Recommendations
Urgent
Strongly suspect meningococcal disease if the patient has any of the following red flag symptoms:[48]
Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)
Rapidly progressive and/or spreading non-blanching petechial or purpuric rash
Any symptoms and signs of bacterial meningitis, when combined with a non-blanching petechial or purpuric rash. In particular, be alert for the red flag combination of bacterial meningitis symptoms:
Fever
Headache
Neck stiffness
Altered level of consciousness or cognition (including confusion or delirium)
Do not rule out meningococcal disease just because a person does not have a rash.[48]
Some patients present with non-specific symptoms and signs.[48][49]
Early recognition and treatment are crucial because patients can deteriorate very rapidly. Bacterial meningitis and meningococcal sepsis are associated with high morbidity and mortality.[49]
Perform a lumbar puncture if you suspect bacterial meningitis unless the procedure is contraindicated.[48][49]
Children and young people
Be alert to the possibility of bacterial meningitis or meningococcal sepsis when assessing any child or young person with acute febrile illness. Symptoms and signs may be more difficult to identify in babies, children, young people and young adults.[48]
If you suspect meningococcal disease, escalate early.
An appropriate senior clinical decision maker (paediatric or emergency care qualified doctor or equivalent with core competencies in the care of acutely ill children [e.g., ST4 level doctor or above in the UK]) should perform an initial assessment and ensure that:[48]
Antibiotics start within 1 hour of the person with suspected meningococcal disease arriving at hospital
Blood tests are performed before starting antibiotics.
Give intravenous antibiotics (for specific recommendations, see Management recommendations) immediately to a child or young person as part of your initial resuscitation alongside microbial tests if septic shock is suspected, and always within 1 hour of arriving at hospital.[50]
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]
Adults
If the patient is an adult and you suspect meningococcal disease, within 1 hour of their arrival at hospital:[48]
Arrange initial assessment by an appropriate senior clinical decision maker (a clinician with core competencies in the care of acutely ill adult patients [e.g., ST3 level doctor or above in the UK])
Perform a lumbar puncture if you suspect bacterial meningitis (unless contraindicated)
Take bloods for culture.
Give intravenous antibiotics immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[49] Perform a lumbar puncture before giving antibiotics if it is safe to do so and will not cause a clinically significant delay to starting antibiotics.[48][49] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started. For specific recommendations, see Management recommendations.
Assess the need for urgent senior review early using a validated scoring system, such as the National Early Warning Score 2 (NEWS2).[49] Consult local guidelines for the recommended scoring system at your institution.
Key Recommendations
Take concerns expressed by the referring doctor or a carer/relative seriously because clinical features are often not clear cut.[48][49]
Examine the patient’s skin very carefully for a rash. In the initial phases there may be only 1 or 2 petechiae. Document the presence or absence of rash.[49]
Rash in meningococcal sepsis is typically purpuric or petechial (non-blanching) but may take other forms, including a maculopapular rash.[49]
Be aware that rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva).[48]
Tell the person and their family members or carers to look out for any changes in the rash, because it can change from blanching to non-blanching.[48]
Take bloods for:[48]
Blood gas (including lactate and ionised calcium)
Blood glucose
Full blood count
C-reactive protein (CRP) and/or procalcitonin (if available)
Do not rule out meningococcal disease based only on a normal CRP, PCT, or white blood cell count.[48]
Coagulation screen
Blood culture
Take as soon as possible and within 1 hour of arrival at hospital
Take before antibiotics wherever possible
Meningococcal and pneumococcal PCR (EDTA sample)
Urea, creatinine, electrolytes
Liver function tests
Cross match in all children that are seriously unwell
Be aware that meningococcal disease (with or without bacterial meningitis):[48]
Is a rapidly evolving condition
Can present with non-specific symptoms and signs, particularly in young babies (<3 months) and older adults (>65 years)
May be difficult to distinguish from other infections with similar symptoms and signs
Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation
Meningitis and sepsis can occur at the same time, particularly in people with a rash
For people with reduced consciousness or communication difficulties, ask family members or carers about recent changes in symptoms.[48]
The National Institute for Health and Care Excellence (NICE) in the UK highlights the following key symptoms for diagnosing meningococcal disease (red flag symptoms):[48]
Haemorrhagic, non-blanching rash with lesions larger than 2 mm (purpura)
Rapidly progressive and/or spreading rash
Symptoms and signs of meningitis (including neck pain or stiffness, photophobia, and a composite clinical factor of signs or symptoms of meningism)
However, meningococcal disease can present with any combination of the non-specific symptoms and signs of severe illness included in the table below.
Symptoms and signs that may indicate meningococcal disease for babies, children, young people and adults:[48]
Symptom or sign | Further information |
|---|---|
Red flags
|
|
Appearance
|
|
Behaviour
|
|
Cardiovascular |
|
Hydration
| |
Neurological
|
|
Respiratory
|
|
Temperature
|
|
Other
|
Practical tip
People with meningococcal disease may present with predominant sepsis (with or without shock), predominant meningitis (with raised intracranial pressure), or both; some may have meningococcal sepsis with neither shock nor meningitis. Purpuric/petechial non-blanching rash is typical but rash may be atypical or absent in some cases.[49]
More info: Symptoms and signs of bacterial meningitis
After reviewing evidence on diagnostic accuracy, the National Institute for Health and Care Excellence (NICE) in the UK concluded that the following signs and symptoms should be considered a red flag combination for strongly suspecting bacterial meningitis:[48]
Fever (moderately to highly sensitive, but not specific)
Headache (mixed evidence)
Neck stiffness (at least moderately specific and moderately sensitive)
Altered level of consciousness or cognition, including confusion or delirium (at least moderately specific and moderately sensitive).
NICE emphasises that bacterial meningitis should not be ruled out just because a person does not have one or more of the symptoms in the red flag combination; and bacterial meningitis can be strongly suspected based on clinical assessment even in people who do not have the red flag combination.[48]
Signs and symptoms vary depending on the age of the patient. For example, fever is less common in babies and older adults, and headache and neck stiffness are harder to identify in babies and young children. See Bacterial meningitis in adults and Bacterial meningitis in children.
Escalate early. Call an appropriate senior clinical decision maker (paediatric or emergency care qualified doctor or equivalent with core competencies in the care of acutely ill children [e.g., ST4 level doctor or above in the UK]) to perform an initial assessment.
Be alert to the possibility of bacterial meningitis or meningococcal sepsis when assessing any child or young person with acute febrile illness. The National Institute for Health and Care Excellence (NICE) in the UK consider fever, headache, neck stiffness, and altered level of consciousness or cognition to be a ‘red flag’ combination for bacterial meningitis in all age groups.[48] However:
Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation.[48]
Headache and neck stiffness are harder to identify in babies and young children.[48]
Do not be reassured by lack of fever in an unwell baby; more than 50% of neonates diagnosed with bacterial meningitis are afebrile on presentation.[52]
Do not allow a patient’s relatively alert state to mislead you into underestimating the potential degree of cardiovascular collapse. Previously healthy adolescents and young people with meningococcal sepsis often maintain brain perfusion and function until relatively late, despite severe shock.[49]
Shock in young people is not always accompanied by arterial hypotension but may be indicated by high blood lactate level (>4 mmol/L).[49]
Clinical features of meningococcal disease that may occur particularly in babies, children and young people are:[48][52]
Bulging fontanelle (in babies and young children with an open fontanelle)
Ill appearance (ask the child or their family members or carers if they have taken antipyretics because this may make ill appearance harder to identify)
Irritability, lethargy, or unusual behaviour (ask family members or carers about changes in behaviour; children may be agitated, aggressive or subdued)
Reduced feeding
Weak, high-pitched or continuous cry (in babies)
Tachypnoea, apnoea, and grunting (non-specific signs of illness, including sepsis and meningitis in babies)
Headache (present in 75% of children older than 5 years with bacterial meningitis)
Vomiting/nausea (present in 55% to 67% of children with bacterial meningitis)
Photophobia (with bacterial meningitis; harder to identify in babies)
Seizures (9% to 34% of neonates and 10% to 56% of children with bacterial meningitis)
Also take into account:[48]
The level of concern being shown by the parent(s) or carer (particularly in the context of previous illness in the child or young person or in their family). Take any reported or perception of fever by the parent(s) or carer seriously.
How quickly the illness is progressing; patients with meningococcal disease can deteriorate rapidly
Your clinical judgement of the overall severity of the illness.
Take concerns expressed by the referring doctor or a carer/relative seriously because clinical features are often not clear cut.[49]
Consider meningococcal meningitis or meningococcal sepsis if the patient is an adult presenting with any of the following:[48][49]
Fever
Headache
Neck stiffness, including more subtle discomfort or reluctance to move the neck
Altered consciousness or cognition (including confusion or delirium)
Rash
Photophobia
Unexplained body pain, including limb, back or abdominal pain
Vomiting
Seizures
Shock. See Shock.
Some of these signs may be absent and combinations of symptoms and signs may be more useful than individual clinical signs to identify serious disease. The National Institute for Health and Care Excellence (NICE) in the UK consider fever, headache, neck stiffness, and altered level of consciousness or cognition to be a ‘red flag’ combination for bacterial meningitis in all age groups.[48]
Practical tip
Meningitis is the commonest presentation of meningococcal disease in adults, occurring in about 60% of patients. Around 10% to 20% of patients may have evidence of shock or fulminant sepsis with or without meningitis, and up to 30% of patients may have mild disease with fever and a rash but no evidence of either meningitis or shock.[49]
Be aware that clinical presentation can differ in specific populations.[49]
Older patients with bacterial meningitis are more likely to have altered consciousness and less likely to have neck stiffness or fever than younger patients.[49]
Headache and neck stiffness are harder to identify in adults with cognitive impairment; neck stiffness is harder to identify in adults with dementia or arthritis.[48]
The most significant risk factor for bacterial meningitis is age <2 years.[53][54] Infants and neonates <3 months of age are particularly susceptible because they have impaired immunity.[53][54]
In addition, ask the patient or their parent/carer about risk factors associated with increased risk of meningococcal infection, including:[49]
Immunocompromise
People with asplenia or hyposplenia are at increased risk from all encapsulated bacteria, including Neisseria meningitidis[48]
Complement deficiency increases risk of meningococcal disease[48]
Patients on immunosuppressants have depressed cell-mediated immunity and are at increased risk for bacterial meningitis
HIV infection, in particular patients with a low CD4 count or high viral load[26][29][30][31]
Pregnancy
Missed meningococcal vaccinations[48]
Visiting an area with a recent outbreak; consider recent travel abroad[48]
Cranial structural defects[54]
Medical devices (e.g., cochlear implants, cerebrospinal fluid shunts) or recent neurosurgery/ear, nose, or throat surgery[54]
Exposure to pathogens (e.g., contact with another person with meningitis or sepsis)[48][54]
Contiguous infections (e.g., sinusitis, pneumonia, mastoiditis, otitis media)[54]
Crowding (e.g., in a household or dormitory, a student in further or higher education in large shared accommodation)[48][54]
Family history of meningococcal disease infections[48]
Previous episode of meningococcal disease[48]
Younger age
Meningococcal disease has a bimodal distribution in children and young adults with peaks in:
Children aged under 5 years
Adolescents and early adulthood (16-25 years).
Consider any risk factors during the perinatal period. Neonates are at increased risk of bacterial meningitis if:[55]
There is premature or prolonged (>18 hours) rupture of membranes
There is maternal colonisation with group B streptococcus
There is maternal chorioamnionitis
They are premature
They have low birth weight
Prioritise assessing:[49]
Airway
Breathing
Circulation
Disability
Assess conscious level and pupils, and check for signs of raised intracranial pressure
Exposure
Look for a non-blanching rash
Practical tip
Think 'Could this be sepsis?' based on acute deterioration in an adult patient in whom there is clinical evidence or strong suspicion of infection.[51][56][57]
Have a low threshold for suspecting sepsis in children. Clinical presentation of sepsis is often subtle and non-specific and progression to organ failure and shock can be very rapid.
Think ‘Could this be sepsis’ in any child with a suspected infection with signs of a systemic response, which may be indicated by a change in observations or a change in a child’s normal behaviour.[51][58] Always acknowledge parent or carer concern.[51]
Meningitis and sepsis can occur at the same time, particularly in people with a rash.[48]
In adults
The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[51][56][57]
Remember that sepsis represents the severe, life-threatening end of infection.[59]
In children
If you suspect sepsis, use a standard ABC (airway, breathing, circulation) approach with particular emphasis on early administration of antibiotics and fluid resuscitation.[60][61]
Initiate treatment as soon as possible and always within the first hour following recognition of severe sepsis.[60][61]
Protocolised care bundles such as The Paediatric Sepsis Six initiative, have proven to be important in the management of paediatric sepsis and should be used in management alongside local guidelines.[5][49][62][63][64][65][66][67][68][69][70][71]
Use paediatric early warning scores (PEWS) for risk stratification in line with local protocols; however, PEWS must not be used as a substitute for clinical assessment. If a child appears unwell to a health professional, this should trigger further assessment independent of PEWS score.[50][72]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2] and PEWS), alongside your clinical judgement, for assessment; urgently consult a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis.[50][51][57][58][73]
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[50][74]
In the community and in custodial settings: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[51]
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis
See Sepsis in adults and Sepsis in children.
Gain vascular access (insert two large intravenous cannulae or establish intraosseous access).
Assess initially for signs of:
Raised intracranial pressure[48]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale of 9 or less or a progressive and sustained or rapid fall in level of consciousness) [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those under 2 years), use the AVPU scale (Alert, Voice, Pain, Unresponsive).
New focal neurological signs, including seizures or posturing
Abnormal pupillary reactions
More info: Clinical signs of meningism (meningeal irritation)
Kernig’s sign and Brudzinski’s sign are classical signs of meningeal irritation used since the early 20th century to aid the diagnosis of meningitis.[75] Kernig’s sign is the inability to straighten the leg when the hip is flexed to 90 degrees, and Brudzinski’s sign is severe neck stiffness causing the patient’s hips and knees to flex when the neck is flexed.
The 2024 UK National Institute for Health and Care Excellence (NICE) guideline on recognition, diagnosis and management of bacterial meningitis and meningococcal disease does not recommend checking for Brudzinski's or Kernig’s sign for suspected bacterial meningitis. This is due to their low sensitivity and the difficulty in eliciting these signs, particularly in babies.[48] NICE notes that these signs were introduced at a time when people often presented later (after a few days) and antibiotics did not exist.[48]
The 2016 UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults states that Kernig's sign and Brudzinski's sign should not be relied upon for diagnosis of suspected meningitis, noting that sensitivity can be as low as 5%, despite their high specificity (up to 95%).[49]
Children and young people
Examine the patient’s skin very carefully for a rash. Always document its presence or absence.[48][49]
In practice, a petechial or purpuric rash is typically associated with meningococcal disease, but it may be present with any type of bacterial meningitis.
In the initial phases there may be only 1 or 2 petechiae.
Rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva).
Remember to check the nappy area.[48]
Tell the person and their family members or carers to look out for any changes in the rash, because it can change from blanching to non-blanching.[48]
Children with petechiae confined to the skin above the nipple line (the distribution of the superior vena cava) may be less likely to have meningococcal disease than those with petechiae below the nipple line.[76]
Be aware of the signs of shock in children:[77][78][79]
Prolonged capillary refill time (e.g., more than 2-3 seconds)
Cold hands/feet
Weak, fast pulse
Pale/mottled/ashen/blue skin, lips or tongue
Other indicators of critical illness in children include decreased level of consciousness, decreased urine output, hypoxia (check arterial blood gas or oxygen saturations), and elevated lactate levels.[74][80]
Measure and record the following at least every hour, in line with local protocols and/or your institution’s recommended early warning or risk stratification system (e.g., Paediatric Early Warning Systems [PEWS]):[50][81]
Heart rate
Respiratory rate and extent of respiratory distress
Oxygen saturations
Blood pressure
Temperature
Perfusion (capillary refill)
Neurological assessment (such as the Alert, Voice, Pain, Unresponsive [AVPU] scale)
Practical tip
In children aged ≤5 years, do not routinely use measurements of oral and rectal temperature to determine body temperature.[80]
Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla[80]
In children aged 4 weeks to 5 years, use of one of the following:[80]
Electronic thermometer in the axilla.
Chemical dot thermometer in the axilla. However, use an alternative type of thermometer if multiple temperature measurements are required.
Infra-red tympanic thermometer.
Do not use forehead chemical thermometers because they are unreliable.[80]
Adults
Assess the need for urgent senior review early using a validated scoring system. Consult local guidelines for the recommended scoring system at your institution. If you are using the National Early Warning Score 2 (NEWS2):[49]
Arrange urgent assessment by a team with critical care competencies if the patient has an aggregate score ≥7
Arrange urgent review by a clinician competent to assess the acutely ill patient with an aggregate score of 5/6 (or score of 3 in any single physiological parameter)
Do not be falsely reassured if the patient’s NEWS2 score is lower than an aggregate score of 5/6 (or score of 3 in any single physiological parameter) because patients with meningitis, particularly those with meningococcal sepsis, can deteriorate rapidly.
Rash
Examine the patient’s skin very carefully for rash and document its presence or absence.[49]
In the initial phases there may be only 1 or 2 petechiae.
Rash in meningococcal sepsis is typically purpuric or petechial (non-blanching) but may take other forms, including a maculopapular rash.[49]
Rash may be atypical or absent in some cases.[82]
Rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva).[48]
In general, do not delay giving antibiotics and other treatments while waiting for investigations if you suspect bacterial meningitis clinically. However, in practice, always use your clinical judgement - lumbar puncture (the most important investigation for suspected bacterial meningitis) can be performed before giving antibiotics if the patient is clinically stable, as long as there are no contraindications and lumbar puncture can be done promptly. See Lumbar puncture below.
Blood tests
Blood gas (including lactate and ionised calcium)
Blood glucose
Full blood count
C-reactive protein (CRP) and/or procalcitonin (PCT) (if available)
Do not rule out meningococcal disease based only on a normal CRP, PCT, or white blood cell count.[48]
Coagulation screen
Blood culture
Take as soon as possible and within 1 hour of arrival at hospital
Take before antibiotics wherever possible
Meningococcal and pneumococcal PCR (EDTA sample)
Urea, creatinine, electrolytes
Liver function tests
Cross match in all children that are seriously unwell.
Test for HIV in adults with bacterial meningitis or meningococcal disease, and consider testing for HIV in babies, children and young people if they have signs of immunodeficiency or risk factors for HIV.[48]
Practical tip
If blood volume is limited, prioritise: blood gas, lactate, glucose, electrolytes, full blood count, coagulation.
PCR test for Neisseria meningitidis
Perform whole blood real-time polymerase chain reaction (PCR) testing (EDTA sample) for N meningitidis to confirm a diagnosis of meningococcal disease.[48]
Take the blood sample for PCR testing as soon as possible because early samples are more likely to be positive.
Use PCR testing of blood samples from other hospital laboratories if available, to avoid repeating the test.
Be aware that a negative blood PCR test result for N meningitidis does not rule out meningococcal disease.
Submit cerebrospinal fluid (CSF) obtained during lumbar puncture (see below) to the laboratory for PCR testing for relevant pathogens (e.g., N meningitidis and Streptococcus pneumoniae). Store the remaining cerebrospinal fluid in case more tests are needed.[48]
Lumbar puncture
Perform a lumbar puncture before starting antibiotics, unless it is not safe to do so or it will cause a clinically significant delay to starting antibiotics.[48]
In practice, timing of lumbar puncture is a clinical decision. Seek senior advice if you are unsure.
Treat and stabilise any of the following before performing a lumbar puncture:[48]
Unprotected airway
Respiratory compromise
Shock
Uncontrolled seizures
Bleeding risk
Do not perform lumbar puncture if there are the following:[48]
Extensive or rapidly spreading purpura
Infection at the lumbar puncture site
Risk factors for an evolving space-occupying lesion (see Cranial computed tomography section below)
Any of the following symptoms or signs which might indicate raised intracranial pressure:
new focal neurological features (including seizures or posturing)
abnormal pupillary reactions
a Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness
Practical tip
Use your clinical assessment to decide whether it is safe to perform a lumbar puncture. Do not routinely perform neuroimaging before lumbar puncture. Evidence shows that performing a lumbar puncture without waiting for a CT scan leads to people receiving antibiotic treatment sooner, which may reduce mortality and morbidity.[48]
However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.
CSF assessment should include:[48]
Red and white blood cell count and examination (including differential white cell count)
Total protein concentration
Glucose concentration
Microscopy with gram stain
Microbiological culture and sensitivities, checking for the causative organism N meningitidis
PCR for relevant pathogens (including N meningitidis and S pneumoniae)
Request CSF results promptly. Store remaining cerebrospinal fluid in case more tests are needed.[48]
CSF white blood cell counts, total protein, and glucose concentrations should be available within 4 hours to inform decision making on adjunctive corticosteroid therapy.[48]
Interpret cerebrospinal fluid results using standard age-appropriate threshold values.
Normal thresholds for white cell count and protein may be higher in babies under 3 months.
Remember earlier antibiotics or immunodeficiency may reduce the diagnostic reliability of these investigations.
Red cells in the sample may suggest blood contamination or a different diagnosis.
If cerebrospinal fluid results are abnormal, consider alternative viral, mycobacterial, fungal or non-infectious causes as well as bacterial meningitis.[48] See Differentials.
If no CSF is available for examination or the CSF findings are uninterpretable, manage as if a diagnosis of bacterial meningitis is confirmed.
Cranial computed tomography
Do not routinely perform neuroimaging before lumbar puncture.[48]
Only perform cranial imaging before lumbar puncture if there are:
Risk factors for an evolving space-occupying lesion[52][83][84]
Any of the following clinical features, which might indicate raised intracranial pressure
new focal neurological features (including seizures or posturing)[48]
abnormal pupillary reactions or papilloedema[49]
a Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness[48] Glasgow Coma Scale: modification for children Opens in new window [ Glasgow Coma Scale Opens in new window ]
Do not perform a lumbar puncture until these factors have been addressed.[48]
Neuroimaging is not indicated unless you suspect alternative pathology (i.e., because there are signs indicating risk of cerebral herniation).[49]
Consider CT or magnetic resonance imaging (MRI) in patients with a history of trauma, recent neurosurgery, rhinorrhoea, or otorrhoea to identify any source of CSF leak and source of contiguous spread of infection to the meninges.[85][86]
Practical tip
Do not use CT to decide whether it is safe to perform a lumbar puncture; use your clinical assessment instead. CT scan will not pick up raised intracranial pressure per se, but it may identify conditions associated with raised ICP such as a tumour or brain abscess, or meningitis-associated complications such as brain infarction, generalised cerebral oedema, or hydrocephalus.[52][87] However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.
More info: Timing of cranial imaging in relation to lumbar puncture
This has been a controversial area.[49][88][89] One review of the evidence in 2024 resulted in the UK National Institute for Health and Care Excellence (NICE) recommending against routinely performing neuroimaging before lumbar puncture.[48]
Delaying lumbar puncture for a CT scan can cause delays in antibiotic administration, which may lead to an increase in mortality.[48][90][91]
Lumbar puncture without prior CT is also associated with lower rates of neurological and/or hearing deficits and functional impairment, and a shorter time to antibiotic treatment (with or without corticosteroids), relative to lumbar puncture after CT.[48]
Magnetic resonance imaging (MRI)
Consider CT or MRI in patients with a history of trauma, recent neurosurgery, rhinorrhoea, or otorrhoea to identify any source of cerebrospinal fluid leak and source of contiguous spread of infection to the meninges.[85]
Throat swab
Take a throat swab for meningococcal culture (N meningitidis), preferably before starting antibiotics.[48]
Screen for predisposing factors
Be aware of the heightened possibility of meningococcal disease in people with any of these risk factors:[48]
Missed meningococcal vaccinations
Reduced or absent spleen function
Complement deficiency or inhibition
They are a student in further or higher education, particularly if they are in large shared accommodation (such as halls of residence)
A family history of meningococcal disease
They have been in contact with someone with meningococcal disease, or have been in an area with an outbreak
A previous episode of meningococcal disease.
The main risk factor for recurrent meningococcal disease is primary or secondary immunodeficiency, including HIV, congenital complement deficiency or acquired inhibition, and reduced or absent spleen function.[48]
Any communication between the cerebrospinal fluid and external surface (e.g., prior trauma or surgery, or a congenital anomaly) increases risk for recurrent bacterial meningitis.[48]
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