Recommendations
Key Recommendations
Escalate early. Initial assessment should be carried out by 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).[2] 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.
If you suspect bacterial meningitis, take the following immediate actions:
Isolate the patient and take droplet precautions, including wearing a surgical mask, if likely to be in close contact with respiratory secretions or droplets.[16][66][67]
Start empirical antibiotics immediately if septic shock is suspected, and always within 1 hour of arriving at hospital.[2][31][44]
Give supportive care as needed, which may include:
Fluid resuscitation
Respiratory support
Management of shock, metabolic disturbances, seizures, and raised intracranial pressure[2]
In the community, arrange urgent transfer by blue-light ambulance if you suspect bacterial meningitis.[2] 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.[2]
Do not delay transfer to hospital to give antibiotics.[2]
Give parenteral antibiotics to patients with strongly suspected bacterial meningitis as soon as possible, unless this will delay transfer to hospital.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends giving antibiotics specifically if there are clinical features indicating high risk from sepsis (e.g., hypotension, poor capillary refill time, or altered mental state) and there is an anticipated delay of more than 1 hour in getting to hospital.[32]
Urgently notify the relevant public health authority and microbiology if you have a patient with suspected meningitis (regardless of the aetiology). National Archives (UK): The Health Protection (Notification) Regulations 2010 Opens in new window
Monitor the patient closely after admission to hospital for signs of deterioration.
Adjust antibiotic therapy to target the causative organism as soon as it is identified, taking account of antibiotic sensitivities.
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice, and suggest follow-up within a specified period if you consider this to be appropriate.[2][74]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.
Isolate all patients with suspected meningitis until meningococcal meningitis is excluded (or considered unlikely) or empirical antibiotics have been given for 24 hours.[16][66] Always follow your local protocols, which may vary in practice.
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.[66][67]
Practical tip
Suspected meningitis is one of the commonest occupational exposures for healthcare workers but healthcare-associated infection is extremely rare.
Urgently notify the relevant public health authority and microbiology if you have a patient with suspected meningitis (regardless of the aetiology).
In the UK, the doctor who suspects a diagnosis of meningitis 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 doctor, but general practitioners may wish to check that it has been done. National Archives (UK): The Health Protection (Notification) Regulations 2010 Opens in new window
Age <1 month
Without delay, give infants aged <1 month with suspected bacterial meningitis acquired in the community:[75]
Intravenous cefotaxime or ceftriaxone plus intravenous amoxicillin.
Amoxicillin is used to cover Listeria monocytogenes, which is rare in the UK.[76] Therefore, amoxicillin is not commonly used in UK practice for suspected bacterial meningitis, unless the patient has specific risk factors for listeria meningitis. These risk factors include the neonatal period (age <28 days), pregnancy, immune compromise, and older age (>65 years).
Do not give ceftriaxone to premature babies or babies receiving calcium-containing infusions (use cefotaxime).[32] Ceftriaxone should also be avoided in babies with jaundice and any of the following: bilirubin level ≥200 umol/L, hypoalbuminaemia, or acidosis.[75]
Give intravenous amoxicillin plus cefotaxime to babies in the neonatal unit with suspected meningitis and unknown causative pathogen.[77]
Have a low threshold for adding intravenous aciclovir to cover for herpes simplex virus (HSV) infection in infants age <1 month with suspected central nervous system infection or sepsis. Features that can suggest HSV infection include:[75]
ALT or AST >2x the upper limit of normal (ULN)
Coagulopathy
Vesicles
Seizures
CSF pleocytosis
Suspected meningitis/encephalitis
Recent maternal herpes simplex disease
Postnatal contact with herpes simplex virus
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[2]
Age 1 month to 15 years
Give children and young people aged 1 month to 15 years with suspected bacterial meningitis intravenous ceftriaxone or cefotaxime without delay.[2]
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]
Do not give ceftriaxone if giving calcium-containing infusions (use cefotaxime).[2]
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[2]
Antibiotic allergy or immunocompromise
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
More info: Empirical antibiotics
Choice of empirical antibiotics is determined by the epidemiology of causative organisms for specific age groups. The introduction of widespread immunisation programmes in the UK and other developed countries, particularly the use of Haemophilus influenzae type b (Hib) and conjugate pneumococcal and meningococcal vaccines, has significantly changed the epidemiology of bacterial meningitis in children.[3][6][8][9][10][11]
In children and young people aged ≥3 months, the most common pathogens are Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae (pneumococcus).[3] H influenzae is no longer a major cause of bacterial meningitis following widespread introduction of the H influenzae type b (Hib) vaccine.[3] Meningitis due to H influenzae may occur incidentally in unvaccinated children or may be due to serotypes other than type b.[3][14]
In neonates, the most common pathogens are Streptococcus agalactiae (group B streptococcus), and Escherichia coli.[1] S pneumoniae and L monocytogenes account for a smaller proportion of cases.[1]
Escalate early. Initial assessment should be carried out by 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).[2] If you suspect bacterial meningitis, consult a consultant/senior doctor in emergency medicine, paediatrics, anaesthesia, or intensive care if you suspect meningococcal sepsis and the child does not respond within 1 hour of any intervention.[32] See Meningococcal disease.
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:[2][31][44]
Signs of shock
Raised intracranial pressure
Signs of dehydration
If the patient shows signs of raised shock or raised intracranial pressure, start emergency management for these conditions. See Shock and Raised intracranial pressure below.
Correct dehydration (if present) in children and young people with suspected bacterial meningitis using enteral fluids or feeds, or intravenous isotonic fluids.[2][32] 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.
Monitor fluid administration and urine output to ensure adequate hydration and avoid overhydration.[78]
Monitor electrolytes and blood glucose regularly (at least daily, while receiving intravenous fluids).[78]
Respiratory support
Give oxygen to children with suspected bacterial meningitis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air.[32]
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 meningitis has persistent hypoxia, respiratory distress, or inadequate ventilation, or if a patient requiring respiratory support does not respond within 1 hour.[31][32]
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%, Plasma-Lyte®, or Hartmann's solution [lactated Ringer's solution]), over 5-10 minutes.[32] The Resuscitation Council UK recommends using 10 mL/kg as a fluid bolus.[79] Give the fluid intravenously or via an intraosseous route and reassess the patient immediately afterwards.[79]
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.[78]
If signs of shock (e.g., hypotension) still persist after 40-60 mL/kg of fluid resuscitation:[78]
Seek urgent expert advice (e.g., from the paediatric intensive care team).[78]
Vasoactive agents should be initiated early, and following the advice from a paediatric intensivist or experienced members of the critical care team.[44]
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.[44] 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 recommends starting maintenance fluids without administering a fluid bolus.[44] 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.[80][81]
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).[44]
Seizures
Follow local or national protocols to treat seizures in children and young people with suspected bacterial meningitis.[82] See Generalised seizures in children.
Raised intracranial pressure
Follow local or national protocols to treat raised intracranial pressure.[82][83]
Arrange urgent transfer by blue-light ambulance for children and young people with suspected bacterial meningitis.[2][32]
In practice, where possible, the patient should arrive at hospital within 1 hour of being assessed in the community.
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.[2]
Do not delay transfer to hospital to give antibiotics.[2][50]
If oxygen and pulse oximetry are available, administer oxygen to patients with suspected bacterial meningitis who have signs of shock or oxygen saturation (SpO₂) of less than 92% when breathing air.[32]
Pre-hospital antibiotics
Give parenteral empirical antibiotics (intramuscular or intravenous ceftriaxone or benzylpenicillin) in the following cases:[2]
Strongly suspected bacterial meningitis if there is likely to be a significant delay of more than 1 hour in transfer to hospital.
Strongly suspected meningococcal disease, provided that this will not delay transfer to hospital. See Meningococcal disease.
Do not delay transfer to hospital to give antibiotics to people with suspected or strongly suspected bacterial meningitis or meningococcal disease.
Do not give antibiotics to patients with a history of severe allergy (e.g., anaphylaxis) to penicillins or cephalosporins; wait until admission to hospital.[2]
Safety netting for patients not transferred to hospital
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice.[2][74]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.
Suggest follow-up within a specified period if you consider this to be appropriate. Use your clinical judgement.
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 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 bacterial meningitis (particularly meningococcal meningitis) can deteriorate rapidly regardless of the results of any initial assessment of severity. See Meningococcal disease.
Discuss any child or young person who needs resuscitation with a paediatric intensivist as soon as possible.
Be alert for metabolic disturbances such as hypoglycaemia and electrolyte abnormalities in children and young people with suspected or confirmed meningitis, which may indicate more severe disease (e.g., sepsis or septic shock). 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.[44]
Hypocalcaemia is common in patients requiring intensive care unit admission for severe sepsis or septic shock.[84]
Give intravenous dexamethasone to children ≥3 months of age with strongly suspected or confirmed bacterial meningitis.[2]
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Get infection specialist advice on using dexamethasone for babies between 28 days and 3 months old with strongly suspected or confirmed bacterial meningitis.[2]
The first dose of dexamethasone, if indicated, should be given before or at the same time as antibiotics if possible.[2]
However, do not delay antibiotics to wait for dexamethasone to be started. In practice, antibiotics are often given prior to dexamethasone due to the time taken for the initial CSF results to be made available.
If dexamethasone is delayed for less than 12 hours after the start of antibiotics, give dexamethasone as soon as possible.
If dexamethasone is delayed for more than 12 hours after the start of antibiotics, get advice from an infection specialist and decide whether dexamethasone is still likely to provide benefit.
When the causative organism is found:[2]
Continue dexamethasone if it is pneumococcus or Haemophilus influenzae type b
Stop dexamethasone for all other organisms
If no causative organism is found, get advice from an infection specialist on whether or not to continue dexamethasone.[2]
If tuberculous meningitis is a possible diagnosis, refer to your local guideline for advice before giving corticosteroids. In these patients, corticosteroids may be harmful if given without antituberculous therapy.[85] See Extrapulmonary tuberculosis.
Do not routinely give corticosteroids to children or young people with meningococcal disease.[2] See Meningococcal disease.
Tailor the antibiotics according to the microbiological results, as well as discussion with microbiology and/or the multidisciplinary team where needed.
Get microbiologist or infectious diseases specialist advice for all cases of bacterial meningitis.[2]
Treat N meningitidis meningitis with high-dose intravenous ceftriaxone for 5 days in total unless directed otherwise by the results of antibiotic sensitivities. See Meningococcal disease.
If the patient has not recovered after 5 days, get microbiologist or infectious diseases specialist advice.
Do not give ceftriaxone to premature babies or children receiving calcium-containing infusions.[2][32] If ceftriaxone is contraindicated, consider cefotaxime.[2]
Seek advice from an infectious disease or microbiology specialist for infants with bacterial meningitis due to N meningitidis. N meningitidis may account for a smaller proportion of bacterial meningitis in this age group compared with older children, and this requires specialist management.[1][3]
Treat Streptococcus pneumoniae meningitis with high-dose intravenous ceftriaxone for 10 days in total unless directed otherwise by the results of antibiotic sensitivities.[2]
If the patient has not recovered after 10 days, get microbiologist or infectious diseases specialist advice.
Do not give ceftriaxone to premature babies or children receiving calcium-containing infusions.[2][32] If ceftriaxone is contraindicated, consider cefotaxime.[2]
Treat Haemophilus influenzae type b meningitis with high-dose intravenous ceftriaxone for 7-10 days unless directed otherwise by the results of antibiotic sensitivities.[2]
After 7 days, stop antibiotics if the patient has recovered, or continue for a total of 10 days if they have not. Get further advice from an infection specialist if the patient has not recovered after 10 days.
Do not give ceftriaxone to premature babies or children receiving calcium-containing infusions.[2][32] If ceftriaxone is contraindicated, consider cefotaxime.[2]
Treat group B streptococcal meningitis in children or babies outside neonatal units with high-dose intravenous ceftriaxone for 14 days, or as guided by culture sensitivities.[2] Give intravenous benzylpenicillin plus gentamicin to babies with group B streptococcal meningitis in neonatal units.[75]
If the patient has not recovered after 14 days, get microbiologist or infectious diseases specialist advice.
Do not give ceftriaxone to premature babies or children receiving calcium-containing infusions.[2][32] If ceftriaxone is contraindicated, consider cefotaxime.[2]
Treat meningitis caused by Enterobacterales (coliforms) with high-dose intravenous ceftriaxone for 21 days unless directed otherwise by the results of antibiotic sensitivities.[2]
If the patient has not recovered after 21 days, get microbiologist or infectious diseases specialist advice.
Do not give ceftriaxone to premature babies or children receiving calcium-containing infusions.[2][32] If ceftriaxone is contraindicated, consider cefotaxime.[2]
Treat meningitis caused by Listeria monocytogenes with intravenous amoxicillin for 21 days unless directed otherwise by the results of antibiotic sensitivities.[2][75]
Get microbiologist or infectious diseases specialist advice on adding intravenous trimethoprim/sulfamethoxazole for the first 7 days
If the patient has not recovered after 21 days, get microbiologist or infectious diseases specialist advice.
Antibiotic allergy or immunocompromise
If the child has an allergy to the recommended antibiotic or they are immunocompromised, follow your local protocols for appropriate alternatives and consult an infectious disease or microbiology specialist.
Patients admitted to hospital
Before discharging a child or young person who has been diagnosed with bacterial meningitis and treated in hospital:[2]
Consider their follow-up requirements, taking into account potential cognitive, neurological, developmental, orthopaedic, skin, hearing, psychosocial, education, and renal morbidities.
Discuss potential long-term effects and likely patterns of recovery with the child or young person and their parents or carers; provide opportunities to discuss issues and ask questions.
See Patient discussions.
Patients seen in hospital or the community and not admitted to hospital
If your initial assessment rules out any suspicion of bacterial meningitis and you decide the patient can be managed in the community, ensure you give thorough safety netting advice.[2][74]
Encourage the parent/patient to trust their instincts and seek medical help again if the illness gets worse, even if this is shortly after the patient was seen.
Give advice on accessing further health care and ensure the parent/patient understands how to get medical help after normal working hours.
Provide information on symptoms of serious illness, including how to identify a non-blanching rash and the tumbler test.
Suggest follow-up within a specified period if you consider this to be appropriate. Use your clinical judgement.
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