Meningococcal disease

Back

1st line –

infection control

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.[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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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 the child 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) 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

If the patient is self-ventilating and there are signs of respiratory distress, give 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

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][51] The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[82] Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[9][51]

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[51]

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][51] Continue to reassess the patient after each fluid bolus to assess for clinical response and signs of fluid overload.[9][51]

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.[51]
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.[9] Local or national protocols should be followed.[9]

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][51]

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

Seizures

Follow local or national protocols to manage seizures.[9] See Generalised seizures in children.

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.[9]

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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 <3 months of age 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.

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.

Primary options

ceftriaxone: neonates: consult specialist for guidance on dose; children ≥1 month of age: 80-100 mg/kg intravenously every 24 hours, maximum 4 g/day

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

ceftriaxone: neonates: consult specialist for guidance on dose; children ≥1 month of age: 80-100 mg/kg intravenously every 24 hours, maximum 4 g/day

-- AND --

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

Consider – vancomycin

3 months to 15 years of age

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

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. Discuss fluid management with a paediatric intensivist and follow your local protocols.

Correct dehydration (if present) 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

Shock

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[51]

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.[51]
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.[9]Local or national protocols should be followed.[9]

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][51]

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

Seizures

Follow local or national protocols to manage seizures.[9] See Generalised seizures in children.

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.[9]

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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 instead) if giving calcium-containing infusions.[9]

Primary options

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

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

Consider – vancomycin

Consider – corticosteroid

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:[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]

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 safety netting advice. See Discharge under Management recommendations.

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Dexamethasone should be given as soon as possible in children ≥3 months of age with suspected or confirmed bacterial meningitis, 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/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.[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]

Primary options

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

16 to 59 years of age and immunocompetent

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.

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 (GCS) 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 GCS <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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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.

Use chloramphenicol instead if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49] Follow your local protocols and consult an infectious disease or microbiology specialist.

Primary options

cefotaxime: 2 g intravenously every 6 hours

ceftriaxone: 2 g intravenously every 12 hours

Secondary options

chloramphenicol: 25 mg/kg intravenously every 6 hours

Consider – corticosteroid

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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]

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

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.

Intravenous corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[49]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

≥60 years of age and immunocompetent; ≥16 years of age and immuncompromised

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.

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

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 (GCS) 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 GCS <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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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][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.

Give chloramphenicol plus trimethoprim/sulfamethoxazole if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49] Follow your local protocols and consult an infectious disease or microbiology specialist.

Primary options

cefotaxime: 2 g intravenously every 6 hours

ceftriaxone: 2 g intravenously every 12 hours

-- AND --

amoxicillin: 2 g intravenously every 4 hours

ampicillin: 2 g intravenously every 4 hours

Secondary options

chloramphenicol: 25 mg/kg intravenously every 6 hours

and

trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours

Consider – corticosteroid

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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]

Back

Consider –

corticosteroid

Additional treatment recommended for SOME patients in selected patient group

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.

Intravenous corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[49]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

suspected meningococcal sepsis: presenting in hospital

<16 years of age

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.[9]

Fluid resuscitation

Correct dehydration (if present) using enteral fluids or feeds, or intravenous isotonic fluids.[9] Follow your local protocols.

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

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] Give 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).

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]

Metabolic disturbances

Anticipate, monitor, and manage the following metabolic disturbances 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

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]

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Give children and young people aged with suspected meningococcal disease intravenous ceftriaxone without delay.[9] [ ]

Do not give ceftriaxone (use cefotaxime) if giving calcium-containing infusions.[9]

Primary options

ceftriaxone: neonates: consult specialist for guidance on dose; children ≥1 month to 11 years of age: 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: neonates: consult specialist for guidance on dose; children: 50 mg/kg intravenously every 6 hours, maximum 12 g/day

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:[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]

16 to 59 years of age and immunocompetent

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.

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

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 (GCS) 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 GCS <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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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.

Primary options

cefotaxime: 2 g intravenously every 6 hours

ceftriaxone: 2 g intravenously every 12 hours

Secondary options

chloramphenicol: 25 mg/kg intravenously every 6 hours

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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]

≥60 years of age and immunocompetent; ≥16 years of age and immuncompromised

Back

1st line –

infection control

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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.

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

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 (GCS) 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 GCS <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]

Seizures

Manage suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Primary options

cefotaxime: 2 g intravenously every 6 hours

ceftriaxone: 2 g intravenously every 12 hours

-- AND --

amoxicillin: 2 g intravenously every 4 hours

ampicillin: 2 g intravenously every 4 hours

Secondary options

chloramphenicol: 25 mg/kg intravenously every 6 hours

and

trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours

1st line – emergency transfer to hospital

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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]

suspected meningococcal disease (meningitis or sepsis): presenting in the community

Back

1st line –

emergency 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).

Safety netting

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 safety netting advice.

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.

Advise parents or carers of children and young people to go/return to hospital if the child or young person appears ill to them.[9]

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.

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.[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.

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]

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 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]

Primary options

benzylpenicillin sodium: adults: 1.2 g intravenously/intramuscularly as a single dose

cefotaxime: adults: 2 g intravenously/intramuscularly as a single dose

ceftriaxone: adults: 2 g intravenously/intramuscularly as a single dose

Consider – supportive care

ACUTE

confirmed or probable bacterial meningitis (including meningococcal meningitis)

<3 months of age

Back

1st line –

pathogen-targeted antibiotics

Give an intravenous cephalosporin once the diagnosis of meningococcal infection is confirmed based on the organism identified and antimicrobial sensitivities.[9] [ ]

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]

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 --

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

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.[9]

Fluid resuscitation

Assess the child with suspected bacterial meningitis for all of the following:[9]

Signs of shock
Raised intracranial pressure
Signs of dehydration.

Correct dehydration (if present) 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

If the patient is self-ventilating and there are signs of respiratory distress, give 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 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

Shock

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[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.
- 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.[9] Local or national protocols should be followed.[9]

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

Seizures

Follow local or national protocols to manage seizures.[9] See Generalised seizures in children.

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.[9]

3 months to 15 years of age

Back

1st line –

pathogen-targeted antibiotics

Treat Haemophilus influenzae type b meningitis with intravenous ceftriaxone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.[9]

TreatStreptococcus 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] [ ]

Primary options

ceftriaxone: children ≥3 months to 11 years of age: 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

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.[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

Correct dehydration (if present) 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 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

Shock

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[51]

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.[51]
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.[9] Local or national protocols should be followed.[9]

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][51]

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

Seizures

Follow local or national protocols to manage seizures.[9] See Generalised seizures in children.

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.[9]

Consider – continue corticosteroid

≥16 years of age

Back

1st line –

pathogen-targeted antibiotics

Give pathogen-targeted antibiotics based on the organism identified (or likely organism) and its antimicrobial susceptibilities.[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]

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.

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.

Give intravenous meropenem if there is a high suspicion that an extended spectrum beta lactamase (ESBL) organism might be present.[48]

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.

See empirical antibiotics in suspected bacterial meningitis section above or check local protocols for doses.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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

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

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 (GCS) 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 GCS <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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.

Consider – continue corticosteroid

Back

Consider –

continue corticosteroid

Additional treatment recommended for SOME patients in selected patient group

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]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

confirmed or probable meningococcal disease

<16 years of age

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.[9]

Fluid resuscitation

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 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

Shock

Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.[51]

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.[51]
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.[9] Local or national protocols should be followed.[9]

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 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

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]

≥16 years of age

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supportive care

Treatment recommended for ALL patients in selected patient group

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.

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

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 (GCS) 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 GCS <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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[48] See Generalised seizures.

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]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.