Recommendations
Urgent
Children and young people aged <16 years
Escalate early. Consult a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care immediately if you suspect meningococcal disease in a child or young person.[50]
Give empirical antibiotics immediately to a child or young person with a petechial rash if any of the following occur at any point during their assessment:[9]
Petechiae start to spread
Their rash becomes purpuric
There are signs of bacterial meningitis
There are signs of meningococcal sepsis
You (or another healthcare professional) think the patient appears ill.
These children are at high risk of having meningococcal disease and need urgent treatment.
Give fluids immediately if there are signs of shock in a child or young person with suspected or confirmed sepsis.[9]
Urgent elective intubation and ventilation is required by paediatric intensivist and anaesthetist if there are signs of shock despite initial fluid resuscitation.[50]
Adults
Within the first hour of arriving at hospital:[48]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration[59][60][73][77]
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK):[78]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6)
Make a decision on the need for senior review and/or intensive care admission
Start treatment with empirical antibiotics and supportive care.
Give empirical antibiotics immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[48][49]
Some guidelines recommend giving antibiotics after LP (where LP is indicated and as long as LP is not delayed) to allow the best chance of definitive diagnosis.[48] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
Get immediate critical care input for any patient with suspected meningococcal disease who has:[49]
Suspected meningitis with signs suggestive of shift of brain compartments secondary to raised intracranial pressure: focal neurological signs; presence of papilloedema; continuous or controlled seizures; Glasgow Coma Scale score ≤12
Signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).
In the community
Arrange emergency transfer to hospital by blue-light ambulance for any patient with suspected bacterial meningitis and/or meningococcal sepsis.[9][61]
Give parenteral empirical antibiotics as soon as possible in patients with:[9][48]
Signs of meningococcal disease
Signs of sepsis
Suspected meningitis and a delay of more than 1 hour in getting to hospital.
Transfer children and young people with suspected meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics. Give antibiotics if urgent transfer to hospital is not possible.[9]
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[9][48]
Do not delay urgent transfer to hospital to give antibiotics.[9][48]
Key Recommendations
Early treatment is crucial because patients with meningococcal disease can deteriorate very rapidly.
Bacterial meningitis and meningococcal sepsis are associated with high morbidity and mortality.[48]
Respiratory isolate all patients with suspected meningitis or meningococcal sepsis until meningococcal meningitis or meningococcal sepsis is excluded (or considered unlikely) or ceftriaxone (or other recommended antibiotic) has been given for 24 hours (or a single dose of ciprofloxacin).[48][49]
Notify:
Microbiology[49]
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7][9][48]
Monitor the patient closely for signs of:[9][48][51]
Raised intracranial pressure
Shock
Dehydration.
Request specialist/critical care input if needed and provide supportive treatment.
Start antibiotics targeting the causative organism as soon as it is identified, taking account of antibiotic sensitivities.[9][48]
Early treatment is crucial because patients with meningococcal disease can deteriorate very rapidly.
Recognise and treat early to reduce deaths and disability.[9]
Implement measures to ensure risk of transmission is minimised.
Respiratory isolate all patients with suspected meningitis or meningococcal sepsis until meningococcal meningitis or meningococcal sepsis is excluded (or considered unlikely) or ceftriaxone (or other recommended antibiotic) has been given for 24 hours (or a single dose of ciprofloxacin).[48][49]
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.[48]
Antibiotic prophylaxis should be given to healthcare workers who have been exposed to respiratory secretions or droplets from a patient with confirmed meningococcal disease (e.g., during intubation or as part of CPR performed without wearing a mask).[48]
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[49]
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7][9][48][79]
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[80]
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[48] They will initiate prophylaxis of contacts.
Escalate early. Call a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care immediately if you suspect meningococcal disease in a child or young person.[50]
Empirical antibiotics
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.[53][81]
Without delay, give infants aged <3 months with suspected bacterial meningitis either:[9]
Intravenous cefotaxime plus amoxicillin or ampicillin or
Intravenous ceftriaxone with or without amoxicillin or ampicillin
Do not give ceftriaxone:[9]
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 the patient has recently travelled outside the UK or had prolonged or multiple exposure to antibiotics within the previous 3 months.[9] Also take this approach if MRSA is identified. However, in practice, discuss these patients with an infectious disease or microbiology specialist because vancomycin may not be needed for infants <3 months.
Consider adding vancomycin if the patient has a central line or ventriculoperitoneal shunt in situ.[52]
Give children and young people aged 3 months to 15 years with suspected bacterial meningitis intravenous ceftriaxone without delay.[9]
Do not give ceftriaxone (use cefotaxime) if giving calcium-containing infusions.[9]
Add vancomycin if the patient has recently travelled outside the UK or had prolonged or multiple exposure to antibiotics within the previous 3 months.[9] Also take this approach if MRSA is identified. Discuss these patients with an infectious disease or microbiology specialist.
Give children and young people (<16 years of age) with suspected meningococcal disease intravenous ceftriaxone without delay.[9][50]
[ 
]
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.
Within the first hour of arriving at hospital:[48]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Make a decision on the need for senior review and/or intensive care admission
Start treatment with empirical antibiotics and supportive care. [
]
Empirical antibiotics
If the patient is an adult with suspected bacterial meningitis or suspected meningococcal disease, choose the most appropriate antibiotic based on the patient’s age and immunocompetence.[48][49]
Immunocompetent adults aged 16 to 59 years
Give intravenous cefotaxime or ceftriaxone immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[48][49]
Some guidelines recommend giving antibiotics after LP (where LP is indicated and as long as LP is not delayed) to allow the best chance of definitive diagnosis.[48] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
If the patient has recently travelled to a country where antimicrobial resistance is prevalent or there are other factors that increase the possibility of antimicrobial resistance (or if MRSA is identified):[48][49]
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Use chloramphenicol instead if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49]
Aged ≥60 years or immunocompromised (including alcohol dependency and diabetes)
Give intravenous cefotaxime or ceftriaxone plus amoxicillin or ampicillin immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[48] Some guidelines recommend giving antibiotics after LP (where LP is indicated and as long as LP is not delayed) to allow the best chance of definitive diagnosis.[48] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
If the patient has recently travelled to a country where antimicrobial resistance is prevalent or there are other factors that increase the possibility of antimicrobial resistance (or if MRSA is identified):[48][49]
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Give chloramphenicol plus trimethoprim/sulfamethoxazole if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49]
Antibiotic allergy
If the patient has an allergy to the recommended antibiotic:
Follow your local protocols and see recommendations above for appropriate alternatives
Consult an infectious disease or microbiology specialist.
Escalate early. Consult a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care immediately if you suspect meningococcal disease in a child or young person.[50]
If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.[9]
Fluid resuscitation
Assess children and young people with suspected bacterial meningitis for all of the following:[9]
Signs of shock
Raised intracranial pressure
Signs of dehydration.
If the patient shows signs of raised intracranial pressure or evidence of shock, start emergency management for these conditions.[9] Discuss fluid management with a paediatric intensivist and follow your local protocols.
Correct dehydration (if present) in children and young people with suspected bacterial meningitis using enteral fluids or feeds, or intravenous isotonic fluids.[9] Follow your local protocols.
Do not restrict fluids unless there is evidence of increased intracranial pressure or increased antidiuretic hormone secretion.[9]
Give full-volume maintenance fluids to maintain electrolyte balance and avoid hypoglycaemia.[9]
Give enteral feeds as maintenance fluid if tolerated.[9]
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[9]
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[9]
Respiratory support
Give self-ventilating children and young people with signs of respiratory distress oxygen via a reservoir rebreathing mask using a 15-litre face mask.[9]
Implement airway-opening manoeuvres if there is threatened loss of airway patency; start bag-valve mask ventilation in preparation for tracheal intubation.[9]
Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.[9]
Follow local or national protocols for intubation.[9]
There is a high risk of sudden deterioration during intubation; anticipate aspiration, pulmonary oedema or worsening shock during the procedure.[9]
Ensure patients are nil by mouth from admission to hospital and the following are available before intubation:[9]
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:[9][50]
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.[9][50] The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[82] The fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[9][50]
Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[50]
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.[9][50] Continue to reassess the patient after each fluid bolus to assess for clinical response and signs of fluid overload.[9][50]
If the signs of shock still persist after 40 mL/kg of fluid resuscitation:[9]
Call for urgent anaesthetic support; tracheal intubation and mechanical ventilation are likely to be required.[50]
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:[9][50]
Hypoglycaemia (glucose <3 mmol/L). This requires urgent management and should be managed by experienced members of the critical care team.
Acidosis (pH <7.2)
Hypokalaemia
Hypocalcaemia
Hypomagnesaemia
Anaemia
Coagulopathy.
Reassess and monitor need for intensive care
Monitor children and young people closely after admission to hospital for signs of deterioration; focus on:[9]
Respiration
Pulse
Blood pressure
Oxygen saturation
Glasgow Coma Scale score [ Glasgow Coma Scale Opens in new window ] Glasgow Coma Scale: modification for children 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, or assess using focal neurological signs.[9]
Be aware that children and young people with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity.[9]
Discuss any child or young person who needs resuscitation with a paediatric intensivist as soon as possible.[9]
Ensure patients are nil by mouth from admission to hospital and that the following are available before intubation:[9]
Facilities to administer fluid boluses
Appropriate vasoactive drugs
Access to a health professional experienced in managing critically ill children.
Corticosteroids
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:[9]
[ ]
Frankly purulent cerebrospinal fluid (CSF)
CSF white cell count >1000/microlitre
Raised CSF white cell count with protein concentration >1 g/litre
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.[9]
The first dose of dexamethasone, if indicated, should be given within 4 hours of starting antibiotics (if not given before or with the first dose of antibiotics). Dexamethasone should not be started more than 12 hours after starting antibiotics.[9]
After the first dose of dexamethasone, discuss whether dexamethasone should be continued with a senior paediatrician.[9]
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.[9]
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).[9]
In children and young people with shock that does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used only when directed by a paediatric intensivist.[9]
Seizures
Follow local or national protocols to treat seizures in children and young people with suspected bacterial meningitis or meningococcal sepsis.[9] See Generalised seizures in children.
Raised intracranial pressure
Follow local or national protocols to treat raised intracranial pressure.[9]
Within the first hour of arriving at hospital:[48]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration[59][60][73][77]
Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK):[78]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6)
Make a decision on the need for senior review and/or intensive care admission
Start treatment with empirical antibiotics and supportive care.
Fluid resuscitation
Start fluid resuscitation immediately in patients with predominantly sepsis or a rapidly evolving rash (with or without signs of meningitis).[49]
Refer to your local sepsis protocol.
See Sepsis in adults.
Give careful fluid resuscitation (avoid fluid overload) in patients with suspected meningitis (meningitis without signs of shock, sepsis, or signs suggesting brain shift).[49]
Keep patients euvolaemic to maintain normal haemodynamic parameters.[48]
Do not restrict fluids in an attempt to reduce cerebral oedema.[48]
Titrate fluids to urine output. A patient with sepsis may have normal blood pressure, but if their urine output has dropped this needs to be addressed.
Practical tip
Adults with bacterial meningitis and meningococcal sepsis vary in their need for intravenous fluid therapy. Some patients, such as those with primarily meningitis and little evidence of sepsis are relatively euvolaemic. Others have profound or occult shock and require early restoration of circulating volume.[48]
Respiratory support
Secure the airway and give high flow oxygen to patients with:[49]
Suspected or confirmed meningitis with signs suggestive of shift of brain compartments secondary to raised intracranial pressure: focal neurological signs; presence of papilloedema; continuous or controlled seizures; Glasgow Coma Scale score ≤12 [ Glasgow Coma Scale Opens in new window ]
Rapidly evolving rash (with or without symptoms and signs of meningitis).
Intubation should be strongly considered in patients with a Glasgow Coma Scale score <12.[48]
Shock
Vasoactive agents may be needed.[48] They should be initiated early and only by experienced members of the critical care team.
Consider low-dose hydrocortisone in patients with persisting hypotensive shock, despite treatment with vasoactive agents.[48]
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[48]
Reassess and monitor need for intensive care
Involve intensive care teams early in patients with:[48]
Rapidly evolving rash
Evidence of limb ischaemia
Cardiovascular instability
Acid/base disturbance
Hypoxia
Respiratory compromise
Frequent seizures
Altered mental state.
Transfer patients to critical care if they:[48]
Have a rapidly evolving rash
Have a Glasgow Coma Scale score of ≤12 or drop of >2 points [ Glasgow Coma Scale Opens in new window ]
Require monitoring or specific organ support
Have uncontrolled seizures
Have evidence of sepsis.
Ensure all patients with meningitis and meningococcal sepsis receive input from an infectious disease or microbiology specialist.[48]
Corticosteroids
Intravenous dexamethasone should be started (only by experienced members of the critical care team) on admission, either shortly before or simultaneously with antibiotics (or up to 12 hours after the first dose of antibiotics if already commenced), in adults with:[48][49]
[ ]
Suspected meningitis without signs of shock, sepsis, or signs suggesting brain shift
Suspected meningitis with signs suggestive of shift of brain compartments secondary to raised intracranial pressure.
Corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[49]
Consider low-dose hydrocortisone in patients with persisting hypotensive shock[48]
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised[48]
Seizures
Manage suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures in adults.
Seizures have been reported to occur in 15% of adult patients with acute bacterial meningitis and are associated with worse outcomes, so start anticonvulsant treatment promptly even when seizures are suspected but not proven.[48]
Arrange electroencephalogram (EEG) monitoring for patients with suspected or proven status epilepticus (including non-convulsive or subtle motor status) such as those with fluctuating GCS off sedation or subtle abnormal movements.[48] See Status epilepticus.
Raised intracranial pressure
Ensure patients with suspected or proven raised intracranial pressure (ICP) receive basic measures to control this and maintain cerebral perfusion pressure.[48] Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
Pathogen-targeted antibiotics
Give an intravenous cephalosporin once the diagnosis of meningococcal infection is confirmed, based on the organism identified and antimicrobial sensitivities.[9]
[ ]
Aged <3 months with confirmed or probable bacterial meningitis (including meningococcal meningitis)
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.[9]
Consult an expert in paediatric infectious diseases and consider extending the duration of treatment if the clinical course is complicated.
Treat infants with unconfirmed but clinically suspected bacterial meningitis with intravenous cefotaxime plus ampicillin or amoxicillin for at least 14 days.[9]
Consult an expert in paediatric infectious diseases and consider extending the duration of treatment if the clinical course is complicated.
Treat infants with group B streptococcal meningitis with intravenous cefotaxime for at least 14 days.[9]
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.[9]
Aged 3 months to 15 years with confirmed or probable bacterial meningitis (including meningococcal meningitis)
Treat Haemophilus influenzae type b meningitis with intravenous ceftriaxone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.[9]
Treat Streptococcus pneumoniae meningitis with intravenous ceftriaxone for 14 days in total unless directed otherwise by the results of antibiotic sensitivities.[9]
Treat unconfirmed but clinically suspected bacterial meningitis with intravenous ceftriaxone for at least 10 days, depending on symptoms and signs and course of the illness.[9]
Aged <16 years with confirmed or probable meningococcal disease
Treat children and young people with confirmed meningococcal disease with intravenous ceftriaxone for 7 days in total, unless directed otherwise by the results of antibiotic sensitivities.[9]
Treat children and young people with unconfirmed but clinically suspected meningococcal disease with intravenous ceftriaxone for 7 days in total.[9]
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.
Corticosteroids
Dexamethasone should be given (only by experienced members of the critical team team) in children aged ≥3 months with suspected or confirmed bacterial meningitis as soon as possible if lumbar puncture reveals any of the following:[9]
Frankly purulent cerebrospinal fluid (CSF)
CSF white cell count >1000/microlitre
Raised CSF white cell count with protein concentration >1 g/litre
Bacteria on Gram stain.
Corticosteroids should not be given in children younger than 3 months with suspected or confirmed bacterial meningitis.[9]
The first dose of dexamethasone, if indicated, should be given within 4 hours of starting antibiotics (if not given before or with the first dose of antibiotics). Dexamethasone should not be started more than 12 hours after starting antibiotics.[9]
After the first dose of dexamethasone, discuss whether dexamethasone should be continued with a senior paediatrician.[9]
Children or young people with meningococcal sepsis should not be treated with high-dose corticosteroids (defined as dexamethasone 0.6 mg/kg/day or equivalent dose of other corticosteroids).[9]
In children and young people with shock that does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids should be used only when directed by a paediatric intensivist.[9]
Pathogen-targeted antibiotics
If a bacterial cause is identified, give pathogen-targeted antibiotics based on the organism (or likely organism) and its antimicrobial susceptibilities (modify once CSF Gram stain is available, and then again if cerebrospinal fluid culture results are positive).[48]
[ ]
Outpatient intravenous therapy (OPAT) may be considered in patients who are afebrile and clinically improving after receiving inpatient therapy and monitoring. The decision to commence OPAT must be made by a physician familiar with OPAT and should be carried out by a specialist OPAT team.[48]
Based on CSF Gram stain result
Continue intravenous ceftriaxone or cefotaxime if gram-negative diplococci (likely Neisseria meningitidis) are visible on Gram stain of cerebrospinal fluids (CSF).[48]
Continue intravenous ceftriaxone or cefotaxime if gram-positive diplococci (likely Streptococcus pneumoniae) are visible on a Gram stain of CSF.[48]
If the patient has recently travelled to a country where antimicrobial resistance is prevalent or there are other factors that increase the possibility of antimicrobial resistance (or MRSA is identified):[48][49]
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Continue intravenous ceftriaxone or cefotaxime and (if not started empirically) add ampicillin or amoxicillin in patients with gram-positive bacilli suggestive of Listeria monocytogenes on Gram stain of CSF until culture confirmed.[48]
If L monocytogenes is identified, stop intravenous ceftriaxone or cefotaxime.[48] See section Based on positive culture or PCR result, below.
Continue intravenous ceftriaxone or cefotaxime and seek specialist advice on local antimicrobial resistance patterns in patients with gram-negative rods visible on Gram stain.[48]
Give intravenous meropenem if there is a high suspicion that an extended spectrum beta lactamase (ESBL) organism might be present.[48]
Based on positive culture or PCR result
Continue intravenous ceftriaxone or cefotaxime in patients where the following are identified by positive culture or polymerase chain reaction (PCR) result from blood or CSF:[48]
Meningococcal meningitis due to N meningitidis
Intravenous benzylpenicillin may be given as an alternative; follow your local protocol.
Add a single dose of oral ciprofloxacin if the patient is not given ceftriaxone. If ciprofloxacin is contraindicated, give rifampicin twice daily for 2 days as an alternative.
Stop treatment if patients have recovered by day 5.
Haemophilus influenzae
Continue intravenous ceftriaxone or cefotaxime for 10 days.
Enterobacteriaceae
Seek specialist advice on local antimicrobial resistance patterns.
If S pneumoniae is identified:[48]
If the pneumococcus is penicillin sensitive (minimum inhibitory concentration [MIC] <0.06 mg/L) give any of: intravenous benzylpenicillin or intravenous ceftriaxone or intravenous cefotaxime (follow your local protocol)
If the pneumococcus is penicillin resistant (MIC >0.06 mg/L) but cephalosporin sensitive: continue intravenous cefotaxime or ceftriaxone
If the pneumococcus is both penicillin and cephalosporin resistant: continue ceftriaxone or cefotaxime and add vancomycin plus rifampicin
Stop treatment by day 10.
Continue treatment for an additional 4 days (therefore treating for 14 days in total) in patients who have not recovered by day 10 and for patients with penicillin or cephalosporin resistant pneumococcal meningitis.
Give intravenous meropenem if there is a high suspicion that an extended spectrum beta lactamase (ESBL) organism might be present.[48]
If L monocytogenes is identified, stop intravenous ceftriaxone or cefotaxime and treat with ampicillin or amoxicillin for at least 21 days.[48]
Give trimethoprim/sulfamethoxazole or chloramphenicol in patients with a history of severe allergy (e.g., anaphylaxis) to beta-lactams.
Confirmed or probable meningococcal sepsis (no lumbar puncture)
Continue intravenous ceftriaxone or cefotaxime.[48]
Intravenous benzylpenicillin may be given as an alternative.
Add a single dose of oral ciprofloxacin if the patient is not given ceftriaxone. If ciprofloxacin is contraindicated, give rifampicin twice daily for 2 days as an alternative.
Stop treatment if the patient has recovered by day 5.
Continue intravenous ceftriaxone or cefotaxime in patients with a typical petechial/purpuric meningococcal rash but no identified pathogen.[48]
Stop treatment if patients have recovered by day 5.
Unconfirmed but clinically suspected bacterial meningitis
In the patient with no pathogen identified by PCR testing, Gram stain, or culture, but clinically suspected bacterial meningitis, continue empirical antibiotics for 10 days. Stop antibiotics after 10 days if the patient has recovered.[48]
In practice, seek advice from a senior infectious disease or microbiology specialist if a patient with clinically suspected but unconfirmed bacterial meningitis has not completely recovered by 10 days.
Antibiotic allergy
If the patient has an allergy to the recommended antibiotic:
Follow your local protocols and see recommendations above for appropriate alternatives
Consult an infectious disease or microbiology specialist.
Corticosteroids
Continue intravenous dexamethasone for 4 days in patients with confirmed or probable pneumococcal meningitis (i.e., caused by S pneumoniae based on clinical, epidemiological, and CSF parameters.[48]
Corticosteroids are associated with a small reduction in mortality in patients with pneumococcal meningitis (but not other causes) and a reduction in hearing loss and short-term neurological sequelae in meningitis of all causes.[83]
Stop intravenous dexamethasone if a cause other than S pneumoniae is identified.[48]
Urgent transfer to hospital
Arrange urgent transfer to hospital by blue-light ambulance for any patient with suspected bacterial meningitis and/or suspected meningococcal sepsis.[9][48][61]
Where possible, the patient should arrive at hospital within 1 hour of being assessed in the community.[48]
Transfer children and young people with suspected meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics. Give antibiotics if urgent transfer to hospital is not possible.[9]
Document presence or absence of:[48]
Headache
Altered mental status
Neck stiffness
Fever
Rash (of any type)
Seizures
Any signs of shock (e.g., hypotension, poor capillary refill time).
In the UK, the doctor who suspects a diagnosis of meningitis or meningococcal sepsis 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, but general practitioners may wish to check that it has been done.[84]
Pre-hospital antibiotics
Give parenteral empirical antibiotics (intramuscular or intravenous benzylpenicillin in children and adults, or a third-generation cephalosporin such as intravenous cefotaxime or ceftriaxone in adults) as soon as possible in patients with:[9][48]
Signs of meningococcal disease (e.g., a rash in combination with signs of meningism or sepsis)
Signs of sepsis (e.g., hypotension, poor capillary refill time; altered mental state)
Suspected meningitis and a delay of more than 1 hour in getting to hospital.
But do not delay urgent transfer to hospital to give parenteral antibiotics.[9][48]
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[9][48]
The aim of giving pre-hospital antibiotics is to reduce the mortality associated with delays in antibiotic therapy.[48]
Pre-hospital supportive care
Administer oxygen if the patient is unconscious.[84]
Give intravenous fluids if the patient has a rapid heart rate, poor capillary refill time, and cold extremities.[84]
Safety netting for patients not transferred to hospital
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.[84]
Give advice on accessing further healthcare.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the Tumbler test.
Suggest follow-up within a specified period (usually 4-6 hours) if you consider this is appropriate.[84]
Ensure the parent/patient understands how to get medical help after normal working hours.
Liaise directly with other healthcare professionals if you have concerns about a patient who is not being sent to hospital.
Children and young people <16 years admitted to hospital
Before discharging a child or young person who has been diagnosed with meningococcal disease and treated in hospital:[9]
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.
Adults admitted to hospital
Assess patients for potential long-term sequelae before discharge; document the following if present:[48]
Overt hearing loss and/or problems with balance, dizziness, or tinnitus
Other neurological injury resulting in:
Cognitive deficits and learning impairment
Epilepsy
Movement disorders
Visual disturbances
Other communication problems
Wounds, tissue damage, or skin scarring
Amputations or other orthopaedic sequelae
Renal impairment
Psychiatric or psychosocial problems.
See Patient discussions.
Patients seen in hospital or the community and not admitted to hospital
When discharging a child or young person assessed as being at low risk of meningococcal disease after initial observation, advise the parents or carers to return to hospital if the child or young person appears ill to them.[9]
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 healthcare.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the Tumbler test.[84]
Suggest follow-up within a specified period (usually 4-6 hours) if you consider this to be appropriate.[84] Use your clinical judgement.
Ensure the parent/patient understands how to get medical help after normal working hours.
Liaise directly with other healthcare professionals if you have concerns about a patient who is not being sent to hospital.
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