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.[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.

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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]

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

Fluid resuscitation

Assess the child with suspected bacterial meningitis for all of the following:[48][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) 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 bacterial meningitis with 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 children 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).
Initiate vasoactive agents early, following 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]

Seizures

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

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Give intravenous antibiotics immediately to a child 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]

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 infants aged <1 month with suspected bacterial meningitis 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] However, age <28 days (neonatal period) is a specific risk factor for listeria meningitis.

Do not give ceftriaxone to:[51]

premature babies
babies receiving calcium-containing infusions
babies with jaundice and any of the following: bilirubin level ≥200 micromoles/L, hypoalbuminaemia, or acidosis.

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

cefotaxime: consult specialist for guidance on neonatal dose

ceftriaxone: consult specialist for guidance on neonatal dose

-- AND --

amoxicillin: consult specialist for guidance on neonatal dose

Consider – aciclovir

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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 with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity. Escalate early.

If the child needs resuscitation, discuss 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 a side 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]

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.

children and young people ≥1 month 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.[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.

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

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.

Fluid resuscitation

Assess children and young people with suspected bacterial meningitis for all of the following:[48][49][50][78]

Raised intracranial pressure
Shock
Dehydration

Correct dehydration (if present) 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 bacterial meningitis with 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 children and young people 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]

Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.

Shock

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

If signs of shock (e.g., hypotension) still persist after 40 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

Seizures

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

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Give intravenous antibiotics 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]

Give children and young people aged 1 month and older intravenous ceftriaxone or cefotaxime for suspected or confirmed bacterial meningitis in hospital.[48][100]

Do not give ceftriaxone to babies receiving calcium-containing infusions (use cefotaxime).[51]

Primary options

cefotaxime: children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day

ceftriaxone: children ≥1 month to 11 years of age and <50 kg body weight: 100 mg/kg intravenously every 24 hours, maximum 4 g/day; children 9-11 years of age and ≥50 kg body weight and children ≥12 years of age and adults: 2 g intravenously every 12 hours, or 4 g intravenously every 24 hours

Consider – corticosteroid

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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. Escalate early.

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

Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as a side 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]

adults <60 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.[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.

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.
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 (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.[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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[49] 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.[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.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

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.

Use chloramphenicol instead if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[48][49][97] Follow your local protocols and consult an infectious disease or microbiology specialist.

Primary options

ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours

cefotaxime: 2 g intravenously every 6 hours, increase to 12 g/day given in 3-4 divided doses if necessary

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:[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]

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:[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]

Intravenous corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[97]

Do not routinely give corticosteroids to patients with meningococcal disease without meningitis.[48]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

adults ≥60 years of age and immunocompetent; immuncompromised adults any 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.[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.

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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.
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

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 (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.[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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[49] 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.[49]

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 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][97] [ ]

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.

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

Primary options

ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours

cefotaxime: 2 g intravenously every 6 hours, increase to 12 g/day given in 3-4 divided doses if necessary

-- 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:[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]

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.

If dexamethasone is delayed for more than 12 hours after the start of antibiotics, get advice from a microbiologist or infectious diseases consultant.[48]

Intravenous corticosteroids should not be given in patients with signs of sepsis or rapidly evolving rash (with or without symptoms and signs of meningitis).[97]

Do not routinely give corticosteroids to patients with meningococcal disease without meningitis.[48]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

suspected meningococcal sepsis: presenting in hospital

children <1 month of age

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 cefotaxime or ceftriaxone (or other recommended antibiotic) has been given for 24 hours.[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.

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

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.

Fluid resuscitation

Assess the child with suspected meningococcal sepsis for all of the following:[48][50][78]

Raised intracranial pressure
Shock
Dehydration

Correct dehydration (if present) 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 bacterial meningitis with 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 children 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]

Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.

Shock

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

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

Seizures

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

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Give intravenous antibiotics immediately to a child 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]

Give infants <1 month with suspected bacterial meningitis 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] However, age <28 days (neonatal period) is a specific risk factor for listeria meningitis.

Do not give ceftriaxone to:[51][100]

premature babies
babies receiving calcium-containing infusions
babies with jaundice and any of the following: bilirubin level ≥200 micromoles/L, hypoalbuminaemia, or acidosis.

Primary options

cefotaxime: consult specialist for guidance on neonatal dose

ceftriaxone: consult specialist for guidance on neonatal dose

-- AND --

amoxicillin: consult specialist for guidance on neonatal dose

Consider – aciclovir

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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 with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity. Escalate early.

If the child needs resuscitation, discuss with a paediatric intensivist as soon as possible.

Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as a side 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]

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.

children and young people ≥1 month 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.[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.

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.

Fluid resuscitation

Correct dehydration (if present) using enteral fluids or feeds, or intravenous isotonic fluids.[48][51] Follow your local protocols.

Respiratory support

Give oxygen to children 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]

Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.

Shock

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

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.
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 routinely treated with corticosteroids.[48]

Practical tip

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.

Back

Plus –

empirical antibiotics

Treatment recommended for ALL patients in selected patient group

Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]

Give children and young people aged 1 month and older intravenous ceftriaxone for suspected or confirmed meningococcal disease in hospital.[48][100]

Do not give ceftriaxone to babies receiving calcium-containing infusions (use cefotaxime).[51]

Primary options

cefotaxime: children ≥1 month of age: 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

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. Escalate early.

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

Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as a side 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]

adults <60 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.[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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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

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 (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.[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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[49] 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.[49]

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 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.

Primary options

ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours

cefotaxime: 2 g intravenously every 6 hours, increase to 12 g/day given in 3-4 divided doses if necessary

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:[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]

adults ≥60 years of age and immunocompetent; immuncompromised adults any 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.[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.

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

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

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 (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.[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]

Seizures

Manage suspected or proven seizures early; follow your local protocol.[49] 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.[49]

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 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][97] [ ]

Additional antibiotic cover is recommended because adults who are aged 60 years or older or immunocompromised are at increased risk of Listeria monocytogenes.[48]

Give chloramphenicol plus trimethoprim/sulfamethoxazole if the patient has a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins.[49][97] Follow your local protocols and consult an infectious disease or microbiology specialist.

Primary options

ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours

cefotaxime: 2 g intravenously every 6 hours, increase to 12 g/day given in 3-4 divided doses if necessary

-- 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:[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]

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

Back

1st line –

emergency 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).

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.[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]

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

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.

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.[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.

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]

Consider – empirical antibiotics

Back

Consider –

empirical antibiotics

Additional treatment recommended for SOME patients in selected patient group

Give parenteral empirical antibiotics (intravenous or intramuscular ceftriaxone or benzylpenicillin) to patients with strongly suspected 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]

Primary options

benzylpenicillin sodium: children 1-11 months of age: 300 mg intravenously/intramuscularly as a single dose; children 1-9 years of age: 600 mg intravenously/intramuscularly as a single dose; children ≥10 years of age and adults: 1.2 g intravenously/intramuscularly as a single dose

ceftriaxone: children 1 month of age: 250 mg intramuscularly as a single dose; children 2-11 months: 500 mg intramuscularly as a single dose; children 1-4 years of age: 1 g intramuscularly as a single dose; children 5-8 years of age: 1.5 g intramuscularly as a single dose; children ≥9 years of age and adults: 2 g intramuscularly as a single dose

Consider – supportive care

ACUTE

confirmed or probable bacterial meningitis (including meningococcal meningitis)

children and young people

Back

1st line –

pathogen-targeted antibiotics

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 (or cefotaxime) for meningitis caused by N meningitidis unless ceftriaxone is contraindicated.

Do not give ceftriaxone to:[51]

premature babies
babies receiving calcium-containing infusions
babies with jaundice and any of the following: bilirubin level ≥200 micromoles/L, hypoalbuminaemia, or acidosis.[100]

After 5 days, stop antibiotics if the patient has recovered, or get advice from an infection specialist if they have not.

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 or when risk factors for listeria meningitis are present (including age <28 days).[48] See Bacterial meningitis in children.

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

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

Fluid resuscitation

Assess the child with suspected bacterial meningitis for all of the following:[48][50][78]

Raised intracranial pressure
Shock
Dehydration

Correct dehydration (if present) 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 fluids enterally if tolerated, orally or by enteral tube.
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 children 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]

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 sodium chloride 0.9%, or a balanced 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 (e.g., hypotension) still persist after 40 mL/kg of fluid resuscitation:[102]

Seek urgent expert advice (e.g., from the paediatric intensive care team).[102]
Initiate vasoactive agents early, following 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.[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

Seizures

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

Raised intracranial pressure

Follow local or national protocols to treat raised intracranial pressure.

Consider – continue corticosteroid

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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 with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity. Escalate early.

If the child needs resuscitation, discuss with a paediatric intensivist as soon as possible.

Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as a side 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]

adults

Back

1st line –

pathogen-targeted antibiotics

Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]

Give pathogen-targeted antibiotics based on the organism identified (or likely organism) and its antimicrobial susceptibilities.[49] [ ]

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] 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.

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

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:[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

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 (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.[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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[49] 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.[49]

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 if the organism is confirmed to be Streptococcus pneumoniae or Haemophilus influenzae.[48][49]

If no causative organism is found, get advice from a microbiologist or infectious diseases consultant on whether or not to continue dexamethasone.[48]
Stop corticosteroid therapy if another organism is identified.[48]

Primary options

dexamethasone: 10 mg intravenously every 6 hours

confirmed or probable meningococcal disease

children and young people

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.

Fluid resuscitation

Respiratory support

Give oxygen to children 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]

Tracheal intubation should only be undertaken by health professionals with expertise in paediatric airway management.

Shock

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

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)
Initiate vasoactive agents early, following 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

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.

Back

Plus –

reassess and monitor

Treatment recommended for ALL patients in selected patient group

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 with meningococcal disease can deteriorate rapidly regardless of the results of any initial assessment of severity. Escalate early.

If the child needs resuscitation, discuss with a paediatric intensivist as soon as possible.

Hyperglycaemia is common as part of the stress response to severe sepsis. It can also occur as a side 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]

adults

Back

1st line –

pathogen-targeted antibiotics

Continue intravenous ceftriaxone or cefotaxime.[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.[48][49]

Stop treatment if patients have recovered by day 5.

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.

See empirical antibiotics in suspected meningococcal disease 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:[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

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 (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.[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]

Seizures

Treat suspected or proven seizures early; follow your local protocol.[49] 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.[49]

Raised intracranial pressure

Routine use of ICP monitoring is not recommended.