Recommendations
Key Recommendations
Escalate early. Consult a senior doctor in emergency medicine or paediatrics immediately if you suspect bacterial meningitis in a child aged <16 years. Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care if you suspect meningococcal meningitis (or there are other signs of meningococcal disease), or if there are features of shock or raised intracranial pressure.[26] Bacterial meningitis is life-threatening and requires urgent intervention and possible critical care input.
Features of meningococcal disease other than meningococcal meningitis are not covered in this topic. See Meningococcal disease.
Babies in neonatal units are also not covered in this topic.
Identify and treat shock and raised intracranial pressure early.[2]
Consider the possibility of bacterial meningitis when assessing any child aged <16 years with acute febrile illness, particularly if they have associated risk factors.[2] Other clinical features can include:[2]
Vomiting/nausea
Headache
Altered mental state (e.g., lethargy, irritability, confusion, reduced conscious level)
Neck stiffness
Photophobia
Seizures
Focal neurological deficit
Non-blanching rash
Poor feeding, respiratory distress, bulging fontanelle (in young infants)
Signs of poor perfusion and shock.
Be aware that:
Children and young people with bacterial meningitis commonly present with non-specific symptoms and signs[2]
Classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis.[2] Do not be reassured by lack of fever in an unwell baby; around 50% of young infants diagnosed with bacterial meningitis are afebrile on presentation.[4]
Take concerns expressed by the referring doctor or a carer/relative seriously because clinical features are often not clear cut.[2][27]
Do not delay giving antibiotics and other treatments while waiting for investigations if you suspect bacterial meningitis clinically.[2]
Order the following blood tests:
C-reactive protein (CRP), procalcitonin (if available)[28][29][30][31]
Do not use a normal CRP to rule out bacterial meningitis, particularly early in the course of the illness.[2] In practice, also do not exclude bacterial meningitis based on normal procalcitonin alone.
Blood culture[2]
Urea, electrolytes, and creatinine[28]
Calcium (Ca2+), magnesium, and phosphate (PO4-) if there is evidence of shock or meningococcal disease[28]
Cross-match in all children who are seriously unwell, especially if there is evidence of shock or meningococcal disease[28]
Whole-blood polymerase chain reaction (PCR) for Neisseria meningitidis[2][4][28]
Perform a lumbar puncture unless the procedure is contraindicated.
Order a computed tomography (CT) scan to look for alternative intracranial pathology if the child has reduced or fluctuating level of consciousness, or focal neurological signs.[2]
Escalate early. Consult a senior doctor in emergency medicine or paediatrics if you suspect bacterial meningitis. Seek immediate support from a consultant in emergency medicine, paediatrics, anaesthesia, or intensive care if you suspect meningococcal meningitis, or if there are features of shock or raised intracranial pressure.[26]
Features of meningococcal disease other than meningococcal meningitis are not covered in this topic. See Meningococcal disease.
Be alert to the possibility of bacterial meningitis when assessing anyone aged <16 years with an acute febrile illness.[2]
Children and young people with bacterial meningitis commonly present with non-specific symptoms and signs.[2]
Classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis.[2] Do not be reassured by lack of fever in an unwell baby; around 50% of young infants diagnosed with bacterial meningitis are afebrile on presentation.[4]
Symptoms and signs of bacterial meningitis in children and young people:[2]
Non-specific symptoms and signs | More specific symptoms and signs |
|---|---|
Less commonly:
|
|
Note that clinical features that may occur in infants <3 months of age (% of cases) are:[4]
Poor feeding (67%)
Lethargy (63%)
Respiratory distress including grunting (44%) and/or need for mechanical ventilation in a term baby
Poor perfusion (44%)
Temperature instability (20%)
Apnoea (23%)
Bulging fontanelle (20%)
Seizures (9% to 34%)[3]
Coma (5%)
Neck stiffness (3%)
Irritability in combination with fever (41%).
For all patients, also take into account:
The level of concern being shown by the parent(s) or carer (particularly in the context of previous illness in the child, or in their family).[2] Take any reported or perception of fever by the parent(s) or carer seriously.[27]
How quickly the illness is progressing.[2]
Your clinical judgement of the overall severity of the illness.[2]
The most significant risk factor for bacterial meningitis is age <2 years.[5][6]
Infants and neonates <3 months of age are particularly susceptible because they have impaired immunity.[5][6]
In addition, ask the patient or their parent/carer about other risk factors associated with increased risk of bacterial meningitis, including:
Incomplete immunisation[17]
Immunocompromising conditions (e.g., cancer, asplenia or hyposplenia, HIV, congenital immunodeficiencies, sickle cell disease)[5][20][21][22]
Cranial structural defects[5]
Medical devices (e.g., cochlear implants, cerebrospinal fluid shunts)[5][23]
Exposure to pathogens (e.g., contact with another person with meningitis)[5]
Contiguous infection (e.g., sinusitis, pneumonia, mastoiditis, or otitis media)[5]
Crowding (e.g., in a household or dormitory).[5]
Consider any risk factors during the perinatal period. Neonates are at increased risk of bacterial meningitis if:[24]
There is premature or prolonged (>18 hours) rupture of membranes
There is maternal colonisation with group B streptococcus
There is maternal chorioamnionitis
They are premature
They have low birth weight.
Prioritise assessing:
Disability
Assess conscious level and pupils, and check for signs of raised intracranial pressure.
Exposure
Look for a non-blanching rash.
Practical tip
Think 'Could this be sepsis?' based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[39] See Sepsis in children.
Gain vascular access and correct dehydration.[4][28] See Management recommendations.
Assess initially for signs of:
Raised intracranial pressure[4][28]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score <0 or drop of ≥3) [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those under 2 years), use the Glasgow Coma Scale with modification for children.[2] Glasgow Coma Scale: modification for children Opens in new window
Relative bradycardia and hypertension
Focal neurological signs
Abnormal posture or posturing
Seizures
Unequal, dilated, or poorly responsive pupils
Papilloedema (late sign)
An enlarged blind spot may be identified when you examine the visual fields.
Abnormal 'doll's eye' movements.
Shock[2]
Capillary refill time >2 seconds
Abnormal skin colour
Tachycardia and/or hypotension
Respiratory symptoms or breathing difficulty
Cold hands/feet
Toxic/moribund state
Altered mental state/decreased conscious level
Poor urine output.
Signs of dehydration.[2]
Examine the patient’s skin very carefully for a rash.[2] Always document its presence or absence.
In practice, a petechial or purpuric rash is typically associated with meningococcal disease, but it may be present with any type of bacterial meningitis.
In the initial phases there may be only 1 or 2 petechiae.
Be aware that a rash may be less visible in patients with darker skin tones - check soles of feet, palms of hands, and conjunctivae.[2]
Children with petechiae confined to the skin above the nipple line (the distribution of the superior vena cava) may be less likely to have meningococcal disease than those with petechiae below the nipple line.[40]
Check for:[2]
Kernig's sign
With the patient lying flat, flex their thigh so that it is at a right angle to the trunk and extend the leg at the knee joint. If the leg cannot be completely extended due to pain, this is considered positive.
Kernig's sign is is more common in older children with bacterial meningitis.[41]
Brudzinksi's sign
When the patient's neck is abruptly flexed passively, meningeal irritation causes involuntary flexion of the hips and knees.
Brudzinski's sign results from inflammation of lumbosacral nerve roots. It is more common in older children with bacterial meningitis.[41]
Measure and record the following at least every hour:[2]
Heart rate
Respiratory rate
Oxygen saturations
Blood pressure
Temperature
Perfusion (capillary refill)
Neurological assessment (such as the Alert, Voice, Pain, Unresponsive [AVPU] scale).
Practical tip
In children aged ≤5 years, do not routinely use measurements of oral and rectal temperature to determine body temperature.[27] Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla.[27]
In children aged 4 weeks to 5 years, use of one of the following:[27]
Electronic thermometer in the axilla.
Chemical dot thermometer in the axilla. However, use an alternative type of thermometer if multiple temperature measurements are required.
Infra-red tympanic thermometer.
Do not use forehead chemical thermometers because they are unreliable.[27]
In general, do not delay giving antibiotics and other treatments while waiting for investigations if you suspect bacterial meningitis clinically.[2] However, in practice, always use your clinical judgement - lumbar puncture (the most important investigation for suspected bacterial meningitis) can be performed before giving antibiotics if the child is clinically stable, as long as there are no contraindications and lumbar puncture can be done promptly. See Lumbar puncture below.
Blood tests
If there are signs or symptoms of bacterial meningitis, order the following investigations:
Blood gas (including lactate).[2][28] Metabolic acidosis and raised lactate may indicate shock. If there is evidence of shock or meningococcal disease, also check ionised calcium (Ca2+) on the blood gas sample.[28]
C-reactive protein (CRP), procalcitonin (if available).[2][28][29][30][31]
Blood cultures.[2]
Whole-blood (EDTA) polymerase chain reaction (PCR) for Neisseria meningitidis.[2][4][28] See Meningococcal disease.
Urea, electrolytes, and creatinine.[28] If there is evidence of shock or meningococcal disease, also check ionised calcium (Ca2+) on a blood gas sample, and order serum magnesium (Mg2+), and phosphate (PO4) on laboratory samples.[28]
Liver function tests.[4]
Cross-match in all children who are seriously unwell, especially if there is evidence of shock or meningococcal disease.[28]
Lumbar puncture
Perform a lumbar puncture to obtain cerebrospinal fluid (CSF) unless any of the following relative contraindications are present:[2][4][28]
Signs suggesting raised intracranial pressure
Shock
Extensive or spreading purpura
After convulsions, until stabilised
Coagulation abnormalities
Coagulation results (if obtained) outside the normal
Platelet count <100 × 109/L
Receiving anticoagulant therapy
Local superficial infection at the lumbar puncture site
Respiratory insufficiency
Lumbar puncture has a high risk of precipitating respiratory failure in this scenario.
Do not allow the lumbar puncture or waiting for lumbar puncture results to delay administration of parenteral antibiotics.[2][4][28]
In practice, timing of lumbar puncture is a clinical decision. Lumbar puncture can be performed before giving antibiotics if the child is clinically stable, as long as there are no contraindications and lumbar puncture can be done promptly. Seek senior advice if you are unsure.
Practical tip
Use your clinical assessment to decide whether it is safe to perform a lumbar puncture.[2][28] Do not use cranial computed tomography (CT) for this purpose.[2][28] CT is unreliable for identifying raised intracranial pressure.[2] However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.[2]
CSF assessment should include:[2]
White blood cell count and examination
Total protein concentration
Glucose concentration
Gram stain
Microbiological culture.
Request CSF results promptly.
CSF white blood cell counts, total protein, and glucose concentrations should be available within 4 hours to inform decision-making on adjunctive corticosteroid therapy.[2]
The National Institute for Health and Care Excellence (NICE) in the UK recommends starting antibiotic treatment for bacterial meningitis in children if the CSF white blood cell count is abnormal:[2]
≥20 cells/microlitre in neonates (but continue to consider bacterial meningitis if <20 cells/microlitre and other symptoms and signs are present)
>5 cells/microlitre or >1 neutrophil/microlitre in older children and young people, regardless of other CSF variables.
If the cell count is lower, still consider bacterial meningitis if other symptoms and signs suggest the diagnosis, especially in neonates.[2]
However, in practice, do not allow lumbar puncture or CSF results to delay the first dose of antibiotics if there is clinical concern.
If the CRP and/or white blood cell count is raised and there is a non-specifically abnormal CSF on lumbar puncture (e.g., consistent with viral meningitis), treat as bacterial meningitis.[2]
If no CSF is available for examination or the CSF findings are uninterpretable, manage as if a diagnosis of meningitis is confirmed.[2]
Consider alternative diagnoses if the patient is significantly ill and has CSF variables within accepted normal ranges.[2] See Differentials.
Perform a repeat lumbar puncture in neonates with any of the following:[2]
Persistent or re-emergent fever
Deterioration in clinical condition
New clinical findings (particularly neurological)
Persistently abnormal inflammatory markers.
Do not perform a repeat lumbar puncture in neonates:[2]
Receiving antibiotic treatment tailored to the causative organism and making a good clinical recovery
Before stopping antibiotic therapy if clinically well.
Cranial computed tomography (CT)
Order a CT scan to look for alternative intracranial pathology if the patient has reduced or fluctuating level of consciousness (Glasgow Coma Scale score <9 or drop of ≥3), or focal neurological signs; in children unable to give a verbal response (in practice, those under 2 years), use the Glasgow Coma Scale with modification for children.[2] Glasgow Coma Scale: modification for children Opens in new window [ Glasgow Coma Scale Opens in new window ]
Do not delay treatment to wait for a CT scan.[28]
Stabilise the patient clinically before CT scanning.[28]
Consult a senior emergency physician, anaesthetist, paediatrician, or intensivist if the child has any of the indications above for CT.[28]
Consider CT or magnetic resonance imaging (MRI) in patients with a history of trauma, recent neurosurgery, rhinorrhoea, or otorrhoea to identify any source of CSF leak and source of contiguous spread of infection to the meninges.[42][43]
Practical tip
Do not use CT to decide whether it is safe to perform a lumbar puncture; use your clinical assessment instead.[28] CT is unreliable for identifying raised intracranial pressure.[28] However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.
Magnetic resonance imaging (MRI)
Consider CT or MRI in patients with a history of trauma, recent neurosurgery, rhinorrhoea, or otorrhoea to identify any source of cerebrospinal fluid leak and source of contiguous spread of infection to the meninges.[42][43]
Immune testing
In practice, consider assessment of immune function for children who have more than one episode of bacterial meningitis, or who develop bacterial meningitis with a bacterial serotype that is covered by a vaccination schedule for which they have completed a primary course. This is particularly important if there are additional concerning features in the history or physical examination (e.g., recurrent infections, poor growth).
Always discuss immune testing with a specialist in infectious disease or immunology.
For information on immune testing for children with meningococcal disease, see Meningococcal disease.
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