g logo nice orange

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

Key priorities for implementation

Symptoms and signs of bacterial meningitis and meningococcal septicaemia

  • Consider bacterial meningitis and meningococcal septicaemia in children and young people who present with the symptoms and signs (see algorithm below)
    • be aware that:
      • some children and young people will present with mostly non-specific symptoms or signs and the conditions may be difficult to distinguish from other less important (viral) infections presenting in this way
      • children and young people with the more specific symptoms and signs are more likely to have bacterial meningitis or meningococcal septicaemia and the symptoms and signs may become more severe and more specific over time
    • recognise shock and manage urgently in secondary care
  • Healthcare professionals should be trained in the recognition and management of meningococcal disease

Management in the pre-hospital setting

  • Primary care healthcare professionals should transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999

Diagnosis in secondary care

  • Investigation and management in children and young people with petechial rash
    • 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):
      • petechiae start to spread
      • the rash becomes purpuric
      • there are signs of bacterial meningitis
      • there are signs of meningococcal septicaemia
      • the child or young person appears ill to a healthcare professional
  • Polymerase chain reaction
    • perform whole blood real-time PCR testing (EDTA sample) for N meningitidis to confirm a diagnosis of meningococcal disease
  • Lumbar puncture
    • in children and young people with suspected meningitis or suspected meningococcal disease, perform a lumbar puncture unless any of the following contraindications are present:
      • signs suggesting raised intracranial pressure
        • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)
        • relative bradycardia and hypertension
        • focal neurological signs
        • abnormal posture or posturing
        • unequal, dilated or poorly responsive pupils
        • papilloedema
        • abnormal ‘doll’s eye’ movements
      • shock
      • extensive or spreading purpura
      • after convulsions until stabilised
      • coagulation abnormalities
        • coagulation results (if obtained) outside the normal range
        • platelet count below 100 x 109/litre
        • receiving anticoagulant therapy
      • local superficial infection at the lumbar puncture site
      • respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency)

Management in secondary care

  • Fluids for bacterial meningitis
    • do not restrict fluids unless there is evidence of:
      • raised intracranial pressure, or
      • increased antidiuretic hormone secretion*
  • Intravenous fluid resuscitation in meningococcal septicaemia
    • in children and young people with suspected or confirmed meningococcal septicaemia:
      • if there are signs of shock give an immediate fluid bolus of 20 ml/kg sodium chloride 0.9% over 5–10 minutes. Give the fluid intravenously or via an intraosseous route and reassess the child or young person immediately afterwards
      • if the signs of shock persist, immediately give a second bolus of 20 ml/kg of intravenous or
      • intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5–10 minutes
      • if the signs of shock still persist after the first 40 ml/kg:
        • immediately give a third bolus of 20 ml/kg of intravenous or intraosseous sodium chloride
        • 0.9% or human albumin 4.5% solution over 5–10 minutes
        • call for anaesthetic assistance for urgent tracheal intubation and mechanical ventilation
        • start treatment with vasoactive drugs
        • be aware that some children and young people may require large volumes of fluid over a short period of time to restore their circulating volume
        • consider giving further fluid boluses at 20 ml/kg of intravenous or intraosseous sodium chloride 0.9% or human albumin 4.5% solution over 5–10 minutes based on clinical signs and appropriate laboratory investigations including urea and electrolytes
      • discuss further management with a paediatric intensivist

Long-term management

  • Long-term effects of bacterial meningitis and meningococcal septicaemia
    • 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 ‘Cochlear implants for children and adults with severe to profound deafness’ [NICE technology appraisal 166]).
    • children and young people should be reviewed by a paediatrician with the results of their hearing test 4–6 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:
      • hearing loss (with the child or young person having undergone an urgent assessment for cochlear implants as soon as they are fit)
      • orthopaedic complications (damage to bones and joints)
      • skin complications (including scarring from necrosis)
      • psychosocial problems
      • neurological and developmental problems
      • renal failure

* See National Patient Safety Agency (2007) Patient safety alert 22: Reducing the risk of hyponatraemia when administering intravenous infusions to children. Available from www.nrls.npsa.nhs.uk

Pre-hospital management—meningococcal disease and bacterial meningitis

Pre-hospital management—meningococcal disease and bacterial meningitis

© NICE 2010. Meningitis (bacterial) and menigococcal septicaemia in under 16s: recognition, diagnosis and management. Available from: www.nice.org.uk/guidance/CG102 . All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: October 2010.