- Meningitis does not always present with the classic triad of fever, headache and nuchal rigidity, and often presents with nonspecific symptoms, especially in young infants.
- Bacterial meningitis is less common than viral meningitis but is a more serious disease that can result in neurological sequelae or even death.
- Laboratory testing (blood and CSF) is required to definitively differentiate between viral and bacterial meningitis.
- If meningitis is clinically suspected and lumbar puncture is contraindicated, or delayed for more than 30 minutes, give empiric antibiotics IV.
This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with suspected acute meningitis in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for use across Queensland by the Statewide Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Division.
Meningitis describes the inflammation of the membranes that surround the brain and spinal cord and may be caused by a variety of different microorganisms, including both viruses and bacteria.1
Analysis of ED data in Queensland found that acute bacterial meningitis represented approximately 0.06% of all paediatric ED presentations. While this is not a common diagnosis, the sequelae can be devastating. The mortality rate from bacterial meningitis ranges from 2% in infants and children to 20% in neonates with up to a third of survivors experiencing neurological sequelae (either transient or permanent).2 Approximately 90% of bacterial meningitis occurs in children < 5 years of age.2
Bacterial infection in infants up to 3 months of age (corrected for prematurity) is typically acquired during birth through aspiration of intestinal and genital tract secretions from the mother (vertical transmission).3 Group B streptococci (subtype III), gram-negative enteric bacilli (Eschericha coli, Klebsiella and Enterobacter), and Listeria monocytogenes (serotype IVb) are the most common causes of bacterial meningitis in this age group.
In the older child, the rates of meningitis are much lower with an estimated incidence of 1 per 5,901 febrile children aged 2 to 24 months.4 In older infants and children, bacterial meningitis usually develops after encapsulated bacteria (that have colonised the nasopharynx) are disseminated in the blood stream. The most common pathogens in children aged over 3 months are Streptococcus pneumoniae and Neisseria meningitidis. The incidence of bacterial meningitis has markedly declined in Australia with the introduction of the Hib and pneumococcal vaccinations in the National Immunisation Program.5,6,7
Viral meningitis is usually diagnosed following exclusion of bacterial meningitis, with enterovirus and coxsackie virus being the major causes.3 Parechovirus is also common in infants ≤ 3 months of age.
Herpes simplex virus meningitis without encephalitis is an infrequent cause of viral meningitis in children and usually has an excellent outcome even without antiviral therapy. HSV encephalitis however is a particularly devastating form of herpes infection (especially in neonates) with significant morbidity and mortality if not treated appropriately. Patients may have a history of HSV in close contacts.
Patients with HSV meningoencephalitis can have disseminated disease, but specific features include:
- focal neurological signs, e.g. dysphasia or hemiparesis
- focal seizures
- predominance of lymphocytes in the CSF
- skin lesions (may not be present)
The aim of the assessment (history and clinical examination) is to identify cases of meningitis promptly to enable appropriate management. Distinguishing between viral and bacterial meningitis on initial assessment can be difficult. Given the importance of early antibiotic treatment, it is safest to assume a bacterial cause until proven otherwise, especially in children < 5 years.
The clinical presentation of bacterial meningitis may be acute (hours to 1 – 2 days) or insidious (over a few days). A history of preceding upper respiratory tract infection is can be present in up to 75% of patients.8 Apparent improvement with paracetamol should not be used to exclude the diagnosis.
History should include specific information on:
- immunisations (reduces but not eliminates risk of infection)
- prior use of oral antibiotics (may modify clinical features and CSF findings resulting in a delay in diagnosis9)
- risk factors for infection
Risk factors for meningitis:
- recent contact with a case of bacterial meningitis (especially in family)
- recent contact with HSV “cold sores” or confirmed enterovirus infection (risk for HSV or EV71 encephalitis)
- recent overseas travel
- maternal GBS colonisation (in infants < 3 months)
- immunocompromised (if so consider cryptococci and mycobacteria)
- recent history of neurosurgical procedure or penetrating head injury
- VP shunt
- cochlear implant
While the classic triad of fever, neck stiffness and headache is suggestive of meningitis, it is found in less than 50% of cases in older children and adolescents.3,10 Older children may present with any combination of these and/or other symptoms including rash, upper or lower respiratory tract, myalgia and abdominal pain. In preverbal children, symptoms are even more non-specific and a high index of suspicion is required to avoid missing cases.7 A collection of non-specific symptoms that include fever, neck stiffness and headache are more common in viral meningitis while neurological complications (including seizures and coma) rarely occur.11
The presence of an apparent explanation for fever such as pharyngitis, UTI or otitis media does not rule out diagnosis.12
A high index of suspicion for meningitis is required for:
- all sick, febrile or hypothermic neonates (with or without the features described)
- all children presenting with fever and convulsions especially if aged < 2 years
Whilst the presentation varies with age, bacterial meningitis should be considered for any child with the clinical features outlined in the table below.
|ANY of the following clinical features
||Clinical features more commonly seen in infants < 3 months*
- vomiting and/or nausea
- lethargy or irritability
- photophobia and/or headaches
- nuchal rigidity (often not present, especially in young children and infants)
- positive Kernig’s or Brudzinski’s sign
- altered mental status
- focal neurological deficit
- petechial rash (an erythematous maculopapular eruption may be present initially)
- bulging fontanelle
- high pitched cry
- poor feeding
- hypothermia or temperature instability
- fever in child < 28 days old
*May also occur in infants > 3 months.
Adapted from: van de Beek et al10 and Oostenbrink et al13 and Feigin et al14
Fever and rash
The presence of a rash in a febrile child is often nonspecific and more likely to be caused by a viral illness than acute bacterial meningitis. Clinical judgement and decision making should be based on the entire clinical presentation and not just the rash. The rash associated with meningococcal disease may be maculopapular (in the earlier stages), petechial, or purpuric.
Other causes of meningitis signs and symptoms:
- viral encephalitis
- intracranial collections, e.g. subdural empyema and brain abscess
- eosinophilic meningitis
- acute disseminated encephalomyelitis
- other infectious diseases, e.g. pneumonia, otitis media, gastroenteritis, sinusitis and pharyngitis
The definitive diagnosis of acute bacterial or viral meningitis is made on analysis of cerebrospinal fluid (CSF) obtained via lumbar puncture (LP). Where a LP is contraindicated or clinically unsafe (see below), investigations such as blood cultures and PCR testing on blood may be useful to diagnose meningococcal, pneumococcal or Hib infection.
||Positive CSF gram stain and culture results seen in 70 – 80% of untreated acute bacterial meningitis cases.
CSF cell count, protein and glucose do not change appreciably with antibiotics.3,15
Meningococcus PCR has 89% sensitivity and 100% specificity.16
Meningococcus or pneumococcus PCR may be positive despite antibiotic treatment.
Viral PCR will guide treatment if clinical picture or CSF cell count suggests a viral aetiology.
||Especially valuable if LP not done.
Positive in 74% of untreated acute bacterial meningitis patients and <50% of treated patients.
||Serum electrolytes – seizures may be secondary to low sodium, calcium or magnesium; hyponatraemia in SIADH.
BSL – check for hypoglycaemia especially in infants < 3 months of age.
UEC, LFT and VBG may suggest sepsis.
CRP – may be high in bacterial meningitis but is nonspecific.
|Full blood count (FBC)
||May be high in bacterial meningitis but is nonspecific.
|Serum for bacterial PCR
(Whole blood – EDTA sample)
|Consider collection with initial venepuncture and bloods. Seek senior advice prior to request.
Meningococcal PCR has a high sensitivity and specificity.
Pneumococcal PCR may be performed at some laboratories.
Sensitivity higher with earlier time of collection but may remain positive up to 72 hours post antibiotics.17
Consider a clotting profile prior to LP if any clinical concerns around pre-existing coagulopathy e.g. sepsis, thrombocytopenia.
Reasons for delaying a LP may include:
- patient instability such as respiratory or cardiovascular compromise
- persistently reduced level of consciousness
- continuing seizures
- suspicion of space-occupying lesion or raised ICP (i.e. Cushing sign, focal seizures, focal neurological defect, irregular breathing and papilloedema; relative bradycardia and hypertension)
- skin infection at the site of LP
- coagulopathy/ thrombocytopenia
For these cases, antibiotics should not be delayed and treatment should be continued until clinical improvement is evident, at which time a LP may be safely performed.
Neither the absence of papilloedema or presence of a normal head CT scan rules out raised ICP (and the associated risk of subsequent brain herniation). Transportation out of ED for radiological investigations may put the unstable child at greater risk.18
Request urgent CSF microscopy (includes Gram stain, WCC and differential), CSF protein and glucose, culture & sensitivity and PCR studies. In addition, if suspect viral aetiology, request viral PCR for enterovirus (and parechovirus if <3 months) and HSV plus VZV PCR (if varicella zoster virus is suspected).
No single CSF test parameter reliably distinguishes bacterial from non-bacterial meningitis. Normal CSF findings can very uncommonly result in culture proven bacterial meningitis. It is important to correlate with clinical findings.
(x 106 /L)
(>1 month of age)
||≥ 0.6 (or ≥ 2.5 mmol/L)
(<1 month of age)
||≥ 0.6 (or ≥ 2.5 mmol/L)
Some guidelines suggest that in traumatic taps you can allow 1 white blood cell for every 500 to 700 red blood cells and 0.01g/L protein for every 1000 red cells. However, rules based on a ‘predicted’ white cell count in the CSF are not reliable.
In order not to miss any patients with meningitis, guidelines relating to decisions about who not to treat for possible meningitis need to be conservative. The safest interpretation of a traumatic tap is to count the total number of white cells, and disregard the red cell count. If there are more white cells than the normal range for age, then the safest option is to treat.
Taken from The Royal Children’s Hospital, Melbourne, Australia, Clinical Practice Guideline on CSF Interpretation, [Internet; cited June 18], Available from: https://wwww.rch.org.au/clinicalguide/
Refer to flowchart for a summary of the recommended emergency management of children with suspected meningitis.
The absence of early appropriate senior input (including the absence of consultant supervision) during the first 24 hours in hospital is an independent risk factor for death.19
The initial management for a child suspected of having meningitis is the same as for any serious illness. The assessment and management should be performed simultaneously and the child moved into the resuscitation area for stabilisation of airway, breathing, circulation, and disability (seizures / hypoglycaemia). This assessment and stabilisation should be prioritised above any illness-specific diagnostic assessment or treatment.
Early use of appropriate antibiotics IV (and antiviral where HSV meningoencephalitis is considered, especially in neonates) has been shown to improve outcome.
Empiric antibiotic regimens are selected to cover the most likely pathogens for the selected age group – refer to the CHQ Antibiocard or follow local guidelines. As per the CHQ Antibiocard, Vancomycin should be added for:
- some children with gram positive cocci in CSF, depending on age and illness severity
- critically ill children with suspected Streptococcus pneumoniae infection
The child should be admitted and empiric antibiotics continued until culture results are known to be negative or an organism and its sensitivity pattern are identified. Multi-resistant Streptococcus pneumoniae is on the rise (20-45% of all strains world-wide have been reported to be resistant to penicillin) and many are also resistant to the third-generation cephalosporins.20,21
Aciclovir is not routinely required in children with meningitis. It is recommended for all children with suspected encephalitis and may be considered in other children if a viral aetiology is suspected. For antiviral dosages refer to the CHQ Antibiocard.
Corticosteroids should be considered in all suspected bacterial meningitis cases, with administration ideally prior to or immediately following the first antibiotic IV dose.
Corticosteroids potentially improve patient outcome in acute bacterial meningitis by modulating the response to inflammatory mediators. The inflammatory response may be initiated in response to lysis of bacterial cell walls after the first dose of antibiotics. However, there is no evidence of benefit in viral meningitis, neonatal bacterial meningitis, Gram-negative bacterial meningitis, or in children already on antibiotics (partially-treated meningitis).22
A Cochrane review concluded that the use of corticosteroids (in conjunction with antibiotics) significantly reduces hearing loss (but not overall mortality) in children with acute bacterial meningitis.23
||For children >3 months of age:
0.15 mg/kg/dose (maximum 10mg/dose), 6 hourly for 4 days if able to start prior to or within 1 hour of first antibiotic IV dose.
Do not delay antibiotic therapy if steroids are not available.
Children with meningitis may require initial fluid resuscitation as clinically indicated. Careful fluid management and electrolyte balance is important. Children with meningitis are at high risk of developing hyponatraemia associated with increased secretion of ADH.3 In the first 48 hours, it is recommended that children are not fluid restricted. There is no current evidence to support that fluid restriction reduces the incidence of cerebral oedema in children with bacterial meningitis.1
||Normal saline (0.9% NaCl) administered in 20 mL/kg bolus to treat shock.
Repeat in 20 mL/kg boluses as clinically indicated.
||0.9% NaCl + 5% glucose preferred.
Infection control measures
Standard precautions and droplet precautions should be observed during the care of a child with suspected or confirmed acute bacterial meningitis. Appropriate personal protective equipment must be worn when undertaking any procedure where there is a risk of exposure to blood or body fluids. All cases of suspected bacterial meningitis should be initially isolated in a single room until cleared or confirmed and ongoing isolation requirements discussed with the local hospital infection control team.
Public health notification
Under the Public Health Act 2005 (Qld) a provisional diagnosis (i.e. prior to laboratory confirmation) of N. meningitidis or Hib meningitis requires urgent notification to your local Public Health Unit to enable timely chemoprophylaxis for identified contacts.
Chemoprophylaxis aims to eradicate asymptomatic carriage in contacts so that susceptible members of the group do not acquire the organism from the original carrier and develop an invasive infection. In meningococcal meningitis and Hib cases, chemoprophylaxis is offered to close (usually household) contacts of the primary index case.24 Despite prophylaxis, disease may still occur. Parent education regarding frequent, careful observation and the need for examination by a medical practitioner at the first signs of any unexplained illness is essential.
Prophylaxis for health care workers is not usually recommended unless they have had direct contact with nasopharyngeal secretions of a child with suspected (or proven) meningococcal meningitis or are in close contact nursing a patient for more than 6 hours.24 This may occur in circumstances where appropriate personal protective equipment was not used e.g. endotracheal intubation (without using a face mask) or mouth-to-mouth resuscitation.
When to escalate care
Follow your local facility escalation protocols for children of concern. Transfer is recommended if the child requires care beyond the level of comfort of the treating hospital. Clinicians can contact the services outlined below to escalate the care of a paediatric patient.
||Reason for contact by clinician
|Local Paediatric service
||For specialist paediatric advice and assistance with local transfers as per local arrangements.
||As per local arrangements
|Children’s Advice and Transport Coordination Hub (CATCH)
||For access to specialist paediatric advice and assistance with inter-hospital transfer of non-critical patients into and out of Lady Cilento Children’s Hospital.
For assistance with decision making regarding safe and appropriate inter-hospital transfer of children in Queensland.
For QH staff, click here for further information including the QH Inter-hospital transfer request form (access via intranet).
|(07) 3068 4510
|Telehealth Emergency Management Support Unit (TEMSU)
||For access to generalist and specialist acute support and advice via videoconferencing, as per locally agreed pathways, in regional, rural and remote areas in Queensland.
For QH staff, click here for further information (access via intranet).
|TEMSU QHEPS website
|Retrieval Services Queensland (RSQ)
||For access to telehealth support for, and to notify of, critically unwell patients requiring retrieval in Queensland.
For any patients potentially requiring aeromedical retrieval or transfer in Queensland.
For QH staff, click here for further information and relevant forms (access via intranet).
|RSQ QHEPS website
When to consider discharge
Discharge may be considered for children who meet the following criteria:
- symptoms such as pain and vomiting are controlled
- meningitis is excluded on CSF analysis and no empiric antibiotics IV administered
- no other investigations necessary for fever or symptoms
- can be safely managed at home and return in event of deterioration (consider time of day, parent/carers comprehension and compliance, access to transport and distance to local hospital)
Children who have meningitis excluded on CSF but had received empiric antibiotics IV will usually require a period of inpatient observation. Disposition of these children will always require discussion with senior emergency/paediatric clinician.
- Advise parent/caregiver to see a doctor if concerned about child prior to scheduled review appointment.
- Provide parent/caregiver with a Fever factsheet.
- with General Practitioner within 24 – 48 hours
When to consider admission
All children with confirmed meningitis should be admitted. Ensure urgent notification to the local Public Health Unit as appropriate.
Consider admission for children who:
- are aged < 1 year
- have any significant comorbidities
- have ongoing symptoms (e.g. pain and fever) after treatment and minimum of 4 hours observation
- require further investigations to identify cause of symptoms
- are representing within 24 hours following discharge with diagnosis of viral meningitis
- have received antibiotics IV prior to the exclusion of meningitis for ongoing management of illness
- Chavez-Bueno, S., McCracken, G.H. (2005), ‘Bacterial meningitis in children’, Pediatric Clinics of North America, Vol. 52 (3): pp. 795-810
- Saez-Llorens, X., McCracken, G.H. (2003), ‘Bacterial meningitis in children, Lancet, Vol. 361 (9375): pp. 2139-2148.
- Strange, G.R., Ahrens, W.R. (2005), ‘Meningitis: Evidence to guide an evolving standard of care’, Paediatric Emergency Medicine Practice, Vol. 2 (4): pp. 1-24.
- Alpern, E.R., Alessandrini, E.A., Bell, L.M., Shaw, K.N., McGowan, K.L. (2000), ‘Occult bacteremia from a pediatric emergency department: Current prevalence, time to detection, and outcome’, Pediatrics, Vol.106 (3): pp. 505-511.
- Williams, S.R, Mernagh, P.J., Lee, M.H.T. et al. (2011), ‘Changing epidemiology of invasive pneumococcal disease in Australian children after introduction of a 7-valent pneumococcal conjugate vaccine’, Medical Journal of Australia, Vol. 194 (3): pp. 116-120.
- Moore, H.C., Lehman, D. (2006), ‘(Letter) Decline in meningitis admission in young children: Vaccines make a difference’, Medical Journal of Australia, Vol. 185 (7): p.404.
- Miller, E., Andrews, N.J., Waight P.A., Slack M.P.E., George R.C. (2011) ‘Effectiveness of the new serotypes in the 13-valent pneumococcal conjugate vaccine’, Vaccine, Vol. 29: p.9127-9131.
- Kipli T, Antilla M, Kallio MJ, Peltola H., Severity of childhood bacterial meningitis and duration of illness before diagnosis. Lancet 1991; Vol. 338:406-9.
- Rothrock, S.G., Green, S.M., Wren, J., Letai, D., Daniel-Underwood, L., (1992), ‘Pillar E. Paediatric bacterial meningitis: Is prior antibiotic therapy associated with an altered clinical presentation’, Annals of Emergency Medicine, Vol. 21(2): pp.146-152.
- van de Beek, D., de Gans, J., Spanjaard, L., Weisfelt, M., Reitsma, J.B., Vermeulen, M. (2004), ‘Clinical features and prognostic factors in adults with bacterial meningitis’, The New England Journal of Medicine, Vol. 351 (18): pp.1849-1859.
- Rorabaugh, M.L., Berlin, L.E., Heldrich, F., Roberts, K., Rosenberg, L.A., Roberts, K., Modlin, J.F. (1992), ‘Aseptic meningitis in infants younger than 2 years of age: Acute illness and neurologic complications’, Pediatrics, Vol. 92 (2): pp. 206-211.
- Kilpi, T., Anttila, M., Kallio, M.J., Peltola, H. (1991), ‘Severity of childhood bacterial meningitis and duration of illness before diagnosis’, Lancet, Vol. 338 (8764): pp. 406-409.
- Oostenbrink, R., Moons, K.G., Theunissen, C.C., Derksen-Lubsen, G., Grobbee, D.E., Moll, H.A. (2001), ‘Signs of meningeal irritation at the emergency department: How often bacterial meningitis?’, Pediatric Emergency Care, Vol. 17 (3): pp.161-164.
- Feigin R.D., McCracken G.H., Klein J.O. (1992) ‘Diagnosis and Management of Meningitis’, Pediatr Infect Dis J, Vol. 11:pp.785-814.
- Kanegaye, J.T., Soliemanzadeh, P., Bradley, J.S. (2001), ‘Lumbar puncture in pediatric bacterial meningitis: Defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment’, Pediatrics, Vol. 108 (5): pp.1169-1174.
- Porritt, R.J., Mercer, J.L., Munro, R. (2000), ‘Detection and serogroup determination of Neisseria meningitides in CSF by polymerase chain reaction’, Pathology, Vol. 32 (1): pp.42-45.
- Department of Health and Ageing, (Commonwealth of Australia). (2009), Guidelines for the early and public health management of meningococcal disease in Australia
- Joffe, A.R. (2007), ‘Lumbar puncture and brain herniation in acute bacterial meningitis: A review’, Journal of Intensive Care Medicine, Vol. 22 (4): pp.194-207.
- Ninis N., Phillips C., Bailey L., et al ‘The role of healthcare delivery in the outcome of meningococcal disease in children: case-control study of fatal and non-fatal cases. BMJ 2005; Vol 330: 1475.
- McCracken, G.H. (1995), ‘Emergence of resistant Streptococcus pneumoniae: A problem in pediatrics’, Pediatric Infectious Disease Journal, Vol. 14 (5): pp.424-428.
- Quagliarello, V.J., Scheld, W.M. (1997), ‘Treatment of bacterial meningitis’, New England Journal of Medicine, Vol. 336 (10): pp. 708-716.
- Schaad, U.B., Lips, U., Gnehm, H.E., Blumberg. A., Heinzer. I., Wedgwood. J. (1993), ‘Dexamethasone therapy for bacterial meningitis in children. Swiss meningitis study group’, Lancet, Vol. 342 (8869): pp.457-461.
- Brouwer, M.C., McIntyre, P., de Gans, J., Prasad, K., van de Beek, D. (2010), ‘Corticosteroids for acute bacterial meningitis’, Cochrane Database of Systematic Reviews, Vol. Iss. 9, Art No.: CD004405.
- Communicable Diseases Network Australia (CDNA). Invasive meningococcal disease: CDNA national guidelines for public health units. Canberra: Australian Government Department of Health, 2017. Available at: (www.health.gov.au/cdnasongs) (accessed July 2018).
|Guideline approval history
||CHQ-GDL-60008 – Meningitis
||Executive Director Medical Services
||Statewide Emergency Care Children Working Group
||CHQ-GDL-07448 (CHQ Meningitis Guideline)
||Queensland Health medical and nursing staff
||Executive Director Clinical Services QCH
||Paediatric, meningitis; guideline, emergency, 600008
||NSQHS Standard: 1, 4, 9