Bacterial meningitis in children

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

Signs of shock[26][28]
Raised intracranial pressure[26][28]
Signs of dehydration.

If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions (see below).[2][26]

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.
- If the patient does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used, but only when directed by a paediatric intensivist.[2] Local or national protocols should be followed.[2]
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.

Plus – infection control

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]

Back

Plus –

infection control

Treatment recommended for ALL patients in selected patient group

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

1st line – empirical antibiotics

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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]

If your initial assessment rules out any suspicion of meningococcal disease and you decide the patient can be managed in the community, ensure you give thorough safety netting advice. See Management recommendations.

3 months to 15 years of age

Back

1st line –

empirical antibiotics

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]

Primary options

ceftriaxone: children ≥3 months to 11 years of age or body weight <50 kg: 80-100 mg/kg intravenously every 24 hours, maximum 4 g/day; children ≥12 years of age or body weight ≥50 kg: 2-4 g intravenously every 24 hours

cefotaxime: children ≥3 months of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day

Consider – vancomycin

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

Signs of shock[26][28]
Raised intracranial pressure[26][28]
Signs of dehydration.

If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions (see below).[2][26]

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

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[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.
- If the patient does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used, but only when directed by a paediatric intensivist.[2] Local or national protocols should be followed.[2]
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.

Consider – corticosteroid

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]

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

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.

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.

Primary options

dexamethasone: children ≥3 months of age: 150 micrograms/kg intravenously every 6 hours for 4 days, maximum 10 mg/dose

Plus – infection control

Back

Plus –

infection control

Treatment recommended for ALL patients in selected patient group

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

1st line – emergency transfer to hospital

suspected bacterial meningitis: presenting in the community

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1st line –

emergency transfer to hospital

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).

Safety netting

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.

Plus – infection control

Back

Plus –

infection control

Treatment recommended for ALL patients in selected patient group

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

Consider – empirical antibiotics

Back

Consider –

empirical antibiotics

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

benzylpenicillin sodium: children 1-11 months of age: 300 mg intravenously/intramuscularly as a single dose; children 1-9 years of age: 600 mg intravenously/intramuscularly as a single dose; children ≥10 years of age: 1200 mg intravenously/intramuscularly as a single dose

Consider – supportive care

ACUTE

confirmed or probable bacterial meningitis

<3 months of age

1st line – pathogen-targeted antibiotics

Back

1st line –

pathogen-targeted antibiotics

Tailor the antibiotics according to the microbiological results, as well as discussion with microbiology and/or the multidisciplinary team where needed.

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 requires specialist management.[1][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.

If the patient 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.

Primary options

Confirmed bacterial meningitis due to gram-negative bacilli; group B streptococcal meningitis

cefotaxime: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day

Confirmed bacterial meningitis due to Listeria monocytogenes

amoxicillin: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 4-6 hours, maximum 12 g/day

ampicillin: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 4-6 hours, maximum 12 g/day

-- AND --

gentamicin: neonates: consult specialist for guidance on dose; children ≥1 month of age: 2.5 mg/kg intravenously every 8 hours for the first 7 days only

Unconfirmed but clinically suspected bacterial meningitis

cefotaxime: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day

-- AND --

ampicillin: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 4-6 hours, maximum 12 g/day

amoxicillin: neonates: consult specialist for guidance on dose; children ≥1 month of age: 50 mg/kg intravenously every 4-6 hours, maximum 12 g/day

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

Signs of shock[26][28]
Raised intracranial pressure[26][28]
Signs of dehydration.

If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions (see below).[2][26]

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

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[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.
- If the patient does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used, but only when directed by a paediatric intensivist.[2] Local or national protocols should be followed.[2]
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.

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]

1st line – pathogen-targeted antibiotics

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

Monitor the patient 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

Discuss any child or young person who needs resuscitation with a paediatric intensivist as soon as possible.[2]

3 months to 15 years of age

Back

1st line –

pathogen-targeted antibiotics

Tailor the antibiotics according to the microbiological results, as well as discussion with microbiology and/or the multidisciplinary team where needed.

Treat Neisseria 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] [ ]

Primary options

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

Signs of shock[26][28]
Raised intracranial pressure[26][28]
Signs of dehydration.

If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions (see below).[2][26]

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

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[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.
- If the patient does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used, but only when directed by a paediatric intensivist.[2] Local or national protocols should be followed.[2]
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.

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]