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.

Definition

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

Bacterial meningitis

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

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.

History

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

Examination

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.

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.

Differential diagnosis

Other causes of meningitis signs and symptoms:

• viral encephalitis
• viremia
• sepsis
• 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.

Lumbar puncture

Laboratory request

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).

CSF analysis

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.

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.

Antibiotics

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

Antivirals

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

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

Fluid management

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

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.

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.

On discharge:

• Advise parent/caregiver to see a doctor if concerned about child prior to scheduled review appointment.
• Provide parent/caregiver with a Fever factsheet.

Follow-up

• 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

Guidelines

• Febrile illness
• Sepsis

Factsheet

• Fever

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