- Children with meningitis often present with nonspecific symptoms and not the classic triad of fever, headache and nuchal rigidity.
- 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, administer empiric antimicrobial therapy 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.
It has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Meningitis is a rare but serious paediatric ED presentation in which the membranes that surround the brain and spinal cord become inflamed. A variety of different microorganisms, including both viruses and bacteria can cause meningitis.1
The mortality rate from bacterial meningitis ranges from 2% in children to 20% in neonates with up to a third of survivors experiencing transient or permanent neurological sequelae.2 Approximately 90% of bacterial meningitis occurs in children less than five years of age.2
Bacterial infection in infants up to three 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 three 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 vaccines in the National Immunisation Program.5-7
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 less than three 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 children with 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 less than five years.
The clinical presentation of bacterial meningitis may be acute (hours to 1 – 2 days) or insidious (over a few days). A preceding upper respiratory tract infection is reported 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 diagnosis)9
- 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 less than three 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 symptoms, myalgia and abdominal pain. In preverbal children, symptoms are even more nonspecific, and a high index of suspicion is required to avoid missing cases.7 A collection of nonspecific symptoms that include fever, neck stiffness and headache are more common in viral meningitis while neurological complications (including seizures and coma) are rare.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 less than two years.
Whilst the presentation varies with age, bacterial meningitis should be considered for any child with the clinical features outlined in the table below.
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. Refer to Fever guideline.
|ANY of the following clinical features
||Common features in infants under three 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) (see above)
- bulging fontanelle
- high pitched cry
- poor feeding
- hypothermia or temperature instability
- fever in neonate (age less than 29 days)
*May also occur in infants greater than three months.
Adapted from: van de Beek et al10 and Oostenbrink et al13 and Feigin et al14
- 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 box below), investigations such as blood cultures and PCR testing on blood may be useful to diagnose meningococcal, pneumococcal or Hib infection.
Consider a clotting profile prior to LP if any clinical concerns around pre-existing coagulopathy e.g. sepsis, thrombocytopenia.
- 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% specificity16
- 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 cases and less than 50% of treated patients.
- Serum electrolytes – seizures may be secondary to low sodium, calcium or magnesium; hyponatraemia in SIADH.
- BGL – check for hypoglycaemia especially in infants aged less than three months.
- UEC, LFT and VBG may suggest sepsis.
- CRP – may be high in bacterial meningitis but is nonspecific.
|Full blood count
- 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 antimicrobial therapy.17
- Carefully consider in child with suspected raised ICP or focal neurological signs.
- 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).
- CT scan rarely changes initial management and transportation out of ED for radiological investigations may put the unstable child at greater risk.18
Reasons for delaying a LP
- 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 LP site
Do NOT delay antibiotics. Continue treatment until clinical improvement is evident, at which time a LP may be safely performed.
Request urgent CSF microscopy (includes Gram stain, WCC and differential), CSF protein and glucose, culture and sensitivity and PCR studies. In addition, if suspect viral aetiology, request viral PCR for enterovirus (and parechovirus if less than three months) and HSV plus VZV PCR (if varicella zoster virus is suspected).
No single CSF test parameter reliably identifies bacterial meningitis. Very rarely, culture proven bacterial meningitis can occur in a child with normal CSF findings. Always correlate CSF results with clinical findings.
||White cell count
||Neutrophils (x 106 /L)
||Lymphocytes (x 106/L)
||Glucose (CSF:blood ratio)
(more than 1 month of age)
||≥ 0.6 (or ≥ 2.5 mmol/L)
(less than 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 meningitis cases, decision making regarding treatment should 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 and medications for 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 antivirals where HSV meningoencephalitis is considered, especially in neonates) has been shown to improve outcome. Empiric antibiotic therapy regimens are selected to cover the most likely pathogens for the selected age group.
Clinicians working in Townsville, Cairns and Gold Coast Hospital and Health Services should follow their local paediatric empirical antibiotic guidelines. Clinicians elsewhere in Queensland should follow the Children’s Health Queensland paediatric empirical antibiotic prescribing guidelines.
The child should be admitted, and empiric antibiotic therapy continued until culture results are known to be negative or an organism and its sensitivity pattern are identified. Although Streptococcus pneumoniae penicillin resistance remains low in Queensland, in some countries the incidence of multi-resistant Streptococcus pneumoniae is on the rise and many are also resistant to the third-generation cephalosporins.20,21 In critically ill children with suspected Streptococcus pneumoniae and children with gram positive cocci in CSF (depending on age and illness severity) add Vancomycin to empiric antibiotics. Consider consulting Infectious diseases physician for advice.
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 relevant antimicrobial guidelines for your site (see above).
Corticosteroids should be considered in all suspected bacterial meningitis cases over three months of age, 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 antibiotic dose. 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 corticosteroids (used in conjunction with antibiotic therapy) significantly reduces hearing loss (but not overall mortality) in children with acute bacterial meningitis.23
||For children greater than three months of age:
0.15 mg/kg/dose (maximum 10 mg/dose), every six hours for four days if able to start prior to or within one hour of first antibiotic IV dose.
If not available, do not delay antibiotics
Initial fluid resuscitation is recommended 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 Fluid restriction is not recommended in the first 48 hours. It has not been shown to reduce the incidence of cerebral oedema in children with bacterial meningitis.1
||Sodium Chloride 0.9% administered in 20 mL/kg bolus.
Repeat in 20 mL/kg boluses as clinically indicated.
||Sodium Chloride 0.9% + Glucose 5% 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. Advise contacts of the need for frequent, careful observation and to seek medical attention at the first signs of any unexplained illness.
Prophylaxis for health care workers is not routinely recommended. It is limited to staff in direct contact with the nasopharyngeal secretions of a child with suspected (or proven) meningococcal meningitis (where appropriate PPE was not used e.g. intubation or mouth-to-mouth resuscitation) or those who have had close contact nursing a child for more than six hours.24
Escalation and advice outside of ED
Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.
Critically unwell or rapidly deteriorating child
|Includes children with the following (as a guide):
- suspected sepsis (see Sepsis guideline)
- suspected raised ICP
- recent seizure
- physiological triggers based on age (see below)
|Less than 1 year
||Over 12 years
|• RR >50
• HR <90 or >170
• sBP <65
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
|• RR >40
• HR <80 or >160
• sBP <70
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
|• RR >40
• HR <70 or >150
• sBP <75
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
|• RR >30
• HR <50 or >130
• sBP <85
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
|Reason for contact
||Who to contact
|For immediate onsite assistance including airway management
||The most senior resources available onsite at the time as per local practices.
Options may include:
- paediatric critical care
- critical care
- Senior Medical Officer (or similar)
|Paediatric critical care advice and assistance
||Onsite or via Retrieval Services Queensland (RSQ).
If no onsite paediatric critical care service contact RSQ on 1300 799 127:
- for access to paediatric critical care telephone advice
- to coordinate the retrieval of a critically unwell child
RSQ (access via QH intranet)
Notify early of child potentially requiring transfer.
Consider early involvement of local paediatric/critical care service.
In the event of retrieval, inform your local paediatric service.
|Advice may be needed regarding:
- timing of lumbar puncture
- antimicrobial therapy following lumbar puncture
- interpretation of CSF microscopy
- management and disposition of unwell child with a normal CSF
|Reason for contact
||Who to contact
- onsite/local paediatric service
- Queensland Children’s Hospital experts via Children’s Advice and Transport Coordination Hub (CATCH) on 13 CATCH (13 22 82)
- local and regional paediatric videoconference support via Telehealth Emergency Management Support Unit TEMSU (access via QH intranet) on 1800 11 44 14 (24-hour service)
||First point of call is the onsite/local paediatric service
Admission is required for:
- children with confirmed meningitis
- children in whom meningitis is suspected and unable to be excluded (due to delay in LP).
Ensure urgent notification to your local Public Health Unit as appropriate.
Children who have meningitis excluded on CSF but had received empiric antibiotic therapy IV will usually require a period of inpatient observation. Always seek senior emergency/paediatric advice on management and disposition of these children.
Consider admission for children with a previous diagnosis of viral meningitis and who represent with symptoms within 24 hours of discharge.
Following the exclusion of meningitis, discharge may be considered providing ALL of the following criteria are met:
- symptoms such as pain and vomiting are controlled
- clear alternative diagnosis which does not require inpatient management
- 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)
- advise parent/caregiver to seek medical attention if any concerns prior to scheduled review appointment
- provide parent/caregiver with a Fever factsheet
- with General Practitioner within 24 – 48 hours
- 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, [online] Available at: [internet]. http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-other-mening-2007.htm [cited 25 Nov 2014]
- 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
||Executive Director Medical Services
||Queensland Emergency Care Children Working Group
||Queensland Health medical and nursing staff
||Internal (QHEPS) + External
||Executive Director Clinical Services (QCH)
||Paediatric, meningitis; bacterial, viral, guideline, emergency, children
||NSQHS Standard: 1, 3, 4, 8