Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management

1.1.2 Be alert to the possibility of bacterial meningitis or meningococcal septicaemia when assessing children or young people with acute febrile illness.

1.1.3 Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis. This recommendation is amended from the NICE guideline on fever in under 5s: assessment and initial management.

1.1.4 Be aware that children and young people with bacterial meningitis commonly present with non-specific symptoms and signs, including fever, vomiting, irritability, and upper respiratory tract symptoms. Some children with bacterial meningitis present with seizures. See table 3 in the NICE guideline on sepsis: recognition, diagnosis and early management.

1.1.5 Consider other non-specific features of the child's or young person's presentation, such as:

1.1.6 In children and young people with suspected bacterial meningitis or meningococcal septicaemia, undertake and record physiological observations of heart rate, respiratory rate, oxygen saturations, blood pressure, temperature, perfusion (capillary refill) and neurological assessment (for example, the Alert, Voice, Pain, Unresponsive [AVPU] scale) at least hourly.

1.1.7 Healthcare professionals should be trained in the recognition and management of meningococcal disease.

1.1.8 Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia. This is a legal requirement under the Health Protection (Notification) Regulations 2010.

1.1.9 Be aware of Public Health England's guidance on meningococcal disease.

1.2.2 Transfer children and young people with suspected bacterial meningitis without non-blanching rash directly to secondary care without giving parenteral antibiotics.

1.2.3 If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), administer antibiotics to children and young people with suspected bacterial meningitis.

1.2.4 Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or secondary care, but do not delay urgent transfer to hospital to give the parenteral antibiotics.

1.2.5 Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication.

1.3.2 Give intravenous ceftriaxone immediately to children and young people with a petechial rash if any of the following occur at any point during the assessment (these children are at high risk of having meningococcal disease):

1.3.3 If a child or young person has an unexplained petechial rash and fever (or history of fever), carry out the following investigations:

1.3.4 In a child or young person with an unexplained petechial rash and fever (or history of fever) but none of the high-risk clinical manifestations (see table 1):

1.3.5 If the child or young person is assessed as being at low risk of meningococcal disease and is discharged after initial observation, advise parents or carers to return to hospital if the child or young person appears ill to them.

1.3.6 Be aware that in children and young people who present with a non-spreading petechial rash without fever (or history of fever) who do not appear ill to a healthcare professional, meningococcal disease is unlikely, especially if the rash has been present for more than 24 hours. In such cases, consider:

1.3.7 In children and young people with suspected bacterial meningitis, perform a CRP and white blood cell count:

1.3.8 Perform whole blood real-time PCR testing (ethylenediaminetetraacetic acid [EDTA] sample) for N meningitidis to confirm a diagnosis of meningococcal disease.

1.3.9 The PCR blood sample should be taken as soon as possible because early samples are more likely to be positive.

1.3.10 Use PCR testing of blood samples from other hospital laboratories if available, to avoid repeating the test.

1.3.11 Be aware that a negative blood PCR test result for N meningitidis does not rule out meningococcal disease.

1.3.12 Submit CSF to the laboratory to hold for PCR testing for N meningitidis and S pneumoniae, but only perform the PCR testing if the CSF culture is negative.

1.3.13 Be aware that CSF samples taken up to 96 hours after admission to hospital may give useful results.

1.3.14 Do not use any of the following techniques when investigating for possible meningococcal disease: skin scrapings, skin biopsies, petechial or purpuric lesion aspirates (obtained with a needle and syringe).

1.3.15 Perform a lumbar puncture as a primary investigation unless this is contraindicated.

1.3.16 Do not allow lumbar puncture to delay the administration of parenteral antibiotics.

1.3.17 CSF examination should include white blood cell count and examination, total protein and glucose concentrations, gram stain and microbiological culture. A corresponding laboratory-determined blood glucose concentration should be measured.

1.3.18 In children and young people with suspected meningitis or suspected meningococcal disease, perform a lumbar puncture unless any of the following contraindications are present:

1.3.19 In children and young people with suspected bacterial meningitis, if contraindications to lumbar puncture exist at presentation, consider delaying lumbar puncture until there are no longer contraindications. Delayed lumbar puncture is especially worthwhile if there is diagnostic uncertainty or unsatisfactory clinical progress.

1.3.20 CSF white blood cell counts, total protein and glucose concentrations should be made available within 4 hours to support the decision regarding adjunctive steroid therapy.

1.3.21 Start antibiotic treatment for bacterial meningitis if the CSF white blood cell count is abnormal:

1.3.22 In children and young people with suspected bacterial meningitis, consider alternative diagnoses if the child or young person is significantly ill and has CSF variables within the accepted normal ranges.

1.3.23 Consider herpes simplex encephalitis as an alternative diagnosis.

1.3.24 If CSF white cell count is increased and there is a history suggesting a risk of tuberculous meningitis, evaluate for the diagnosis of tuberculous meningitis in line with the NICE guideline on tuberculosis.

1.3.25 Perform a repeat lumbar puncture in neonates with:

1.3.26 Do not perform a repeat lumbar puncture in neonates:

1.3.27 Use clinical assessment and not cranial computed tomography (CT), to decide whether it is safe to perform a lumbar puncture. CT is unreliable for identifying raised intracranial pressure.

1.3.28 If a CT scan has been performed, do not perform a lumbar puncture if the CT scan shows radiological evidence of raised intracranial pressure.

1.3.29 In children and young people with a reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more) or with focal neurological signs, perform a CT scan to detect alternative intracranial pathology.

1.3.30 Do not delay treatment to undertake a CT scan.

1.3.31 Clinically stabilise children and young people before CT scanning.

1.3.32 If performing a CT scan, consult an anaesthetist, paediatrician or intensivist.

1.4.1 Treat children and young people aged 3 months or older with suspected bacterial meningitis without delay using intravenous ceftriaxone.

1.4.2 Treat children younger than 3 months with suspected bacterial meningitis without delay using intravenous cefotaxime plus either amoxicillin or ampicillin.

1.4.3 Treat suspected meningococcal disease without delay using intravenous ceftriaxone.

1.4.4 Treat children and young people with suspected bacterial meningitis who have recently travelled outside the UK or have had prolonged or multiple exposure to antibiotics (within the past 3 months) with vancomycin in addition to the above antibiotics.

1.4.5 If calcium-containing infusions are being administered, do not use ceftriaxone. Instead, use cefotaxime. See the Medicines and Healthcare products Regulatory Agency Drug Safety Update: Vol. 3 Issue 3.

1.4.6 In children younger than 3 months, ceftriaxone may be used as an alternative to cefotaxime (with or without ampicillin or amoxicillin), but be aware that ceftriaxone should not be used in premature babies or in babies with jaundice, hypoalbuminaemia or acidosis as it may exacerbate hyperbilirubinaemia.

1.4.7 If tuberculous meningitis is part of the differential diagnosis, use antibiotic treatment appropriate for tuberculous meningitis in line with the NICE guideline on tuberculosis.

1.4.8 If herpes simplex meningoencephalitis is part of the differential diagnosis, give appropriate antiviral treatment.

1.4.14 In children and young people aged 3 months or older with unconfirmed, uncomplicated but clinically suspected bacterial meningitis, treat with intravenous ceftriaxone for at least 10 days depending on symptoms and signs and course of the illness.

1.4.15 In children younger than 3 months with unconfirmed but clinically suspected bacterial meningitis, treat with cefotaxime plus either ampicillin or amoxicillin for at least 14 days. If the clinical course is complicated, (for example, if there is poor response to antibiotic therapy, effusion or abscess, or concomitant intraventricular haemorrhage in a premature baby), consider extending the duration of treatment and consulting an expert in paediatric infectious diseases.

1.4.16 In children and young people with confirmed meningococcal disease, treat with intravenous ceftriaxone for 7 days in total unless directed otherwise by the results of antibiotic sensitivities.

1.4.17 In children and young people with unconfirmed but clinically suspected meningococcal disease, treat with intravenous ceftriaxone for 7 days in total.

1.4.44 Do not treat with high-dose corticosteroids (defined as dexamethasone 0.6 mg/kg/day or an equivalent dose of other corticosteroids).

1.4.45 In children and young people with shock that is unresponsive to vasoactive agents, steroid replacement therapy using low-dose corticosteroids (hydrocortisone 25 mg/m² four times daily) should be used only when directed by a paediatric intensivist. The dosage given in the recommendation is based on high-quality evidence and is consistent with established clinical practice (see the full guideline for further details). The guideline will assume that prescribers will use a drug's SPC to inform their decisions for individual patients. Dexamethasone does not have UK marketing authorisation for use at the dose specified in the recommendation. Such use is an off-label use. Informed consent should be obtained and documented in line with normal standards in emergency care.

1.4.46 Do not use activated protein C or recombinant bacterial permeability-increasing protein in children and young people with meningococcal septicaemia.

1.4.47 Monitor children and young people closely after admission to hospital for signs of deterioration (monitor respiration, pulse, blood pressure, oxygen saturation and Glasgow Coma Scale score).

1.4.48 Be aware that children and young people with meningococcal disease can deteriorate rapidly, regardless of the results of any initial assessment of severity.

1.4.49 Children and young people who need resuscitation should be discussed with a paediatric intensivist as soon as possible.

1.4.50 Transfer of children and young people to tertiary care should be undertaken by an experienced paediatric intensive care retrieval team comprising medical and nursing staff.

1.5.1 Before discharging children and young people from hospital:

1.5.2 Offer children and young people and their parents or carers:

1.5.3 Offer a formal audiological assessment as soon as possible, preferably before discharge, within 4 weeks of being fit to test.

1.5.4 Offer children and young people with a severe or profound deafness an urgent assessment for cochlear implants as soon as they are fit to undergo testing (further guidance on the use of cochlear implants for severe to profound deafness can be found in the NICE technology appraisal guidance on cochlear implants for children and adults with severe to profound deafness).

1.5.5 Children and young people should be reviewed by a paediatrician with the results of their hearing test 4 to 6 weeks after discharge from hospital to discuss morbidities associated with their condition and offered referral to the appropriate services. The following morbidities should be specifically considered:

1.5.6 Inform the child's or young person's GP, health visitor and school nurse (for school-age children and young people) about their bacterial meningitis or meningococcal septicaemia.

1.5.7 Healthcare professionals with responsibility for monitoring the child's or young person's health should be alert to possible late-onset sensory, neurological, orthopaedic and psychosocial effects of bacterial meningitis and meningococcal septicaemia.

1.5.8 Test children and young people for complement deficiency if they have had either:

1.5.9 Children and young people with recurrent episodes of meningococcal disease should be assessed by a specialist in infectious disease or immunology.

1.5.10 Do not test children and young people for complement deficiency who have had either:

1.5.11 Discuss appropriate testing for complement deficiency with local immunology laboratory staff.

1.5.12 If a child or young person who has had meningococcal disease has a family history of meningococcal disease or complement deficiency, test the child or young person for complement deficiency.

1.5.13 If a child or young person who has had meningococcal disease is found to have complement deficiency, test their parents and siblings for complement deficiency.

1.5.14 Refer children and young people with complement deficiency to a healthcare professional with expertise in the management of the condition.

1.5.15 Do not test children and young people for immunoglobulin deficiency if they have had meningococcal disease, unless they have a history suggestive of an immunodeficiency (that is, a history of serious, persistent, unusual, or recurrent infections).