Meningococcal disease
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
suspected bacterial meningitis: presenting in hospital
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [107]Okike IO, Johnson AP, Henderson KL, et al. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 days in the United kingdom and Republic of Ireland: prospective, enhanced, national population-based surveillance. Clin Infect Dis. 2014 Nov 15;59(10):e150-7. https://academic.oup.com/cid/article/59/10/e150/2895279 http://www.ncbi.nlm.nih.gov/pubmed/24997051?tool=bestpractice.com
Give infants aged <1 month with suspected bacterial meningitis acquired in the community:[100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
Intravenous cefotaxime or ceftriaxone plus intravenous amoxicillin.
Amoxicillin is used to cover Listeria monocytogenes, which is rare in the UK.[101]UK Health Security Agency. Listeria monocytogenes: surveillance reports. May 2025 [internet publication]. https://www.gov.uk/government/publications/listeria-monocytogenes-surveillance-reports However, age <28 days (neonatal period) is a specific risk factor for listeria meningitis.
Do not give ceftriaxone to:[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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
or
ceftriaxone: consult specialist for guidance on neonatal dose
-- AND --
amoxicillin: consult specialist for guidance on neonatal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefotaxime: consult specialist for guidance on neonatal dose
or
ceftriaxone: consult specialist for guidance on neonatal dose
-- AND --
amoxicillin: consult specialist for guidance on neonatal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefotaxime
or
ceftriaxone
-- AND --
amoxicillin
aciclovir
Additional treatment recommended for SOME patients in selected patient group
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]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
ALT or AST >2x upper limit normal, coagulopathy
Vesicles
Seizures
CSF pleocytosis
Suspected meningitis/encephalitis
Recent maternal herpes simplex disease OR
Postnatal contact with herpes simplex virus
Primary options
aciclovir: consult specialist for guidance on neonatal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
aciclovir: consult specialist for guidance on neonatal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
aciclovir
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
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.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
If signs of shock (e.g., hypotension) still persist after 40 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Seek urgent expert advice (e.g., from the paediatric intensive care team)[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Vasoactive agents should be initiated early, and following the advice from a paediatric intensivist or experienced members of the critical care team.[78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Give children and young people aged 1 month and older intravenous ceftriaxone or cefotaxime for suspected or confirmed bacterial meningitis in hospital.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
Do not give ceftriaxone to babies receiving calcium-containing infusions (use cefotaxime).[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [107]Okike IO, Johnson AP, Henderson KL, et al. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 days in the United kingdom and Republic of Ireland: prospective, enhanced, national population-based surveillance. Clin Infect Dis. 2014 Nov 15;59(10):e150-7. https://academic.oup.com/cid/article/59/10/e150/2895279 http://www.ncbi.nlm.nih.gov/pubmed/24997051?tool=bestpractice.com
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: children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day
OR
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
More ceftriaxoneIn children 1 month to 11 years of age, if the total daily dose exceeds 2 g/day, consider giving in 2 divided doses. In children 9-11 years of age and ≥50 kg body weight, doses of 50 mg/kg or more should be given by intravenous infusion rather than intravenous injection.
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefotaxime: children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day
OR
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
More ceftriaxoneIn children 1 month to 11 years of age, if the total daily dose exceeds 2 g/day, consider giving in 2 divided doses. In children 9-11 years of age and ≥50 kg body weight, doses of 50 mg/kg or more should be given by intravenous infusion rather than intravenous injection.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefotaxime
OR
ceftriaxone
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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.
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
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.
corticosteroid
Additional treatment recommended for SOME patients in selected patient group
Give intravenous dexamethasone to children aged ≥3 months with strongly suspected or confirmed bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
See Bacterial meningitis in children.
Primary options
dexamethasone: children ≥3 to 15 years months of age: 150 micrograms/kg intravenously every 6 hours, maximum 10 mg/dose; children ≥16 years of age: 10 mg intravenously every 6 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: children ≥3 to 15 years months of age: 150 micrograms/kg intravenously every 6 hours, maximum 10 mg/dose; children ≥16 years of age: 10 mg intravenously every 6 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone
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 (or a single dose of ciprofloxacin).[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Treat suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017 Alternatively, consider intravenous cefotaxime.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017 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
OR
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
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
These drug options and doses relate to a patient with no comorbidities.
Primary options
ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours
OR
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
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
OR
cefotaxime
Secondary options
chloramphenicol
vancomycin or rifampicin
Additional treatment recommended for SOME patients in selected patient group
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:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Also take this approach if MRSA is identified.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
rifampicin
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Do not routinely give corticosteroids to patients with meningococcal disease without meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Primary options
dexamethasone: 10 mg intravenously every 6 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: 10 mg intravenously every 6 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone
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 (or a single dose of ciprofloxacin).[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Treat suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication].
https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
[ ]
In suspected cases of meningococcal disease, do pre-admission antibiotics improve outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.99/fullShow me the answer
Additional antibiotic cover is recommended because adults who are aged 60 years or older or immunocompromised are at increased risk of Listeria monocytogenes.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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
or
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
or
ampicillin: 2 g intravenously every 4 hours
Secondary options
chloramphenicol: 25 mg/kg intravenously every 6 hours
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
and
trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim only. Also known as cotrimoxazole.
These drug options and doses relate to a patient with no comorbidities.
Primary options
ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours
or
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
or
ampicillin: 2 g intravenously every 4 hours
Secondary options
chloramphenicol: 25 mg/kg intravenously every 6 hours
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
and
trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim only. Also known as cotrimoxazole.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
or
cefotaxime
-- AND --
amoxicillin
or
ampicillin
Secondary options
chloramphenicol
and
trimethoprim/sulfamethoxazole
vancomycin or rifampicin
Additional treatment recommended for SOME patients in selected patient group
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:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Also take this approach if MRSA is identified.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
rifampicin
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication].
https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
[ ]
In adults with acute bacterial meningitis, is adding corticosteroids to standard treatment with antibacterial agents helpful?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1273/fullShow me the answer
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Do not routinely give corticosteroids to patients with meningococcal disease without meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Primary options
dexamethasone: 10 mg intravenously every 6 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: 10 mg intravenously every 6 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone
suspected meningococcal sepsis: presenting in hospital
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Seek urgent expert advice (e.g., from the paediatric intensive care team).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Vasoactive agents should be initiated early, and following the advice from a paediatric intensivist or experienced members of the critical care team.[78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [107]Okike IO, Johnson AP, Henderson KL, et al. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 days in the United kingdom and Republic of Ireland: prospective, enhanced, national population-based surveillance. Clin Infect Dis. 2014 Nov 15;59(10):e150-7. https://academic.oup.com/cid/article/59/10/e150/2895279 http://www.ncbi.nlm.nih.gov/pubmed/24997051?tool=bestpractice.com
Give infants <1 month with suspected bacterial meningitis acquired in the community:[100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
Intravenous cefotaxime or ceftriaxone plus intravenous amoxicillin.
Amoxicillin is used to cover Listeria monocytogenes, which is rare in the UK.[101]UK Health Security Agency. Listeria monocytogenes: surveillance reports. May 2025 [internet publication]. https://www.gov.uk/government/publications/listeria-monocytogenes-surveillance-reports However, age <28 days (neonatal period) is a specific risk factor for listeria meningitis.
Do not give ceftriaxone to:[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 [100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
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
or
ceftriaxone: consult specialist for guidance on neonatal dose
-- AND --
amoxicillin: consult specialist for guidance on neonatal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
cefotaxime: consult specialist for guidance on neonatal dose
or
ceftriaxone: consult specialist for guidance on neonatal dose
-- AND --
amoxicillin: consult specialist for guidance on neonatal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
cefotaxime
or
ceftriaxone
-- AND --
amoxicillin
aciclovir
Additional treatment recommended for SOME patients in selected patient group
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]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
ALT or AST >2x ULN, coagulopathy
vesicles
seizures
CSF pleocytosis
suspected meningitis/encephalitis
recent maternal herpes simplex disease OR
postnatal contact with herpes simplex virus.
Primary options
aciclovir: consult specialist for guidance on neonatal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
aciclovir: consult specialist for guidance on neonatal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
aciclovir
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
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.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.
Fluid resuscitation
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Seek urgent expert advice (e.g., from the paediatric intensive care team)[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Give children and young people aged 1 month and older intravenous ceftriaxone for suspected or confirmed meningococcal disease in hospital.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
Do not give ceftriaxone to babies receiving calcium-containing infusions (use cefotaxime).[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [107]Okike IO, Johnson AP, Henderson KL, et al. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 days in the United kingdom and Republic of Ireland: prospective, enhanced, national population-based surveillance. Clin Infect Dis. 2014 Nov 15;59(10):e150-7. https://academic.oup.com/cid/article/59/10/e150/2895279 http://www.ncbi.nlm.nih.gov/pubmed/24997051?tool=bestpractice.com
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
Primary options
ceftriaxone: 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
More ceftriaxoneIn children 1 month to 11 years of age, if the total daily dose exceeds 2 g/day, consider giving in 2 divided doses. In children 9-11 years of age and ≥50 kg body weight, doses of 50 mg/kg or more should be given by intravenous infusion rather than intravenous injection.
OR
cefotaxime: children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day
These drug options and doses relate to a patient with no comorbidities.
Primary options
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
More ceftriaxoneIn children 1 month to 11 years of age, if the total daily dose exceeds 2 g/day, consider giving in 2 divided doses. In children 9-11 years of age and ≥50 kg body weight, doses of 50 mg/kg or more should be given by intravenous infusion rather than intravenous injection.
OR
cefotaxime: children ≥1 month of age: 50 mg/kg intravenously every 6 hours, maximum 12 g/day
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
OR
cefotaxime
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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.
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
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.
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 (or a single dose of ciprofloxacin).[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Treat suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication].
https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication].
https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
[ ]
In suspected cases of meningococcal disease, do pre-admission antibiotics improve outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.99/fullShow me the answer Alternatively, consider intravenous cefotaxime.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication].
https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017 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
OR
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
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
These drug options and doses relate to a patient with no comorbidities.
Primary options
ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours
OR
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
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
OR
cefotaxime
Secondary options
chloramphenicol
vancomycin or rifampicin
Additional treatment recommended for SOME patients in selected patient group
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:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Also take this approach if MRSA is identified.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
rifampicin
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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.
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 (or a single dose of ciprofloxacin).[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Notify:
Microbiology[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
The relevant public health authority urgently if you have a patient with suspected meningitis or meningococcal sepsis (regardless of the aetiology).[7]UK Health Security Agency. Meningococcal disease: guidance on public health management. Nov 2024 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-guidance-on-public-health-management [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [98]UK Health Security Agency. Meningococcal disease enhanced surveillance plan. Dec 2022 [internet publication]. https://www.gov.uk/government/publications/meningococcal-disease-enhanced-surveillance-plan
Meningitis and meningococcal sepsis are notifiable diseases in the UK so this is a legal requirement under the Health Protection (Notification) Regulations 2010.[99]The Health Protection (Notification) Regulations 2010. https://www.legislation.gov.uk/uksi/2010/659/contents/made
In the UK, contact the consultant in communicable disease control or the consultant in health protection at your local health protection team early.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com They will initiate prophylaxis of contacts.
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Manage suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication].
https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
[ ]
In suspected cases of meningococcal disease, do pre-admission antibiotics improve outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.99/fullShow me the answer
Additional antibiotic cover is recommended because adults who are aged 60 years or older or immunocompromised are at increased risk of Listeria monocytogenes.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017 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
or
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
or
ampicillin: 2 g intravenously every 4 hours
Secondary options
chloramphenicol: 25 mg/kg intravenously every 6 hours
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
and
trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim only. Also known as cotrimoxazole.
These drug options and doses relate to a patient with no comorbidities.
Primary options
ceftriaxone: 2 g intravenously every 12 hours; or 4 g intravenously every 24 hours
or
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
or
ampicillin: 2 g intravenously every 4 hours
Secondary options
chloramphenicol: 25 mg/kg intravenously every 6 hours
More chloramphenicolDose may be reduced to 12.5 mg/kg every 6 hours if the patient is recovering, to reduce the risk of a dose-related anaemia.
and
trimethoprim/sulfamethoxazole: 10-20 mg/kg/day intravenously given in divided doses every 6 hours
More trimethoprim/sulfamethoxazoleDose refers to trimethoprim only. Also known as cotrimoxazole.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ceftriaxone
or
cefotaxime
-- AND --
amoxicillin
or
ampicillin
Secondary options
chloramphenicol
and
trimethoprim/sulfamethoxazole
vancomycin or rifampicin
Additional treatment recommended for SOME patients in selected patient group
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:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Also take this approach if MRSA is identified.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
rifampicin
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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.
suspected meningococcal disease (meningitis or sepsis): presenting in the community
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Do not delay transfer to hospital to give antibiotics.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Document presence or absence of:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Meningitis Research Foundation. Meningococcal meningitis and sepsis guidance notes: diagnosis and treatment in general practice. 2018 [internet publication]. https://www.meningitis.org/getmedia/cf777153-9427-4464-89e2-fb58199174b6/gp_booklet-UK-sept-16
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]Meningitis Research Foundation. Meningococcal meningitis and sepsis guidance notes: diagnosis and treatment in general practice. 2018 [internet publication]. https://www.meningitis.org/getmedia/cf777153-9427-4464-89e2-fb58199174b6/gp_booklet-UK-sept-16 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.
infection control
Treatment recommended for ALL patients in selected patient group
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Meningitis Research Foundation. Meningococcal meningitis and sepsis guidance notes: diagnosis and treatment in general practice. 2018 [internet publication]. https://www.meningitis.org/getmedia/cf777153-9427-4464-89e2-fb58199174b6/gp_booklet-UK-sept-16
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Give antibiotics to patients with suspected meningitis and/or sepsis and anticipated delay of more than 1 hour in getting to hospital.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
The aim of giving pre-hospital antibiotics is to reduce the mortality associated with delays in antibiotic therapy.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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
OR
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
More ceftriaxoneFor children <11 years of age, the actual dose given should be communicated to the receiving hospital where the child’s weight should be obtained and the remainder of the dose given if necessary. Dose may be given intravenously in children ≥12 years of age and adults.
These drug options and doses relate to a patient with no comorbidities.
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
OR
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
More ceftriaxoneFor children <11 years of age, the actual dose given should be communicated to the receiving hospital where the child’s weight should be obtained and the remainder of the dose given if necessary. Dose may be given intravenously in children ≥12 years of age and adults.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
benzylpenicillin sodium
OR
ceftriaxone
supportive care
Additional treatment recommended for SOME patients in selected patient group
Administer oxygen if the patient is unconscious.[108]Meningitis Research Foundation. Meningococcal meningitis and sepsis guidance notes: diagnosis and treatment in general practice. 2018 [internet publication]. https://www.meningitis.org/getmedia/cf777153-9427-4464-89e2-fb58199174b6/gp_booklet-UK-sept-16
Give intravenous fluids if the patient has a rapid heart rate, poor capillary refill time, and cold extremities.[108]Meningitis Research Foundation. Meningococcal meningitis and sepsis guidance notes: diagnosis and treatment in general practice. 2018 [internet publication]. https://www.meningitis.org/getmedia/cf777153-9427-4464-89e2-fb58199174b6/gp_booklet-UK-sept-16
confirmed or probable bacterial meningitis (including meningococcal meningitis)
pathogen-targeted antibiotics
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/27062097?tool=bestpractice.com [107]Okike IO, Johnson AP, Henderson KL, et al. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 days in the United kingdom and Republic of Ireland: prospective, enhanced, national population-based surveillance. Clin Infect Dis. 2014 Nov 15;59(10):e150-7. https://academic.oup.com/cid/article/59/10/e150/2895279 http://www.ncbi.nlm.nih.gov/pubmed/24997051?tool=bestpractice.com
Give ceftriaxone (or cefotaxime) for meningitis caused by N meningitidis unless ceftriaxone is contraindicated.
Do not give ceftriaxone to:[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
premature babies
babies receiving calcium-containing infusions
babies with jaundice and any of the following: bilirubin level ≥200 micromoles/L, hypoalbuminaemia, or acidosis.[100]UK Paediatric Antimicrobial Stewardship (UK-PAS). Antimicrobial paediatric guide. Dec 2024 [internet publication]. https://uk-pas.co.uk/Antimicrobial-Paediatric-Summary-UKPAS.pdf
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations See Bacterial meningitis in children.
See empirical antibiotics in suspected bacterial meningitis section above or check local protocols for doses.
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [78]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
If signs of shock (e.g., hypotension) still persist after 40 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
Seek urgent expert advice (e.g., from the paediatric intensive care team).[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
continue corticosteroid
Additional treatment recommended for SOME patients in selected patient group
After the first dose of dexamethasone (if indicated), discuss whether dexamethasone should be continued with a senior paediatrician.
pathogen-targeted antibiotics
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Give pathogen-targeted antibiotics based on the organism identified (or likely organism) and its antimicrobial susceptibilities.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[ ]
How do third generation cephalosporins compare with conventional antibiotics at improving outcomes in people with acute bacterial meningitis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.75/fullShow me the answer
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication].
https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38.
https://www.doi.org/10.1016/j.jinf.2016.01.007
http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
[ ]
How do third generation cephalosporins compare with conventional antibiotics at improving outcomes in people with acute bacterial meningitis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.75/fullShow me the answer
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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.
vancomycin or rifampicin
Additional treatment recommended for SOME patients in selected patient group
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 and gram-positive diplococci (likely S pneumoniae) are visible on a Gram stain of CSF:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Seek advice from an infectious disease or microbiology specialist
Add vancomycin or rifampicin.
Also take this approach if MRSA is identified.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15-20 mg/kg intravenously every 8-12 hours
OR
rifampicin: 600 mg intravenously/orally every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
rifampicin
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Treat suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
If no causative organism is found, get advice from a microbiologist or infectious diseases consultant on whether or not to continue dexamethasone.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Stop corticosteroid therapy if another organism is identified.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Primary options
dexamethasone: 10 mg intravenously every 6 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
dexamethasone: 10 mg intravenously every 6 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
dexamethasone
confirmed or probable meningococcal disease
pathogen-targeted antibiotics
Give intravenous ceftriaxone to children and young people with suspected or confirmed meningococcal disease in hospital.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
Stop antibiotics if the person has recovered after 5 days; get advice from an infectious disease or microbiology specialist if they have not.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
If the child has an antibiotic allergy:[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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
See empirical antibiotics in suspected meningococcal disease section above or check local protocols for doses.
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
If the patient needs resuscitation, discuss with a paediatric intensivist as soon as possible.
Fluid resuscitation
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.
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
Consider treatment with oxygen for children with an SpO₂ of greater than 92% as clinically indicated.[51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51 The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[103]ResuscitationCouncil UK. Paediatric advanced life support guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/paediatric-advanced-life-support-guidelines
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]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[102]National Institute for Health and Care Excellence. Intravenous fluid therapy in children and young people in hospital. Jun 2020 [internet publication]. https://www.nice.org.uk/guidance/ng29
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com 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]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011 Jun 30;364(26):2483-95. https://www.nejm.org/doi/10.1056/NEJMoa1101549 http://www.ncbi.nlm.nih.gov/pubmed/21615299?tool=bestpractice.com [105]Li D, Li X, Cui W, et al. Liberal versus conservative fluid therapy in adults and children with sepsis or septic shock. Cochrane Database Syst Rev. 2018 Dec 10;12(12):CD010593. https://pmc.ncbi.nlm.nih.gov/articles/PMC6517253 http://www.ncbi.nlm.nih.gov/pubmed/30536956?tool=bestpractice.com
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
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.
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]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [81]Royal College of Paediatrics and Child Health. UK Paediatric Early Warning Systems (PEWS). Jul 2024 [internet publication]. https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
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]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med. 2020 Feb;46(suppl 1):10-67. https://pmc.ncbi.nlm.nih.gov/articles/PMC7095013 http://www.ncbi.nlm.nih.gov/pubmed/32030529?tool=bestpractice.com
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[106]Melchers M, van Zanten ARH. Management of hypocalcaemia in the critically ill. Curr Opin Crit Care. 2023 Aug 1;29(4):330-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC10328536 http://www.ncbi.nlm.nih.gov/pubmed/37395330?tool=bestpractice.com
pathogen-targeted antibiotics
Continue intravenous ceftriaxone or cefotaxime.[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com [97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Stop treatment if patients have recovered by day 5.
If the patient has an allergy to the recommended antibiotic:[48]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations
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.
supportive care
Treatment recommended for ALL patients in selected patient group
Within the first hour of arriving at hospital:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]Royal College of Physicians. National early warning score (NEWS) 2: standardising the assessment of acute-illness severity in the NHS. Dec 2017 [internet publication]. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 [57]NHS England. Sepsis guidance implementation advice for adults. September 2017 [internet publication]. https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf [73]Nutbeam T, Daniels R; The UK Sepsis Trust. Professional resources: clinical. 2022 [internet publication]. https://sepsistrust.org/professional-resources/clinical [74]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021 Nov 1;49(11):e1063-143. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx http://www.ncbi.nlm.nih.gov/pubmed/34605781?tool=bestpractice.com
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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [50]Academy of Medical Royal Colleges. Statement on the initial antimicrobial treatment of sepsis. Oct 2022 [internet publication]. https://www.aomrc.org.uk/reports-guidance/statement-on-the-initial-antimicrobial-treatment-of-sepsis-v2-0 [51]National Institute for Health and Care Excellence. Suspected sepsis: recognition, diagnosis and early management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng51
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
Keep patients euvolaemic to maintain normal haemodynamic parameters.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Do not restrict fluids in an attempt to reduce cerebral oedema.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Respiratory support
Secure the airway and give high flow oxygen to patients with:[97]Meningitis Research Foundation. Early management of suspected meningitis and meningococcal sepsis in immunocompetent adults. Jan 2016 [internet publication]. https://www.meningitis.org/getmedia/e8ea82ee-e0e9-466d-8526-572108ad6d06/Adult-Protocol-Poster-Nov-2017
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Shock
Vasoactive agents may be needed.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]National Institute for Health and Care Excellence. Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management. Mar 2024 [internet publication]. https://www.nice.org.uk/guidance/ng240/chapter/Recommendations [49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
A mean arterial pressure (MAP) ≥65 mmHg is recommended, although this many need to be individualised.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
Seizures
Treat suspected or proven seizures early; follow your local protocol.[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com 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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com Follow your local or national protocol.
Routine use of ICP monitoring is not recommended.
reassess and monitor
Treatment recommended for ALL patients in selected patient group
Involve intensive care teams early in patients with:[49]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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]McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016 Apr;72(4):405-38. https://www.doi.org/10.1016/j.jinf.2016.01.007 http://www.ncbi.nlm.nih.gov/pubmed/26845731?tool=bestpractice.com
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