Recommendations
Urgent
Ensure that a senior clinical decision maker performs an initial assessment and that:[48]
Antibiotics start within 1 hour of the patient with suspected meningococcal disease arriving at hospital.
Blood tests are performed before starting antibiotics.
Children and young people
Escalate early. Initial assessment should be carried out by 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]).[48]
Give empirical antibiotics immediately to a child or young person as part of resuscitation and alongside microbial tests if septic shock is suspected, and always within 1 hour of arriving at hospital.[48][50][78]
Give fluids immediately if there are signs of shock in a child or young person with suspected or confirmed sepsis.[78]
Urgent intensive care support is required if there are signs of shock despite initial fluid resuscitation.
Adults
Within the first hour of arriving at hospital:[49]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration[56][57][73][74]
Arrange urgent review by an appropriate senior clinical decision-maker (e.g., a clinician with core competencies in the care of acutely ill patients, usually ST3 level doctor or above in the UK):[48][50][51]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6) or within 1 hour of any intervention for suspected sepsis (antibiotics/fluid resuscitation/oxygen) if there is no improvement in the patient’s condition
A patient is also at high risk of severe illness or death from sepsis if they have a NEWS2 score below 7, or a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk.
Make a decision on the need for senior review and/or intensive care admission
Start treatment with empirical antibiotics and supportive care.
Give empirical antibiotics immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[49][97]
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.[49] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
Get immediate critical care input for any patient with suspected meningococcal disease who has:[97]
Suspected meningitis with signs suggestive of shift of brain compartments secondary to raised intracranial pressure: focal neurological signs; presence of papilloedema; continuous or controlled seizures; Glasgow Coma Scale score ≤12
Signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).
In the community
Arrange emergency transfer to hospital by blue-light ambulance for any patient with suspected bacterial meningitis and/or meningococcal sepsis.[48][51] Tell the hospital that a patient with suspected bacterial meningitis or meningococcal disease is being transferred and that they will need assessment by a senior clinical decision maker.[48]
Give parenteral empirical antibiotics to patients with strongly suspected meningococcal disease as soon as possible, unless this will delay transfer to hospital.[48][49]
Do not delay transfer to hospital to give antibiotics.[48][49]
Give antibiotics to patients with suspected meningitis and/or sepsis and an anticipated delay of more than 1 hour in getting to hospital.[49][51]
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[48][49]
Key Recommendations
Early treatment is crucial because patients with meningococcal disease can deteriorate very rapidly.
Bacterial meningitis and meningococcal sepsis are associated with high morbidity and mortality.[49]
Respiratory isolate all patients with suspected meningitis or meningococcal sepsis until meningococcal meningitis or meningococcal sepsis is excluded (or considered unlikely) or ceftriaxone (or other recommended antibiotic) has been given for 24 hours (or a single dose of ciprofloxacin).[49][97]
Notify:
Microbiology[97]
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7][49]
Monitor the patient closely for signs of:[48][49][50][78]
Raised intracranial pressure (i.e., regular GCS monitoring and clinical evaluation for new neurological signs or abnormal pupillary reactions)
Shock
Dehydration
Request specialist/critical care input if needed and provide supportive treatment.
Start antibiotics targeting the causative organism as soon as it is identified, taking account of antibiotic sensitivities.[48][49]
Early treatment is crucial because patients with meningococcal disease can deteriorate very rapidly.
Recognise and treat early to reduce deaths and disability.
Implement measures to ensure risk of transmission is minimised.
Respiratory isolate all patients with suspected meningitis or meningococcal sepsis until meningococcal meningitis or meningococcal sepsis is excluded (or considered unlikely) or ceftriaxone (or other recommended antibiotic) has been given for 24 hours (or a single dose of ciprofloxacin).[49][97]
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.[49]
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).[49]
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7][49][98]
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49] They will initiate prophylaxis of contacts.
Escalate early. Initial assessment should be carried out by 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]).[48]
Empirical antibiotics
Give children and young people aged 1 month and older intravenous ceftriaxone or cefotaxime for suspected or confirmed meningococcal disease in hospital.[48][100]
Give infants aged <1 month with meningococcal sepsis acquired in the community:[100]
Intravenous cefotaxime or ceftriaxone plus intravenous amoxicillin.
Amoxicillin is used to cover Listeria monocytogenes, which is rare in the UK.[101] Although amoxicillin is not commonly used in UK practice for suspected bacterial meningitis, age <28 days (neonatal period) is a specific risk factor for listeria meningitis.
Do not give ceftriaxone to premature babies or babies receiving calcium-containing infusions.[51] Ceftriaxone should also be avoided in babies with jaundice and any of the following:[100]
bilirubin level ≥200 micromoles/L
hypoalbuminaemia, or
acidosis.
Have a low threshold for adding intravenous aciclovir to cover for herpes simplex virus (HSV) infection in infants aged <1 month with suspected central nervous system infection or sepsis. Features that can suggest HSV infection include:[100]
ALT or AST >2x upper limit of normal, coagulopathy
vesicles
seizures
CSF pleocytosis
suspected meningitis/encephalitis
recent maternal herpes simplex disease OR
postnatal contact with herpes simplex virus.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]
Antibiotic allergy or immunocompromise
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
Within the first hour of arriving at hospital:[49]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Make a decision on the need for senior review and/or intensive care admission
Start treatment with empirical antibiotics and supportive care. [
]
Empirical antibiotics
If the patient is an adult with suspected bacterial meningitis or suspected meningococcal disease, choose the most appropriate antibiotic based on the patient’s age and immunocompetence.[49]
Immunocompetent adults aged under 60 years
Give intravenous ceftriaxone immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[48][49][97] Alternatively, consider intravenous cefotaxime.[49][97]
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.[49] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
If the patient has recently travelled to a country where antimicrobial resistance is prevalent or there are other factors that increase the possibility of antimicrobial resistance (or if MRSA is identified):[49][97]
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Use chloramphenicol instead if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49][97]
Aged ≥60 years or immunocompromised (including alcohol dependency and diabetes)
Give intravenous ceftriaxone or cefotaxime plus amoxicillin or ampicillin immediately after blood cultures have been taken and definitely within the first hour of arrival at hospital.[49]
Additional antibiotic cover is recommended because adults who are aged 60 years or older or immunocompromised are at increased risk of Listeria monocytogenes.[48]
Some guidelines recommend giving antibiotics after LP (where LP is indicated and as long as LP is not delayed) to allow the best chance of definitive diagnosis.[49] Bear in mind, however, that prompt molecular tests will still identify the causative organism even after antibiotics have been started.
If the patient has recently travelled to a country where antimicrobial resistance is prevalent or there are other factors that increase the possibility of antimicrobial resistance (or if MRSA is identified):[49][97]
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Give chloramphenicol plus trimethoprim/sulfamethoxazole if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[49][97]
Antibiotic allergy
If the patient has an allergy to the recommended antibiotic:[48]
Ask about the reaction they get.
Give ceftriaxone if their reaction was not severe allergy.
If their reaction was severe allergy, get advice from an infectious disease or microbiology specialist and consider chloramphenicol.
Escalate early. Initial assessment should be carried out by 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]).[48] Consult a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care if a patient with meningococcal sepsis does not respond within 1 hour of any intervention.[51][82]
If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.
Fluid resuscitation
Assess children and young people with suspected meningococcal sepsis or bacterial meningitis for all of the following:[48][49][50][78]
Raised intracranial pressure
Shock
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) in children and young people with suspected meningococcal sepsis and/or bacterial meningitis using enteral fluids or feeds, or intravenous isotonic fluids.[48][51] Follow your local protocols.
Do not routinely restrict fluids to below routine maintenance needs.
Give maintenance fluid enterally if tolerated, orally or by enteral tube.
Give a bolus of 10 mL/kg over less than 10 minutes to patients with meningococcal sepsis who need intravenous fluid resuscitation.[51]
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[102]
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[102]
Respiratory support
Give oxygen to people under 18 years with suspected meningococcal sepsis who have signs of shock or oxygen saturation (SpO₂) of less than 92% when breathing air.[51]
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]
Ensure that appropriate respiratory support is provided for patients with respiratory compromise. Consult a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care if a patient with meningococcal sepsis has persistent hypoxia, respiratory distress, or inadequate ventilation, or if a patient requiring respiratory support does not respond within 1 hour.[50][51]
Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.
Shock
If there are signs of shock, give an immediate intravenous fluid bolus of isotonic crystalloid (such as sodium chloride 0.9%, Plasmalyte®, or Hartmann's solution [lactated Ringer's solution]), over 5-10 minutes.[51] The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103] Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]
Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care.
If signs of shock persist, give further fluid boluses of intravenous crystalloid over 5-10 minutes. Continue to reassess the patient after each fluid bolus to assess for clinical response and signs of fluid overload.[102]
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[102]
Seek urgent expert advice (e.g., from the paediatric intensive care team).[102]
Vasoactive agents should be initiated early, and following the advice from a paediatric intensivist or experienced members of the critical care team.[78]
If the patient does not respond to vasoactive agents, corticosteroid replacement therapy using low-dose corticosteroids may be used, but only when directed by a paediatric intensivist.[78] Local or national protocols should be followed.
Consider giving further fluid boluses under senior guidance, based on clinical signs and laboratory investigations (such as blood gases).
Practical tip
If you are working in a setting without access to critical care and a child with sepsis has normal blood pressure, the paediatric Surviving Sepsis Campaign recommend starting maintenance fluids without administering a fluid bolus.[78] This recommendation is based on the FEAST trial, in which rapid bolus fluid in the first hour of resuscitation given in a resource-limited setting increased mortality compared with maintenance fluids only.[104][105]
If you are working in a setting without access to critical care and the child is hypotensive, up to 40 mL/kg in bolus fluid is recommended over the first hour, given as individual boluses of 10-20 mL/kg at a time and titrated according to clinical markers of cardiac output. This should be discontinued if signs of fluid overload develop (i.e., increased work of breathing, pulmonary crepitations, hepatomegaly, gallop rhythm).[78]
Reassess and monitor need for intensive care
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:[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)
Be aware that children and young people with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity.[48] Escalate early.
Discuss any child or young person who needs resuscitation with a paediatric intensivist as soon as possible.
Be alert for metabolic disturbances in children and young people with suspected or confirmed meningococcal sepsis, which may indicate more severe disease. Manage according to local or national protocols.
Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as an adverse effect of corticosteroid treatment.
Hypoglycaemia may occur as a result of depleted glycogen stores. Even brief episodes of severe hypoglycaemia during septic shock may be a risk factor for poor developmental outcomes in children.[78]
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]
Corticosteroids
Do not routinely give corticosteroids to children with meningococcal disease.[48]
Consider low-dose replacement corticosteroids for children with meningococcal septic shock that is not responding to high-dose vasoactive agents, under the direction of a paediatric intensivist.[48] Get infectious disease specialist advice on using dexamethasone for younger babies.[48]
Give intravenous dexamethasone to children aged ≥3 months with strongly suspected or confirmed bacterial meningitis.[48] Get infection specialist advice on using dexamethasone for babies aged between 28 days and 3 months old with strongly suspected or confirmed bacterial meningitis.[48] See Bacterial meningitis in children.
Seizures
Follow local or national protocols to treat seizures in children and young people with suspected bacterial meningitis or meningococcal sepsis. See Generalised seizures in children.
Raised intracranial pressure
Follow local or national protocols to treat raised intracranial pressure.
Within the first hour of arriving at hospital:[49]
Stabilise the patient’s airway, breathing, and circulation as an immediate priority
Document the patient’s level of consciousness using the Glasgow Coma Scale [ Glasgow Coma Scale Opens in new window ]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration[56][57][73][74]
Arrange urgent review by an appropriate senior clinical decision-maker (e.g., a clinician with core competencies in the care of acutely ill patients, usually ST3 level doctor or above in the UK):[48][50][51]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns)
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6) or within 1 hour of any intervention for suspected sepsis (antibiotics/fluid resuscitation/oxygen) if there is no improvement in the patient’s condition
A patient is also at high risk of severe illness or death from sepsis if they have a NEWS2 score below 7 or a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk.
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).[97]
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).[97]
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]
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.[49]
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]
Suspected or confirmed meningitis with signs suggestive of shift of brain compartments secondary to raised intracranial pressure: focal neurological signs; presence of papilloedema; continuous or controlled seizures; Glasgow Coma Scale score ≤12 [ Glasgow Coma Scale Opens in new window ]
Rapidly evolving rash (with or without symptoms and signs of meningitis).
Intubation should be strongly considered in patients with a Glasgow Coma Scale score <12.[49]
Shock
Vasoactive agents may be needed.[49] 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][49]
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]
Reassess and monitor need for intensive care
Involve intensive care teams early in patients with:[49]
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:[49]
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.[49]
Corticosteroids
Do not routinely give corticosteroids to patients with meningococcal disease.[48]
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:[49][97]
[ ]
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.
If dexamethasone is delayed for more than 12 hours after the start of antibiotics, get advice from a microbiologist or infectious diseases consultant.[48]
Corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[97]
Consider low-dose hydrocortisone in patients with persisting hypotensive shock despite use of high-dose vasoactive agents.[48][49]
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised[49]
Seizures
Manage suspected or proven seizures early; follow your local protocol.[49] See Generalised seizures in adults.
Seizures have been reported to occur in 15% of adult patients with acute bacterial meningitis and are associated with worse outcomes, so start anticonvulsant treatment promptly even when seizures are suspected but not proven.[49]
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.[49] 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.[49] Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
Pathogen-targeted antibiotics
Give an intravenous cephalosporin once the diagnosis of meningococcal infection is confirmed, based on the organism identified and antimicrobial sensitivities.[48]
[ ]
Confirmed or probable bacterial meningitis (including meningococcal meningitis)
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]
In particular, 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.[52][107]
Give ceftriaxone for meningitis caused by N meningitidis unless ceftriaxone is contraindicated. After 5 days, stop antibiotics if the patient has recovered, or get advice from an infection specialist if they have not.
Consider cefotaxime if ceftriaxone is contraindicated (e.g., if a pre-term baby is receiving a calcium infusion).[48]
If the child has an antibiotic allergy:[48]
Ask about the reaction they get.
Give ceftriaxone if their reaction was not severe allergy.
Get advice from an infectious disease or microbiology specialist and consider chloramphenicol, and/or follow your local protocols.
Give ceftriaxone for Streptococcus pneumoniae, Haemophilus influenzae type b, group B streptococcus, and Enterobacterales (coliforms). Give intravenous amoxicillin or ampicillin for meningitis caused by Listeria monocytogenes.[48]
See Bacterial meningitis in children.
Confirmed meningococcal disease (Neisseria meningitidis) without meningitis
Give intravenous ceftriaxone to children and young people with suspected or confirmed meningococcal disease in hospital.[48]
Stop antibiotics if the person has recovered after 5 days; get advice from an infectious disease or microbiology specialist if they have not.[48]
If the child has an antibiotic allergy:[48]
Ask about the reaction they get.
Give ceftriaxone if their reaction was not severe allergy.
Get advice from an infectious disease or microbiology specialist and consider chloramphenicol, and/or follow your local protocols.
Corticosteroids
Do not routinely give corticosteroids to children with meningococcal disease.[48]
Consider low-dose replacement corticosteroids for children with meningococcal septic shock that is not responding to high-dose vasoactive agents, under the direction of a senior emergency medicine or paediatric physician, or paediatric intensivist where available.[48] Get infectious disease specialist advice on using dexamethasone for younger babies.[48]
Give intravenous dexamethasone to children aged ≥3 months with strongly suspected or confirmed bacterial meningitis.[48] See Bacterial meningitis in children.
Pathogen-targeted antibiotics
Confirmed or probable bacterial meningitis (including meningococcal meningitis)
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]
If a bacterial cause is identified, give pathogen-targeted antibiotics based on the organism (or likely organism) and its antimicrobial susceptibilities.
Give ceftriaxone for meningitis caused by N meningitidis unless ceftriaxone is contraindicated. After 5 days, stop antibiotics if the patient has recovered, or get advice from an infection specialist if they have not.[48] Consider cefotaxime if ceftriaxone is contraindicated.[48]
Give ceftriaxone for S pneumoniae, H influenzae type b, group B streptococcus, and Enterobacterales (coliforms). Give intravenous amoxicillin or ampicillin for meningitis caused by Listeria monocytogenes.[48]
Modify antibiotic therapy once CSF Gram stain is available, and then again if cerebrospinal fluid culture results are positive, in line with microbiologist or infectious diseases specialist advice.[49]
[ ]
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.[49]
See Bacterial meningitis in adults.
Unconfirmed but clinically suspected bacterial meningitis
In the patient with clinical features and/or cerebrospinal fluid results suggesting bacterial meningitis but no pathogen identified by PCR testing, Gram stain, or culture, continue empirical antibiotics for 10 days. Stop antibiotics after 10 days if the patient has recovered.[48][49]
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.
Confirmed or probable meningococcal sepsis (Neisseria meningitidis) without meningitis
Continue intravenous ceftriaxone.[48][49][97]
Stop treatment if the patient has recovered by day 5.
Continue intravenous ceftriaxone in patients with a typical petechial/purpuric meningococcal rash but no identified pathogen and stop treatment if the patient has recovered by day 5.[48][49]
Antibiotic allergy
If the patient has an allergy to the recommended antibiotic:[48]
Ask about the reaction they get
Where ceftriaxone is recommended, give ceftriaxone if their reaction was not severe allergy
If their reaction was severe allergy, get advice from an infectious disease or microbiology specialist and consider chloramphenicol
Corticosteroids
Continue intravenous dexamethasone for 4 days if the organism is confirmed to be S pneumoniae or H influenzae.[48][49]
Urgent transfer to hospital
Arrange emergency transfer to hospital by blue-light ambulance for any patient with suspected bacterial meningitis and/or meningococcal sepsis.[48][51]
Tell the hospital that a patient with suspected bacterial meningitis or meningococcal disease is being transferred and that they will need assessment by a senior clinical decision maker.[48]
Do not delay transfer to hospital to give antibiotics.[48][49]
Document presence or absence of:[49]
Headache
Altered mental status
Neck stiffness
Fever
Rash (of any type)
Seizures
Any signs of shock (e.g., hypotension, poor capillary refill time).
In the UK, the doctor who suspects a diagnosis of meningitis or meningococcal sepsis has a legal duty to notify the case to the local health protection team or the on-call Public Health Specialist. This is usually done by the hospital, but general practitioners may wish to check that it has been done.[108]
Pre-hospital antibiotics
Give parenteral empirical antibiotics (intravenous or intramuscular ceftriaxone or benzylpenicillin) to patients with strongly suspected bacterial meningitis or meningococcal disease as soon as possible, unless this will delay transfer to hospital.[48][49]
Give antibiotics to patients with suspected meningitis and/or sepsis and anticipated delay of more than 1 hour in getting to hospital.[49][51]
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[48][49]
The aim of giving pre-hospital antibiotics is to reduce the mortality associated with delays in antibiotic therapy.[49]
Pre-hospital supportive care
Administer oxygen if the patient is unconscious.[108]
Give intravenous fluids if the patient has a rapid heart rate, poor capillary refill time, and cold extremities.[108]
Safety netting for patients not transferred to hospital
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.[108]
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.
Ask them to return for further assessment if they develop new symptoms, if a rash changes from blanching to non-blanching, or if existing symptoms get worse.[48]
Suggest follow-up within a specified period (usually 4-6 hours) if you consider this is appropriate.[108]
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.
Before discharging a patient who has been diagnosed with meningococcal disease and treated in hospital.
Consider their follow-up requirements, taking into account potential cognitive, neurological, developmental, orthopaedic, skin, hearing, psychosocial, education, and renal complications:[48][49]
Refer patients to psychological services for cognitive and psychological support if follow-up needs have been identified
Refer patients with skin and orthopaedic complications (e.g., amputation) to rehabilitation services for assessment as needed; coordinate management with tissue viability and community nursing services, and consider referral to psychological services
Offer an audiological assessment within 4 weeks of recovery
Refer patients taking anti-epileptic drugs for a medicines review 3 months after hospital discharge, with a clinician with an interest in epilepsy, an epilepsy specialist nurse, or a neurologist
Refer babies, children and young people with cognitive, neurological or developmental complications for community neurodevelopmental follow-up
Children and young people admitted to hospital
Arrange for a review with a paediatrician at 4-6 weeks after discharge from hospital. The review should cover:[48]
The results of their audiological assessment, and whether cochlear implants are needed
Damage to bones and joints
Skin complications (including scarring from necrosis)
Psychosocial problems
Neurological and developmental problems, in liaison with community child development services
For babies aged under 12 months, arrange a further paediatrician review for 1 year after discharge to assess for possible late-onset neurodevelopmental, orthopaedic, sensory and psychosocial complications.[48]
Community child development services should follow up and assess the risk of long-term neurodevelopmental complications for at least 2 years after discharge.[48]
Discuss potential long-term effects and likely patterns of recovery with the child or young person and their parents or carers; provide opportunities to discuss issues and ask questions.
See Patient discussions.
Adults admitted to hospital
Arrange for a review with a hospital doctor at 4-6 weeks after discharge from hospital. As part of this review, cover:[48]
The results of their audiological assessment (if available at this time), and whether cochlear implants are needed
Damage to bones and joints
Skin complications (including scarring from necrosis)
Psychosocial problems
Neurological problems
Care needs
See Patient discussions.
Patients seen in hospital or the community and not admitted to hospital
When discharging a patient assessed as being at low risk of meningococcal disease after initial observation, explain which symptoms and signs to look out for, and what changes should prompt them to return to hospital.[48]
Ask them to return for further assessment if they develop new symptoms, if a rash changes from blanching to non-blanching, or if existing symptoms get worse.[48]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.
Give advice on accessing further healthcare.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the Tumbler test.[108]
Suggest follow-up within a specified period (usually 4-6 hours) if you consider this to be appropriate.[108] Use your clinical judgement.
Ensure the parent/patient understands how to get medical help after normal working hours.
Liaise directly with other healthcare professionals if you have concerns about a patient who is not being sent to hospital.
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