Recommendations
Key Recommendations
Escalate early. Consult a senior doctor in emergency medicine or paediatrics immediately if you suspect bacterial meningitis in a child. 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.
Strongly suspect bacterial meningitis when assessing any child or young person with the following red flag symptoms:[2]
Fever
Headache
Neck stiffness
Altered level of consciousness or cognition (including confusion or delirium)
Other clinical features include:[2]
Vomiting/nausea
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:
Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation.
Young people can present with non-specific symptoms and signs.
Take concerns expressed by the referring doctor or a carer/relative seriously because clinical features are often not clear cut.[2][27]
A senior clinical decision-maker (paediatric or emergency care qualified doctor or equivalent with core competencies in the care of acutely ill children e.g., ST4 level doctor or above in the UK) should perform an initial assessment and ensure that:[2]
Antibiotics start within 1 hour of the child with bacterial meningitis arriving at hospital.
Blood tests and lumbar puncture are performed before starting antibiotics (if it is safe to do so and will not cause a clinically significant delay to starting antibiotics).
Start parenteral empirical antibiotics before lumbar puncture if performing a lumbar puncture is likely to cause a clinically significant delay.[2]
Order the following blood tests:[2]
Blood gas (including lactate and ionised calcium)
Blood glucose
Full blood count
C-reactive protein (CRP), and/or procalcitonin (if available)[28][29][30]
Do not rule out bacterial meningitis based only on a normal CRP, procalcitonin, or white blood cell count.[2]
Blood culture
Take as soon as possible and within 1 hour of arrival at hospital
Take before antibiotics wherever possible
Coagulation screen
Urea, electrolytes, and creatinine
Cross-match in all children who are seriously unwell, especially if there is evidence of shock or meningococcal disease
Meningococcal and pneumococcal PCR (EDTA sample)
Perform a lumbar puncture unless the procedure is contraindicated.[2]
Do not routinely perform neuroimaging before lumbar puncture. Consider computed tomography (CT) scan to look for alternative intracranial pathology if the child has reduced or fluctuating level of consciousness, or new focal neurological features which might indicate raised intracranial pressure.[2]
Escalate early. Call a senior clinical decision-maker (paediatric or emergency care qualified doctor or equivalent with core competencies in the care of acutely ill children - e.g., ST4 level doctor or above in the UK) to perform an initial assessment if you suspect bacterial meningitis.
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 any child or young person with an acute febrile illness. Be aware that bacterial meningitis:[2]
Is a rapidly evolving condition.
Can present with non-specific symptoms and signs, particularly in young babies (<3 months).
May be difficult to distinguish from other infections with similar symptoms and signs.
Symptoms and signs may be more difficult to identify in young people and young adults, who may appear well at presentation.
Meningitis and sepsis can occur at the same time, particularly in people with a rash.
Headache and neck stiffness are harder to identify in babies and young children.
Do not be reassured by lack of fever in an unwell baby; more than 50% of neonates diagnosed with bacterial meningitis are afebrile on presentation.[3]
Symptoms and signs that may indicate bacterial meningitis in babies, children, and young people.[2]
Symptoms and signs | Further information |
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Red flag combination | |
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Appearance
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Behaviour
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Cardiovascular
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Neurological
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Respiratory
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Other
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Also take into account:[2]
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). Take any reported or perception of fever by the parent(s) or carer seriously.[27]
How quickly the illness is progressing.
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)[2][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]
Visiting an area with a recent outbreak of meningococcal disease; consider recent travel abroad, particularly to hyperendemic or epidemic areas[2][25]
Contiguous infection (e.g., sinusitis, pneumonia, mastoiditis, or otitis media)[5]
Crowding (e.g., in a household or dormitory; for example, a student in further or higher education in large shared accommodation)[2][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
Airway
Breathing
Circulation
Disability
Assess conscious level and pupils, and check for signs of raised intracranial pressure.
Exposure
Look for a non-blanching rash
Practical tip
Have a low threshold for suspecting sepsis. Clinical presentation of sepsis in children is often subtle and non-specific and progression to organ failure and shock can be very rapid.
Think ‘Could this be sepsis’ in any child with a suspected infection with signs of a systemic response, which may be indicated by a change in observations or a change in a child’s normal behaviour.[32][33] Always acknowledge parent or carer concern.[32] See Sepsis in children.
Meningitis and sepsis can occur at the same time, particularly in children with a rash.[2]
Involve senior clinicians/specialists early.
If you suspect sepsis, use a standard ABC (airway, breathing, circulation) approach with particular emphasis on early administration of antibiotics and fluid resuscitation.[34][35]
Initiate treatment as soon as possible and always within the first hour following recognition of severe sepsis.[31][34][35]
Protocolised care bundles, such as the Paediatric Sepsis Six initiative, have proven to be important in the management of paediatric sepsis and should be used in management alongside local guidelines.[36][37][38][39][40][41]
Use paediatric early warning scores (PEWS) for risk stratification in line with local protocols; however, PEWS must not be used as a substitute for clinical assessment. If a child appears unwell to a health professional, this should trigger further assessment independent of PEWS score.[31][42]
Gain vascular access and correct dehydration. See Management recommendations.
Assess initially for signs of:
Raised intracranial pressure[2]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score of 9 or less or a progressive and sustained or rapid fall in level of consciousness) [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those under 2 years), use the AVPU scale (Alert, Voice, Pain, Unresponsive)[32]
New focal neurological signs, including seizures or posturing
Abnormal pupillary reactions
Shock. Check for:[43][44][45][46]
Prolonged capillary refill time (e.g., more than 2-3 seconds)
Cold hands/feet
Weak, fast pulse
Pale/mottled/ashen/blue skin, lips or tongue
Other indicators of critical illness in children include decreased level of consciousness, decreased urine output, hypoxia (check oxygen saturations), and elevated lactate levels.[27][44]
Examine the patient’s skin very carefully for a rash. Always document its presence or absence.[2]
In practice, a petechial or purpuric rash is typically associated with meningococcal disease, but it may be present with any type of bacterial meningitis.
In the initial phases there may be only 1 or 2 petechiae.
Rashes can be hard to detect on brown, black, or tanned skin (look for petechiae in the conjunctiva).
Remember to check the nappy area.[2]
Tell the person and their family members or carers to look out for any changes in the rash because it can change from blanching to non-blanching.[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.[47]
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:[31][48]
Heart rate
Respiratory rate
Oxygen saturations
Blood pressure
Temperature
Perfusion (capillary refill)
Neurological assessment (such as the Alert, Voice, Pain, Unresponsive [AVPU] scale)
More info: Clinical signs of meningism (meningeal irritation)
Kernig’s sign and Brudzinski’s sign are classical signs of meningeal irritation used since the early 20th century to aid the diagnosis of meningitis.[49] Kernig’s sign is the inability to straighten the leg when the hip is flexed to 90 degrees, and Brudzinski’s sign is severe neck stiffness causing the patient’s hips and knees to flex when the neck is flexed.
The 2024 UK National Institute for Health and Care Excellence (NICE) guideline on recognition, diagnosis and management of bacterial meningitis and meningococcal disease does not recommend checking for Brudzinski's or Kernig’s sign for suspected bacterial meningitis. This is due to their low sensitivity and the difficulty in eliciting these signs, particularly in babies.[2] NICE notes that these signs were introduced at a time when people often presented later (after a few days) and antibiotics did not exist.[2]
The 2016 UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults states that Kernig's sign and Brudzinski's sign should not be relied upon for diagnosis of suspected meningitis, noting that sensitivity can be as low as 5%, despite their high specificity (up to 95%).[50]
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. 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:[2]
Blood gas (including lactate and ionised calcium)
Blood glucose
Full blood count
C-reactive protein (CRP) and/or procalcitonin (if available)[28][29][30]
Do not rule out bacterial meningitis based only on a normal CRP, procalcitonin, or white blood cell count.[2]
Blood culture
Take as soon as possible and within 1 hour of arrival at hospital
Take before antibiotics wherever possible
Coagulation screen[2]
Urea, electrolytes, and creatinine
Cross-match in all children who are seriously unwell, especially if there is evidence of shock or meningococcal disease
Meningococcal and pneumococcal PCR (EDTA sample). See Meningococcal disease
Lumbar puncture
Perform a lumbar puncture to obtain cerebrospinal fluid (CSF) before starting antibiotics, unless it is not safe to do so or it will cause a clinically significant delay to starting antibiotics.[2]
In practice, timing of lumbar puncture is a clinical decision. Seek senior advice if you are unsure.
Treat and stabilise any of the following before performing a lumbar puncture:[2]
Unprotected airway
Respiratory compromise
Shock
Uncontrolled seizures
Bleeding risk
Do not perform lumbar puncture if there are the following:[2]
Extensive or rapidly spreading purpura
Infection at the lumbar puncture site
Risk factors for an evolving space-occupying lesion (see Cranial computed tomography)
Any of the following symptoms or signs which might indicate raised intracranial pressure:
New focal neurological features (including seizures or posturing)
Abnormal pupillary reactions
A Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness
Practical tip
Use your clinical assessment to decide whether it is safe to perform a lumbar puncture. Do not routinely perform neuroimaging before lumbar puncture. Evidence shows that performing a lumbar puncture without waiting for a CT scan leads to people receiving antibiotic treatment sooner, which may reduce mortality and morbidity.[2] However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.
CSF assessment should include:[2]
Red and white blood cell count and examination (including differential white cell count)
Total protein concentration
Glucose concentration
Microscopy with Gram stain
Microbiological culture and sensitivities
Request CSF results promptly. Store remaining cerebrospinal fluid in case more tests are needed.[2]
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]
Interpret cerebrospinal fluid results using standard age-appropriate threshold values
Normal thresholds for white cell count and protein may be higher in babies under 3 months
Remember earlier antibiotics or immunodeficiency may reduce the diagnostic reliability of these investigations
Red cells in the sample may suggest blood contamination or a different diagnosis
If cerebrospinal fluid results are abnormal, consider alternative viral, mycobacterial, fungal or non-infectious causes as well as bacterial meningitis.[2] See Differentials.
If no CSF is available for examination or the CSF findings are uninterpretable, and the clinical presentation is concerning for possible meningitis, manage as per bacterial meningitis.
Cranial computed tomography (CT)
Do not routinely perform neuroimaging before lumbar puncture.
Only perform cranial imaging before lumbar puncture if there are:
Risk factors for an evolving space-occupying lesion[3][51][52] Children's Brain Tumour Research Centre. the brain pathways guideline Opens in new window
Any of the following clinical features, which might indicate raised intracranial pressure
New focal neurological features (including seizures or posturing)[2]
Abnormal pupillary reactions or papilloedema[50]
A Glasgow Coma Scale (GCS) score of 9 or less, or a progressive and sustained or rapid fall in level of consciousness.[2] Glasgow Coma Scale: modification for children Opens in new window [ Glasgow Coma Scale Opens in new window ]
Do not perform a lumbar puncture until these factors have been addressed.[2]
Neuroimaging is not routinely indicated in the initial investigation of a child with suspected meningitis, unless you suspect alternative pathology (e.g. intracranial abscess, space occupying lesion, neurovascular event, head trauma).[50]
Consider neuroimaging before lumbar puncture in children with a CSF shunt in place or a history of hydrocephalus.
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.[53][54]
Practical tip
Do not use CT to decide whether it is safe to perform a lumbar puncture; use your clinical assessment instead. CT scan will not pick up raised intracranial pressure per se, but it may identify conditions associated with raised ICP such as a tumour or brain abscess, or meningitis-associated complications such as brain infarction, generalised cerebral oedema, or hydrocephalus.[3][55] However, if a CT scan has been performed and shows radiological evidence of raised intracranial pressure, do not proceed with a lumbar puncture.
More info: Timing of cranial imaging in relation to lumbar puncture
This has been a controversial area.[56][57] A review of the evidence in 2024 resulted in the National Institute for Health and Care Excellence (NICE) recommending against routinely performing neuroimaging before lumbar puncture.[2]
Delaying lumbar puncture for a CT scan can cause delays in antibiotic administration, which may lead to an increase in mortality.[2][58][59]
Lumbar puncture without prior CT is also associated with lower rates of neurological and/or hearing deficits and functional impairment, and a shorter time to antibiotic treatment (with or without corticosteroids), relative to lumbar puncture after CT.[2]
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.[53][54]
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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