This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

Background

The commonest organisms causing bacterial meningitis in children over 2 months of age are:

• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae type B (in unimmunised children)

As a result of immunisations Hib meningitis is now rare and there has been a reduction in the incidence of pneumococcal meningitis.

Organisms to consider in infants less than 2 months of age include those listed above and the following:

• Group B streptococcus
• E. coli and other Gram-negative organisms
• Listeria monocytogenes

Consider other pathogens in those who have anatomical abnormalities of the CNS, ventricular shunts, immunosuppressed children and those who have a history of travel.

Encephalitis can be caused by:

• Enterovirus
• HSV
• Other herpes viruses (EBV, CMV, HHV6, VZV)
• Arboviruses.
• Less commonly, encephalitis can be caused by bacteria, fungi or parasites.

Assessment

Features on history:

• Infants with meningitis frequently present with non-specific symptoms such as fever, irritability, lethargy, poor feeding, vomiting and diarrhoea
• Older children may complain of headache or photophobia
• Seizures
• Prior antibiotics – clinical presentation may be altered by prior use of antibiotics.

Features on examination:

• In infants, the fontanelle may be full
• Neck stiffness may or may not be present (not a reliable sign in young children)
• A purpuric rash is suggestive of meningococcal septicaemia
• Kernig’s sign: hip flexion with an extended knee causes pain in the back and legs
• CSF shunts, spinal and cranial abnormalities (eg dermal sinuses) which may have predisposed a child to meningitis
• Signs of encephalitis: altered conscious state, focal neurological signs

Investigations

• Lumbar puncture (LP)
  • Prior to performing a LP
    •  You must always discuss with a senior registrar or consultant.
    • Read the Lumbar Puncture guideline.
  • See CSF Interpretation guideline
  • Sterilisation of the CSF can occur within 2 hours after a dose of Ceftriaxone 50 mg/kg/dose (2g) iv 12H /Ceftriaxone for N. meningitidis and within 4 hours for S. pneumoniae

• Blood tests
  • Full blood count/differential
  • Glucose, urea and electrolytes
  • Blood cultures

Acute Management

Antimicrobials

• Antibiotics must not be delayed for more than 30 minutes after the decision to treat is made.

If encephalitis is suspected on examination then give:

• Aciclovir 20 mg/kg iv 8H (age <3m ) 500 mg/m2 iv 8H (age 3m-12y) 10 mg/kg iv 8H (age >12y). Surface area calculator

Notes:

• *Benzylpenicillin can be substituted with amoxycillin 50mg/kg iv
• Cefotaxime can be substituted with Ceftriaxone 100 mg/kg (max 2gm) iv daily in children > 1 month.
• Empiric use of vancomycin is not currently recommended for pneumococcal meningitis in Victoria
• Delay in antibiotics is associated with poorer outcomes.

Steroids

• Current evidence suggests that steroids may reduce the risk of hearing loss in bacterial meningitis.
• Consider giving Dexamethasone to children > 2 months of age 15 minutes prior to parenteral antibiotics or, if this is not possible, within one hour of receiving their first dose of antibiotics: 0.15mg/kg IV. Consider giving steroids at the time of lumbar puncture if the clinical suspicion of meningitis is high.
• Steroids should be ceased if a decision is made to cease antibiotic treatment for meningitis before 4 days (eg CSF microscopy not suggestive, CSF cultures negative at 48 hours).
• Steroids are not recommended in neonates due to concern regarding effects on neurodevelopment.

Seizure management

• Treat seizures in the setting of meningitis immediately with benzodiazepines and load with phenytoin (20mg/kg over one hour).
• See Afebrile convulsion guideline for further information. 

Fluid Management

• See Fluids in Meningitis Guideline

Bacterial meningitis – ongoing management

Monitor:

• Neurological observations including blood pressure should be performed every 15 minutes for the first two hours and then at intervals determined by the child’s conscious state.
• Weight and head circumference should be monitored on a daily basis.
• Electrolytes and glucose should be checked 6-12 hourly until the serum sodium is normal (and/or the child is no longer on IV fluids).
• Ensure adequate analgesia

Duration of Antibiotic treatment:

Notification

• All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified to the Department of Human Services by telephone 1300 651 170 (during hours) or 03 9625 5000 pager number 46870 (after hours).
• Haemophilus influenzae type b, and Streptococcus pneumoniae are also notifiable diseases.
• DHS info on notification, and notification form

Contact chemoprophylaxis

• Who requires prophylaxis – see Contact Chemoprophylaxis Table
• Doses and ordering (RCH specific) – see Meningococcal Prophylaxis 

Causes of persistent fever in bacterial meningitis:

• Nosocomial infection
• Subdural effusion
• Other foci of suppuration
• Less common: inadequately treated meningitis, parameningeal focus or drugs.

Follow-up

• All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks after discharge (earlier if there are concerns regarding hearing).
• Neurodevelopmental progress should be monitored in outpatients.

Management of viral meningitis

• CSF findings may be suggestive (see CSFinterpretation guideline).
• Admission is required if bacterial meningitis cannot be excluded or intravenous hydration is required.
• Ensure adequate analgesia

When to consult local paediatric team:

• Any child with suspected bacterial meningitis

Who to phone consult at RCH/tertiary centre for further advice:

• Consider transfer when:
  • Haemodynamic or respiratory instability
  • Altered conscious state or focal neurological signs
  • Child requiring care above the level of comfort of the local hospital

• Contact the Infectious Diseases consultant on call if advice is needed regarding empiric antibiotic treatment in the following patients:
  • Spinal and cranial abnormalities
  • Neonates
  • Immunosuppressed patients.

Parent information sheets:

• Meningitis (HTML)
• Meningococcalinfection (HTML)

 Last updated September 2012

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