormone secretion.[2][28]
Give full-volume maintenance fluids to maintain electrolyte balance and avoid hypoglycaemia.[2][28]
Give enteral feeds as maintenance fluid if tolerated.[2][28]
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[2][28]
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[2][28]
Respiratory support
Give self-ventilating children and young people with signs of respiratory distress oxygen via a reservoir rebreathing mask using a 15 L face mask.[2]
Implement airway-opening manoeuvres if there is threatened loss of airway patency; start bag-valve mask ventilation in preparation for tracheal intubation.[2]
Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.[2][28]
Follow local or national protocols for intubation.[2]
There is a high risk of sudden deterioration during intubation in children with bacterial meningitis; anticipate aspiration, pulmonary oedema, or worsening shock during the procedure.[2]
If respiratory support or oxygen are required, ensure patients are nil by mouth from admission to hospital, and ensure the following are available before intubation:[2][26]
Facilities to administer fluid boluses
Appropriate vasoactive drugs
Access to a health professional experienced in managing critically ill children.
More info: Indications for intubation
Indications for intubation include:[2][28]
Threatened or actual loss of airway patency
Any need for assisted ventilation
Increasing work of breathing
Hypoventilation or apnoea
Respiratory failure
Irregular respiration (e.g., Cheyne-Stokes)
Hypoxia (PaO2 <13 kPa or decreased saturations in air)
Hypercapnia (PaCO2 >6 kPa)
Ongoing shock following infusion of 40 mL/kg resuscitation fluid
Raised intracranial pressure
Impaired mental status
Fluctuating or reduced Glasgow Coma Scale score <9 or drop of ≥3
Moribund
Intractable seizures
Need for stabilisation for brain imaging or transfer to a paediatric intensive care unit or another hospital.
Shock
If there are signs of shock, give an immediate fluid bolus of sodium chloride 0.9%, or a balanced crystalloid (such as Plasmalyte®), over 5-10 minutes.[2][26] The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[55] Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[2][26]
Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[26]
If signs of shock persist, give further fluid boluses of sodium chloride 0.9% or a balanced crystalloid (such as Plasmalyte®) over 5-10 minutes.[2][26] Continue to reassess the patient after each fluid bolus to assess for clinical response and signs of fluid overload.[2][26]
If the signs of shock still persist after 40 mL/kg of fluid resuscitation:[2]
Call for urgent anaesthetic support; tracheal intubation and mechanical ventilation are likely to be required.[26]
Discuss further management options with a paediatric intensivist. Vasoactive agents should be initiated early, and following the advice from a paediatric intensivist or experienced members of the critical care team.
Consider giving further fluid boluses under senior guidance, based on clinical signs and laboratory investigations (such as blood gases).
Metabolic disturbances
Anticipate, monitor, and manage the following metabolic disturbances in children and young people with suspected or confirmed meningococcal sepsis using local or national protocols:[2][26]
Hypoglycaemia (glucose <3 mmol/L); urgently correct this using intravenous treatment
Acidosis (pH <7.2)
Hypokalaemia
Hypocalcaemia
Hypomagnesaemia
Anaemia
Coagulopathy.
See Meningococcal disease and Sepsis in Children.
Seizures
Follow local or national protocols to treat seizures in children and young people with suspected bacterial meningitis.[2] See Generalised seizures in children.
Raised intracranial pressure
Follow local or national protocols to treat raised intracranial pressure.[2]
Arrange urgent transfer by blue-light ambulance for children and young people with suspected bacterial meningitis.[2][39]
In practice, where possible, the patient should arrive at hospital within 1 hour of being assessed in the community.
If the patient does not have a non-blanching rash, transfer them directly to hospital without giving parenteral antibiotics.[2] Give antibiotics if urgent transfer to hospital is not possible (e.g., in remote locations).[2]
In practice, document presence or absence of:
Headache
Altered mental status
Neck stiffness
Fever
Rash (of any type)
Seizures
Any signs of shock (e.g., hypotension, poor capillary refill time).
Pre-hospital antibiotics
Give parenteral empirical antibiotics (intramuscular or intravenous benzylpenicillin) as soon as possible in patients with:[2]
Signs of meningococcal disease such as a rash in combination with signs of meningism or sepsis - see Meningococcal disease
Signs of sepsis such as hypotension, poor capillary refill time, or altered mental state - see Sepsis in children
Suspected meningitis and urgent transfer to hospital is not possible. In the UK, the National Institute for Health and Care Excellence (NICE) recommends antibiotics specifically if there will be a delay of more than 1 hour in getting to hospital.[2] Check your local protocol.
However, do not delay urgent transfer to hospital to give parenteral antibiotics.[2]
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[2]
Pre-hospital supportive care
Administer oxygen if the patient is unconscious.[53]
Give intravenous fluids if the patient has a rapid heart rate, poor capillary refill time, and cold extremities.[53]
Safety netting for patients not transferred to hospital
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice.[53]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.[53]
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.[53]
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.[53]
Suggest follow-up within a specified period if you consider this to be appropriate.[53] Use your clinical judgement.
Monitor children and young people closely after admission to hospital for signs of deterioration; focus on:[2]
Respiration
Pulse
Blood pressure
Oxygen saturation
Glasgow Coma Scale score [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those aged under 2 years), use the Glasgow Coma Scale with modification for children.[2] Glasgow Coma Scale: modification for children Opens in new window
Be aware that children and young people with bacterial meningitis (particularly meningococcal meningitis) can deteriorate rapidly regardless of the results of any initial assessment of severity.[2] See Meningococcal disease.
Discuss any child or young person who needs resuscitation with a paediatric intensivist as soon as possible.[2]
Intravenous dexamethasone should be given in children ≥3 months of age with suspected or confirmed bacterial meningitis as soon as possible if lumbar puncture reveals any of the following:[2]
[ 
]
Frankly purulent cerebrospinal fluid (CSF)
CSF white cell count >1000/microlitre
Raised CSF white cell count with protein concentration >1 g/L
Bacteria on Gram stain.
Dexamethasone should be given only by experienced members of the critical care team.
Corticosteroids should not be given in children younger than 3 months with suspected or confirmed bacterial meningitis.[2]
The first dose of dexamethasone, if indicated, should ideally be given before or at the same time as antibiotics.[2]
However, in practice this is often not possible due to the time taken for the initial CSF results to be made available (and antibiotics must not be delayed to wait for CSF results if there is clinical suspicion of bacterial meningitis).
If possible, try to give dexamethasone within 4 hours of starting antibiotics.[2] Dexamethasone should not be started more than 12 hours after starting antibiotics.[2]
After the first dose of dexamethasone, discuss whether dexamethasone should be continued with a senior paediatrician.[2]
If tuberculous meningitis is a possible diagnosis, refer to your local guideline for advice before giving corticosteroids. In these patients, corticosteroids may be harmful if given without antituberculous therapy.[2][56] See Extrapulmonary tuberculosis.
Children or young people with meningococcal sepsis should not be treated with high-dose corticosteroids (defined as dexamethasone 0.6 mg/kg/day or an equivalent dose of other corticosteroids).[2] See Meningococcal disease.
Tailor the antibiotics according to the microbiological results, as well as discussion with microbiology and/or the multidisciplinary team where needed.
Aged <3 months with confirmed or probable bacterial meningitis
Based on experience in practice, seek urgent advice from an infectious disease or microbiology specialist for infants with bacterial meningitis due to Neisseria meningitidis. N meningitidis may account for a smaller proportion of bacterial meningitis in this age group compared with older children, and this requires specialist management.[1][2][3]
Treat infants with group B streptococcal meningitis with intravenous cefotaxime for at least 14 days, or as guided by culture sensitivities.[2]
Consult an expert in paediatric infectious diseases and consider extending the duration of treatment if the clinical course is complicated.
Treat infants with confirmed bacterial meningitis due to gram-negative bacilli with intravenous cefotaxime for at least 21 days unless directed otherwise by results of antibiotic sensitivities.[2]
Consult an expert in paediatric infectious diseases and consider extending the duration of treatment if the clinical course is complicated.
Treat infants with bacterial meningitis due to Listeria monocytogenes with intravenous amoxicillin or ampicillin for 21 days in total plus gentamicin for at least the first 7 days.[2]
Treat infants with unconfirmed but clinically suspected bacterial meningitis (i.e., causative pathogen not identified on culture and polymerase chain reaction [PCR]) with intravenous cefotaxime plus ampicillin or amoxicillin for at least 14 days.[2]
Consult an expert in paediatric infectious diseases and consider extending the duration of treatment if the clinical course is complicated.
Aged 3 months to 15 years with confirmed or probable bacterial meningitis
Treat N meningitidis meningitis with intravenous ceftriaxone for 7 days in total unless directed otherwise by the results of antibiotic sensitivities.[2] See Meningococcal disease.
Treat Streptococcus pneumoniae meningitis with intravenous ceftriaxone for 14 days in total unless directed otherwise by the results of antibiotic sensitivities.[2]
Treat Haemophilus influenzae type b meningitis with intravenous ceftriaxone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.[2]
Treat unconfirmed, uncomplicated, but clinically suspected bacterial meningitis (i.e., causative pathogen not identified on culture and PCR) with intravenous ceftriaxone for at least 10 days, depending on symptoms and signs and course of the illness.[2]
[ ]
Antibiotic allergy or immunocompromise
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
Patients admitted to hospital
Before discharging a child or young person who has been diagnosed with bacterial meningitis and treated in hospital:[2]
Consider their follow-up requirements, taking into account potential sensory, neurological, psychosocial, orthopaedic, cutaneous, and renal morbidities
Discuss potential long-term effects and likely patterns of recovery with the child or young person and their parents or carers; provide opportunities to discuss issues and ask questions.
See Patient discussions.
Patients seen in hospital or the community and not admitted to hospital
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice.[53]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.[53]
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.[53]
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.[53]
Suggest follow-up within a specified period if you consider this to be appropriate.[53] Use your clinical judgement.
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