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

Clinical guideline [CG102]Published: 23 June 2010 Last updated: 01 February 2015

Introduction

This guideline covers recognising, diagnosing and managing bacterial meningitis and meningococcal septicaemia (blood poisoning) in babies, children and young people under 16. It aims to reduce deaths and disability by promoting early recognition of symptoms and timely effective management.

Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream.

In children and young people aged 3 months or older, the most frequent causes of bacterial meningitis include Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib).

These organisms occur normally in the upper respiratory tract and can cause invasive disease when acquired by a susceptible person. In neonates (children younger than 28 days), the most common causative organisms are Streptococcus agalactiae (Group B streptococcus), Escherichia coli, S pneumoniae and Listeria monocytogenes.

Symptoms and signs of bacterial meningitis and meningococcal septicaemia

Symptom/sign	Bacterial meningitis (meningococcal meningitis and meningitis caused by other bacteria)	Meningococcal disease (meningococcal meningitis and/or meningococcal septicaemia)	Meningococcal septicaemia	Notes
Common non-specific symptoms/signs
Fever	√	√	√	Not always present, especially in neonates
Vomiting/nausea	√	√	√
Lethargy	√	√	√
Irritable/unsettled	√	√	√
Ill appearance	√	√	√
Refusing food/drink	√	√	√
Headache	√	√	√
Muscle ache/joint pain	√	√	√
Respiratory symptoms/signs or breathing difficulty	√	√	√
Less common non-specific symptoms/signs
Chills/shivering	√	√	√
Diarrhoea, abdominal pain/distension	√	√	NK
Sore throat/coryza or other ear, nose and throat symptoms/signs	√	√	NK
More specific symptoms/signs
Non-blanching rash	√	√	√	Be aware that a rash may be less visible in darker skin tones – check soles of feet, palms of hands and conjunctivae
Stiff neck	√	√	NK
Altered mental state	√	√	√	Includes confusion, delirium and drowsiness, and impaired consciousness
Capillary refill time more than 2 seconds	NK	√	√
Unusual skin colour	NK	√	√
Shock	√	√	√
Hypotension	NK	√	√
Leg pain	NK	√	√
Cold hands/feet	NK	√	√
Back rigidity	√	√	NK
Bulging fontanelle	√	√	NK	Only relevant in children aged under 2 years
Photophobia	√	√	X
Kernig’s sign	√	√	X
Brudzinski’s sign	√	√	X
Unconsciousness	√	√	√
Toxic/moribund state	√	√	√
Paresis	√	√	X
Focal neurological deficit including cranial nerve involvement and abnormal pupils	√	√	X
Seizures	√	√	X
Signs of shock Capillary refill time more than 2 seconds Unusual skin colour Tachycardia and/or hypotension Respiratory symptoms or breathing difficulty Leg pain Cold hands/feet Toxic/moribund state Altered mental state/decreased conscious level Poor urine output
√ symptom/sign present X symptom/sign not present NK not known if a symptom/sign is present (not reported in the evidence)

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.

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 (see table 1)
- there are signs of meningococcal septicaemia (see table 1)
- the child or young person appears ill to a healthcare professional.

Polymerase chain reaction

Perform whole blood real-time polymerase chain reaction testing (EDTA^[1] 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 (see table 1)
- 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).

Intravenous fluid resuscitation

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.

Link to full NICE guidance

Overview | Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management | Guidance | NICE