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PURPOSE
The Infants and Children: Acute Management of Bacterial Meningitis: Clinical Practice
Guideline has been developed to provide direction to clinicians and is aimed at
achieving the best possible paediatric care in all parts of the state.
The Clinical Practice Guideline was prepared for the NSW Ministry of Health by an
expert clinical reference group under the auspice of the state wide Paediatric Clinical
Practice Guideline Steering Group.
KEY PRINCIPLES
This guideline applies to all facilities where paediatric patients are managed. It requires
the Chief Executives of all Local Health Districts to have local guidelines based on the
attached Clinical Practice Guideline in place in all hospitals and facilities that are
required to assess or manage children with bacterial meningitis.
The clinical practice guideline reflects what is currently regarded as a safe and
appropriate approach to the acute management of bacterial meningitis in infants and
children. However, as in any clinical situation there may be factors which cannot be
covered by a single set of guidelines. This document should be used as a guide, rather
than as a complete authoritative statement of procedures to be followed in respect of
each individual presentation. It does not replace the need for the application of
clinical judgement to each individual presentation.
Local protocols are developed based on the Infants and Children: Acute
Management of Bacterial Meningitis Clinical Practice Guideline
Local protocols are in place in all hospitals and facilities likely to be required to
assess or manage paediatric patients with bacterial meningitis
Ensure that all staff treating paediatric patients are educated in the use of the
locally developed paediatric protocols.
Directors of Clinical Governance are required to inform relevant clinical staff treating
paediatric patients of the revised protocols.
REVISION HISTORY
Version Approved by Amendment notes
July 2014 Deputy Secretary, Fourth edition: Some medication dosages have been
(GL2014_013) Population and Public revised and typographical and formatting changes
Health aligned.
December 2013 Third edition: The antibiotic section of the document has
(PD2013_044) been revised to align with NSW Health (Clinical
Excellence Commission) “Sepsis Pathway” antibiotic
guidelines.
August 2012 Deputy Director-General Second edition: The document has been revised to
(PD2012_065) Strategic Development make some concepts clearer or more succinct, with an
increase in emphasis for consultation with senior
medical staff. The antibiotic dosing schedule has been
revised and guidance on the duration of antibiotics has
been added.
January 2005 Director-General New policy
(PD2005_383)
ATTACHMENT
1. Infants and Children: Acute Management of Bacterial Meningitis: Clinical Practice Guideline.
This work is copyright. It may be reproduced in whole or part for study or training
purposes subject to the inclusion of an acknowledgement of the source. It may not be
reproduced for commercial usage or sale. Reproduction for purposes other than those
indicated above, requires written permission from the NSW Ministry of Health.
This Clinical Practice Guideline booklet is extracted from the GL2014_013 and
as a result, this booklet may be varied, withdrawn or replaced at any time.
Compliance with the information in this booklet is mandatory for NSW Health.
July 2014
A revision of this document is due in 2016.
Contents
Introduction................................................................................................. 2
Overview
Key points in the acute management of bacterial meningitis in children ................ 4
Algorithm: acute management of suspected bacterial meningitis in children ......... 8
Assessment and initial management of bacterial meningitis ................................ 10
Clinical presentations........................................................................................... 10
Minimise delay in diagnosis ................................................................................ 12
Initial management.............................................................................................. 13
Diagnostic tests .................................................................................................. 14
The lumbar puncture (LP).................................................................................... 17
Antibiotic management....................................................................................... 21
Adjunctive therapy – corticosteroids.................................................................... 23
Nursing issues .................................................................................................... 24
Psychosocial needs of the family.......................................................................... 27
Transfer of patient to tertiary referral centre ....................................................... 27
Related issues...................................................................................................... 27
Appendices
Appendix 1 – References .................................................................................... 29
Appendix 2 – Glossary......................................................................................... 33
Appendix 3 – Resources ..................................................................................... 34
Appendix 4 – Parent information......................................................................... 35
Appendix 5 – Expert working party membership................................................. 36
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 1
Introduction
These guidelines are aimed at achieving does not replace the need for the
the best possible paediatric care in all application of clinical judgment to each
parts of the State. The document should individual presentation.
not be seen as a stringent set of rules to
be applied without the clinical input and This document represents clinical practice
discretion of the managing professionals. guidelines for the acute management of
Each patient should be individually bacterial meningitis in children. Further
evaluated and a decision made as to information may be required in practice;
appropriate management in order to suitable widely available resources are
achieve the best clinical outcome. included in Appendix Three.
Field, M.J. & Lohr, K.N. (1990) define Each Local Health District and Specialty
clinical practice guidelines as: Health Network is responsible for ensuring
that local protocols based on these
‘systematically developed statements guidelines are developed. They are also
to assist practitioner and patient responsible for ensuring that all staff
decisions about appropriate health treating paediatric patients are educated
care for specific clinical in the use of the locally developed
circumstances.’ (Field MJ, Lohr KN paediatric guidelines and protocols.
(Eds). Clinical Practice Guidelines:
Directions for a New Program, In the interests of patient care it is critical
Institute of Medicine, Washington, that contemporaneous, accurate and
DC: National Academy Press) complete documentation is maintained
during the course of patient management
It should be noted that this document from arrival to discharge.
reflects what is currently regarded as a
safe and appropriate approach to care. Parental anxiety should not be
However, as in any clinical situation there discounted: it is often of significance
may be factors which cannot be covered even if the child does not appear
by a single set of guidelines and therefore especially unwell.
this document should be used as a guide,
rather than as a complete authoritative
statement of procedures to be followed in
respect of each individual presentation. It
PAGE 2 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Changes from previous clinical
practice guideline (incorporated in
2nd & 3rd editions)
The following outlines changes to the n Guidance on the duration of
document: antibiotics has been added;
n The document, in general, has been n A link to the NSW Health (Clinical
revised to make some concepts clearer Excellence Commission) Sepsis
or more succinct; Pathway has been included;
n There is an increase in emphasis for n The section on steroids has been
consultation with senior medical staff modified and simplified;
n A comment on considering Herpes n The “Nursing/Triage” section has been
Simplex Virus (HSV) infection in expanded;
newborns in the differential diagnosis n UK National Institute for Health and
has been added;
Clinical Excellence (NICE) guidelines
n Interpretation of cerebrospinal fluid 2010 have been added as a reference
(CSF) parameters has been simplified source;
(please note that the neonatal CSF n Updates to the fact sheet for parents
white cell count (WCC)
have been recommended.
recommendation remains the same,
with an accompanying note below Changes to 4th edition are limited to
table); revision of some medication dosages
n A section on epidemiology of and typographical and formatting
meningococcus and streptococcus in alignment.
Australia has been added;
n A section on antibiotic resistance in
Australia has been added;
n The antibiotic dosing schedule has
been revised. Neonatal dosing has
been included. Recommendations for
alternative antibiotics in
hypersensitivity to penicillin have been
added.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 3
Key points in the acute Initial Management
management of bacterial n The priorities are ensuring the
meningitis in children adequacy of Airway, Breathing,
Circulation, Disability (level of
First Principles consciousness), Exposure (rash
n A high index of suspicion for assessment and environmental
meningitis must be maintained in control), Fluids and Glucose i.e.
infants or children presenting with any “ABCDEFG”;
signs of sepsis, particularly if there is n The risks from inadequate cerebral
no focus or there is altered mental circulation may be higher than the
status; risks of cerebral oedema so volume
n Prompt recognition and early expanders should be titrated against
management are key goals; the patient’s perfusion;
PAGE 4 NSW HEALTH Infants and children: Acute management of bacterial meningitis
n Other tests(WCC: total and differential Steroid therapy
CRP, ESR) are not specific for
n The early use (just before or with first
meningitis. Taken in the correct clinical
dose of antibiotics) of adjunctive
context, they may be useful additional
steroid therapy in children who have
indicators of a significant bacterial
not been pre-treated with antibiotics,
infection. Clinical decisions must not
is recommended in children ≥ 3
be dictated by these in isolation;
months of age;
n The initiation of appropriate antibiotic
n There is insufficient information to
therapy assumes high priority. If the
recommend steroids in the < 3 months
patient is too sick or unstable for
age group.
immediate definitive investigations,
then appropriate antibiotics should be Thus, in suspected / confirmed acute
commenced (intravenous, bacterial meningitis, commence steroids if:
intramuscular or intraosseous route);
n ≥ 3 months of age;
n The LP should be performed when the
n not pre-treated with parenteral
patient is resuscitated and stable
antibiotics.
provided there are no signs of raised
intracranial pressure (ICP) or other
Regimen
contraindications (section 5);
n Dexamethasone, 0.15 mg/kg/dose IV
n Neuroimaging (e.g. head cerebral
(maximum dose 10 mg), 6 hourly for
computed tomogram (CT) scan or
four days*;
MRI) is not part of the routine workup.
Neuroimaging is indicated only in n Give as a “push” followed by first dose
specific situations (section 5) and of antibiotics for practical purposes.
should only be done when the patient
*Note: The decision to continue
is stable;
steroids for 4 days should be
n The limits of sensitivity of the CSF reviewed after laboratory and
diagnostic tests, especially if pre- microbiological information (CSF and/
treated with parenteral antibiotics, or blood) becomes available over the
should be recognised; next ≥ 48 hours (section 7).
n CSF samples should be expeditiously
transported to the laboratory and
urgently analysed.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 5
Antibiotic therapy for delivery, including intraosseous, see
NSW Health Paediatric Sepsis Toolkit
The recommended empiric antibiotic (www.cec.health.nsw.gov.au/programs/
therapy is: sepsis).
Neonates to 3 months:
Ampicillin (or benzylpenicillin) plus
Infection control and prevention
cefotaxime n Appropriate infection prevention and
control measures must be observed;
(Ceftriaxone should not be used in
n Standard and transmission based
neonates–except in extraordinary
(droplet) precautions must be
circumstances where cefotaxime is not
observed and appropriate personal
available)
protective equipment used when
Note: If HSV encephalitis is attending to patient and contact with
suspected in newborns, aciclovir (20 body secretions/fluid is expected;
mg/kg/dose IV, 8 hourly) should be n Isolation of patients must be
commenced until further clinical
considered, particularly if
information is available
meningococcal infection is suspected.
≥ 3 months:
Cefotaxime or ceftriaxone Further acute care
(NB: Ceftriaxone should not be n Once the patient is resuscitated and
administered concurrently with calcium stabilised, further management and
containing fluids) investigations can be arranged under
direction of the responsible team;
When infection with antibiotic resistant
Streptococcus pneumoniae is suspected, n The decision to transfer the patient or
vancomycin should be added. Mono to continue to provide care locally will
therapy with vancomycin is not be determined by the local resources
recommended. Stop vancomyin when and the patient’s needs;
cultures confirm a penicillin or 3rd n If there is doubt, then a tertiary centre
generation cephalosporin sensitive should be consulted as soon as
Streptococcus pneumoniae strain. possible. This can be done via the
NETS Clinical Coordination Centre
In case of penicillin anaphylaxis use
(1300 36 2500);
moxifloxacin (10mg/kg/dose IV, 24 hourly,
maximum dose 400mg) or ciprofloxacin n If the patient is to be transferred, the
(10mg/kg/dose IV, 12 hourly, maximum degree of urgency and the use of a
dose 400mg) plus vancomycin. retrieval team should also be discussed
as soon as possible. Use of the NETS
For further information regarding line allows for simultaneous
antibiotics, as well as dilutions and options consultation and transfer.
PAGE 6 NSW HEALTH Infants and children: Acute management of bacterial meningitis
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NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 7
Algorithm: Acute management of suspected bacterial meningitis in children
PAGE 8
(Use in conjunction with text)
Triage Category 1*
Clinical presentations (Section 1)
*The Australasian Triage Scale (ATS): Table 8.2 of the Emergency
n History & examination Triage Education Kit
n Clinical presentation by age (1.1)
n Presentation with prior antibiotics (1.2) CHILD CLINICALLY SUSPECTED OF HAVING MENINGITIS* (Section 1)
n Complications (1.3) *Note: Consult a senior staff member if in doubt
Minimize delay in diagnosis
ASSESS AND ATTEND TO AIRWAY, BREATHING, CIRCULATION,
(Section 2)
LEVEL OF CONSCIOUSNESS +/- SEIZURES, FLUIDS AND GLUCOSE *
Initial management (Section 3)
(Section 3)
n ABCDEFG (section 3.1) n Take blood for investigations (Section
n Seizures (section 3.2) 4 & Table 1) at the time of
establishing IV access if practical
PATIENT STABLE
n “Routine” tests include: Blood
cultures, FBC/diff, U&E/Creatinine,
blood glucose
Diagnostic tests INDICATION TO DELAY LP?
NO YES
(Sections 4 & 5) (Section 5)
# Expedite lab analysis of the
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 9
(chemoprophylaxis)
Assessment and initial 1. Clinical presentations
management of bacterial n Viral meningitis is more common than
meningitis bacterial meningitis, particularly in the
era of conjugate polysaccharide
Bacterial meningitis is a medical
vaccines (Haemophilus influenzae type
emergency. Despite medical advances,
b (Hib) and Pneumococcus);
acute bacterial meningitis continues to be
a disease with high mortality and n However, it can be difficult to
morbidity. Bacterial meningitis in distinguish between viral and bacterial
childhood is associated with morbidity meningitis at the time of presentation.
rates of ~20% and mortality rates of As the clinical manifestations of viral
~ 5% in developed countries1 even after meningitis can be indistinguishable
widespread pneumococcal vaccination.2 from bacterial meningitis, it is
prudent to assume a bacterial
These guidelines describe basic clinical cause in the initial management;
practice in the acute assessment and
n Mycobacterium tuberculosis (MTB)
management of bacterial meningitis in
meningitis is rare in Australia3 but
otherwise healthy infants and children.
must also be considered in the
They are intended for medical and nursing
differential diagnosis particularly in the
staff working in an emergency
context of overseas travel or
department (ED) and focus on the acute
immigrants from areas with high MTB
management in the ED. Follow-up
prevalence.
management is outside the scope of this
document. It is anticipated that
1.1. Common presentations
modifications may be required for local
practice. Variations in management may n Clinical presentations of bacterial
also be required in individual cases. It is meningitis vary, depending on age,
stressed that the guidelines are, by duration of illness, pre-treatment
necessity, general in nature and are not antibiotics, the infecting organism and
intended as a substitute for clinical the patient’s response to infection;
judgement. n The presentations could be insidious
(evolving over a few days) or acute
Early consultation with a senior ED or
(fulminant) (occurring over a few
paediatric staff member must occur in
hours);4
all cases of suspected meningitis. If
working in an environment where no n Fever, seizures, meningeal signs and/or
senior emergency or paediatric staff are altered consciousness are consistent
immediately available, early consultation features of acute bacterial meningitis;5
with senior clinical staff from your n Overall, severity of illness at
referral hospital must be undertaken, presentation6 including level of
without delaying patient care.
PAGE 10 NSW HEALTH Infants and children: Acute management of bacterial meningitis
consciousness at admission7 appear – Poor feeding;
most predictive of outcome; – Vomiting.
n The procedure of taking a history and n A high index of suspicion for
examination of a child presenting with meningitis must exist in sick,
suspected meningitis is the same as febrile or hypothermic newborns
any acutely unwell child. In addition to with or without the above
the usual history and examination, ask features.
about:
– Age (~ 90% of bacterial Note: Herpes Simplex Virus (HSV)
meningitis occurs at age infection in newborns, although
< 5 years); uncommon, can present in a similar
manner and should be considered in the
– Vaccination history;
differential diagnosis.
– Predisposing factors: recent
infections, known contact with ≥3 months
someone with meningitis, recent n Symptoms become more CNS specific
travel, head trauma or cranial after this age. Acute presentations
surgery and maternal obstetric include:8-10
history if child < 3 months,
– Fever (not always present on
including maternal group B
presentation to ED ~ 50% in
streptococcus status;
infants);6,10
– Recent use of antibiotics;
– Bulging fontanelle or acute increase
– Drug allergies. in head circumference (more useful
in children 2 - 12 months of age);8
0 – 3 months
– Neck stiffness (60 - 80%, more
n The diagnosis may be more difficult in
useful in children > 3 years);11,12
the very young as history and
presentations can be non-specific. – Kernig’s sign (inability to completely
Features include: extend the leg) in older children.
Absence does not exclude
– Fever or hypothermia;
meningitis;
– Bulging fontanelle;
– Brudzinki’s sign (flexion at the hip
– Irritability; and knee in response to forward
– High pitched cry; flexion of the neck) in older children.
– Lethargy; Absence does not exclude
meningitis;
– Altered mental state;
– Irritability or lethargy;
– Seizures;
– Altered mental state (highly
– Apnoea;
variable);
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 11
– Anorexia, nausea and/or vomiting (a but the complication rate is not
common/non-specific symptom); necessarily increased.16
– Photophobia (older children); 1.3. Complications
– Seizures (about 20 - 30% incidence).
n Patients may uncommonly present
NB: Papilloedema in uncomplicated early with early complications of sepsis or
bacterial meningitis is rare. The presence raised intracranial pressure which
of papilloedema suggests complications include:
like venous sinus thrombosis, – Septic shock;
hydrocephalus, abscess or subdural
– Disseminated intravascular
empyema.
coagulopathy (DIC);
– Purpura fulminans;
1.2. C
hildren who have received prior
antibiotics – Waterhouse-Friderichsen syndrome;
PAGE 12 NSW HEALTH Infants and children: Acute management of bacterial meningitis
association with fever, particularly in 3. Initial management
children aged < 12 months, or the
n The assessment of any critically unwell
fever is prolonged in nature or
child must always focus initially on
refractory to management;
resuscitation;
n Not all children presenting with fever n The diagnostic test for meningitis is
and convulsions will have meningitis.19
the lumbar puncture (LP);
Simple, first febrile seizures in infants
aged 6-18 months who appear well n The LP should not be undertaken until
have a low risk of bacterial meningitis.20 the patient has been resuscitated and
However, a high index of suspicion is stabilised and does not have any
recommended; contraindications for LP (see section 5.1:
Indicators to delay the lumbar puncture);
n An apparent explanation for fever e.g.
pharyngitis or otitis media does not n Assessment of “Airway, Breathing,
rule out the possibility of meningitis. Circulation, Disability (level of
A history of a preceding upper consciousness), Exposure (presence
respiratory tract infection is present of rash, temperature control), Fluids
in ~ 75%;21 (input and output) and Glucose” is
the first priority;
n Maculopapular, petechial or purpuric
rashes may sometimes be associated n Once the patient has been stabilised,
with Neisseria meningitidis meningitis/ the examination should include
septicaemia. Petechiae and/or purpura general assessment looking for
have also (less commonly) been features of sepsis and meningitis.
observed in Haemophilus influenzae
type b or Streptococcus pneumoniae 3.1. Resuscitation
sepsis; 3.1a Airway and Breathing
n Prior oral antibiotics for unexplained n Ensure that the airway is patent and
fever or other focus may confuse and adequate ventilation is established;
delay diagnosis; n Supplemental oxygen should always
n Apparent improvement with be administered;
paracetamol does not exclude a n If ventilation or oxygenation is
diagnosis of meningitis or other inadequate, then respiratory support
significant disease; should be commenced in the form of
n Examination of any CSF sample taken bag and mask technique, followed by
is URGENT. Thus, appropriate labelling endotracheal intubation.
of requests, facilitation of delivery of
3.1b Circulation
specimens and direct communication
with the pathology laboratory is n Fluid restriction is not an issue in the
recommended. initial stabilisation of children with
meningitis;22
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 13
n Patients with evidence of shock should 3.1f Glucose (blood glucose levels)
be treated with a rapid infusion n Blood glucose levels must be checked
intravenous/intraosseous crystalloid
early in the management process and
(0.9% sodium chloride) 20ml/kg;
corrected if necessary;
n Considerations for fluid restriction (for n A bedside whole blood glucose
Syndrome of Inappropriate Anti-
(reflectance meter) e.g. “Dextrostix™”
diuretic Hormone, SIADH) should only
should be performed in the early
be undertaken once the patient is no
assessment, especially in infants.
longer shocked.
PAGE 14 NSW HEALTH Infants and children: Acute management of bacterial meningitis
n However, laboratory diagnosis is often
made using the combination of blood
and/or CSF cultures along with Gram
stain and chemical analysis of the CSF.
4.1. Investigations
Table 1 Routine investigations for all patients with suspected bacterial meningitis
In the context of ED care, samples may be taken and marked for storage (particularly CSF)
for the later addition of relevant studies to avoid haphazard ordering of tests.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 15
Table 2 Possible additional tests based on clinical presentation
PAGE 16 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Category of test Tests Comments
Cytology Indicated if CNS leukaemia
is possible. Ask lab to send
to haematology for cytology
if eosinophilic meningitis is
suspected, as eosinophils are
labile.
5. T
he Lumbar Puncture n A CT scan before the LP delays
diagnosis.26 Herniation is unlikely in
n An LP for CSF analysis should be
children, unless there are focal
performed once the diagnosis of
neurological findings or they are
meningitis is suspected and after the
comatose;20
patient is stabilised;
n A CT scan cannot rule out raised
n If there are reasons to delay LP
intracranial pressure. A normal CT
(see below) and bacterial
scan does not absolutely exclude
meningitis is clinically suspected,
subsequent risk of herniation;27
antibiotics should be given prior to
the LP; n A CT scan prior to LP is only
recommended in patients who have
n CSF taken after antibiotics are
clinical evidence of raised
administered may still be useful.
intracranial pressure e.g.
Antibiotics may sterilise the CSF within
significantly altered mental state
1 hour in meningococcal meningitis
bradycardia, hypertension or focal
and within 4 hours in pneumococcal
neurological signs or in those who
meningitis;23
may have an alternative diagnosis (e.g.
n Blood cultures +/- CSF bacterial trauma, subarachnoid haemorrhage);
antigens should also be done to
n Do not delay antibiotics or
increase the diagnostic yield;24, 25
supportive management to
undertake or wait for a CT scan;
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 17
n The potential disadvantage of
transporting a sick child for neuro-
imaging should be factored in as the
transport itself and the neuro-imaging
area may pose risks to a critically ill
child. Movement artefact can also lead
to poor or useless image quality in the
non-anaesthetised child.
*note: If there is no pathology service readily available, take a sample if no other contraindications exist and process later.
PAGE 18 NSW HEALTH Infants and children: Acute management of bacterial meningitis
n Post-ictal CSF abnormalities If there is difficulty in interpreting the
(pleocytosis or raised protein) are rare, CSF, an infectious diseases physician,
and should not be readily accepted as clinical microbiologist, or senior staff
a cause for an abnormal CSF.32 member should be consulted.
Table 4: CSF - normal ranges and typical findings in patients with meningitis
Bacterial meningitis 100 - 10,000 Usually < 100 > 1.0 (but Usually < 0.4 (but may
(but may be may be decreased be normal)
normal) normal)
Viral meningitis Usually <100 10 - 1000 (but 0.4 - 1 Usually normal Usually normal
may be normal) (but
may be
normal)
Table from the Royal Children’s Hospital, Melbourne, Clinical Practice Guidelines on
Meningitis, “CSF interpretation” http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5185
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 19
n As the ‘predicted’ WC in CSF in n The protein levels may be elevated in a
determining a traumatic tap may not traumatic tap. There will be an
be reliable, the safest strategy is to use approximate 0.01 - 0.015 g/L
the un-adjusted total WBC count increase in protein levels for every
(disregard the RC count) and treat for 1000 RBCs in uncentrifuged CSF
bacterial meningitis in the initial samples.
management if there are more WC
than the normal range pending further 5.2.5 Gram stain
information (laboratory and clinical n This is the best single test for rapidly
course). diagnosing bacterial meningitis, and
initiating appropriate therapy;34-36
5.2.3 CSF glucose concentration
n The Gram stain will identify bacteria in
n Blood glucose levels obtained at the
60 - 90% of cases.35 A negative
time of the LP enables proper
Gram stain does not exclude
interpretation of the CSF glucose as
bacterial meningitis.
changes in the CSF glucose level
follow changes in the blood glucose n Occasionally, the Gram stain will be
by ≥ 30 minutes;33 positive despite the absence of
pleocytosis;34,37
n Low CSF glucose (< 2.2 mmol/L) is
found in about two thirds of patients n Gram stain yields are reduced if there
with bacterial meningitis;34 has been prior treatment with
antibiotics, but other CSF indices may
n However, a normal glucose does
still indicate a likely bacterial infection.15
not exclude bacterial meningitis.
PAGE 20 NSW HEALTH Infants and children: Acute management of bacterial meningitis
6. Antibiotic management n Serogroup B Neisseria meningitidis,
the predominant invasive strain, is not
6.1 General currently covered by immunisation;40
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 21
Table 6 summarises the common bacterial pathogens by age and antibiotic selection.
6.2 E
mpiric antibiotic 6.3 Duration of therapy
management of suspected
As a guide, the duration of antibiotic
Streptococcus pneumoniae
therapy in ‘uncomplicated’ cases of acute
meningitis
bacterial meningitis are:
When S. pneumoniae meningitis is n Group B streptococcus, 14 days;
suspected, a third generation
n Gram negative rods, 21 days;
cephalosporin PLUS vancomycin as empiric
antibiotic regimen is recommended e.g. n Listeria monocytogenes, 21 days;
CSF with Gram positive diplococci or Gram n Neisseria meningitidis, 7 days;
positive cocci resembling streptococci seen
n Haemophilus influenzae type b,
on Gram stain.
10 days;
n CSF is negative by Gram stain but the
n Streptococcus pneumoniae, 14 days;
clinical presentation and/or other CSF
findings are highly suspicious for n ‘Culture negative’ but significant CSF
bacterial meningitis; pleocytosis present, minimum of 7
days recommended.
n High clinical suspicion of bacterial
meningitis but an LP is contra-
indicated (see Table 3).
PAGE 22 NSW HEALTH Infants and children: Acute management of bacterial meningitis
6.4 Antibiotic doses IV (Note: further information in text:
Introduction and Section 6)
Antibiotic doses are shown in Table 7
Table 7: Antibiotic doses (IV)
Drug Dose Frequency of Dose by Age
First Week of Life Weeks 2 – 4 of Age Age > 4 Weeks
Antibiotic doses are adapted from the current Australian Antibiotic Therapeutic Guidelines 38
*
Ceftriaxone should not be used in newborns (≤ 28 days old). Do not mix ceftriaxone together with calcium
containing solutions or administer calcium containing solutions simultaneously with ceftriaxone.
#
The vancomycin dose and frequency recommended are CNS dosing regimens for children (adult regimens differ).
Therapeutic drug monitoring with vancomycin trough levels should be performed just prior to the fifth dose.
Trough levels between 15 to 20 mg per litre are preferred; if not achieved discussion with an infectious diseases
physician may assist in dose escalation.
7. A
djunctive Therapy - time applicable to ”after the first
Corticosteroids dose” has not been adequately
defined;
n Current evidence suggests that early
steroids (first dose given before, with n There is insufficient information about
or just after antibiotics) in children steroids in infants < 3 months of age
with acute bacterial meningitis reduce and in those presenting with severe
the risk of hearing loss and sepsis;
neurological sequelae;43,44 n The influence of antibiotic penetration
n These benefits are seen in paediatric into the CNS if steroids are used is
patients with acute bacterial uncertain.
meningitis from “high income”
Summary: Steroids are recommended
countries and not in children living in
early in children ≥3 months of age with
low income countries;
acute bacterial meningitis, provided that
n Steroid use in children with acute they have not been pre-treated with
bacterial meningitis does not appear parenteral antibiotics.
to influence mortality;
Recommendations:
n Steroid use is not associated with
increased adverse events; a) In children ≥3 months of age with
suspected bacterial meningitis, steroids
n The timing of steroids (before, with or
(dexamethasone) should be given early,
after first dose of antibiotics) appears
just before or at the time of antibiotics,
equivalent in efficacy. The range of
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 23
as a single push to minimise potential (see table below), presenting complaint,
delay in antibiotic administration. past history and parental concerns;
PAGE 24 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Refer to the age appropriate Standard 8.1.3 Primary assessment of Disability
Paediatric Observation Chart (SPOC) for n Recognition of potential respiratory
guidance in normal and abnormal
failure:
parameters for vital signs. If an infant,
– Neurological function including
child or adolescent has vital signs outside
conscious level (AVPU), posture,
of the specified normal parameters then
and pupils;
manage according to local processes and
– AVPU stands for:
guidelines.
• Alert;
8.1.1 Primary assessment of Airway • Responds to Voice;
and Breathing • Responds to Pain only;
• Unresponsive;
n Recognition of potential respiratory
– Respiratory effects of central
failure:
neurological failure including
– Effort of breathing including breathing pattern abnormalities.
respiratory rate, recession,
inspiratory or expiratory noises, 8.1.4 Exposure
grunting, accessory muscle use, n Examination for markers of illness such
flaring of nasal alae, gasping
as temperature and rash.
(sign of severe hypoxia);
– Efficacy of breathing including 8.2 Summary: the rapid clinical
chest expansion (or in infants, assessment of an infant or
abdominal expansion), child46
auscultation of chest;
– Effects of respiratory inadequacy Airway and Breathing
on other organs including heart
Effort of breathing;
rate, skin colour, mental status.
Respiratory rate/rhythm;
8.1.2 Primary Assessment of Stridor/wheeze;
Circulation Auscultation;
Skin colour.
n Recognition of potential respiratory
failure:
Circulation
– Cardiovascular status including
heart rate, pulse volume, Heart rate;
capillary refill, blood pressure; Pulse volume;
– Effects of circulatory inadequacy Blood pressure;
on other organs including Capillary refill;
respiratory system, skin, mental Skin temperature.
status and urinary output.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 25
Disability differences in normal values for
blood pressure, heart rate and
Mental status/conscious level (AVPU); respiratory rate. The SPOC
Posture; facilitates trending of vital
Pupils. signs, and provides guidance
The whole assessment should take regarding normal ranges.
less than a minute to complete 2. Valuable information can be
Once this rapid assessment is undertaken gained from frequent repeated
and intervention commenced as needed, a observations to detect a trend
structured primary assessment and in the patient’s condition.
resuscitation should occur. Repeated observations over
time are required to ensure
subtle signs or cues of illness
8.3 Additional information:
are detected as recommended
n Serious illness should not be in the Recognition of a Sick
automatically excluded if young Baby or Child in the Emergency
children present with non-specific Department Clinical Practice
symptoms such as fever, decreased Guideline found at http://
activity/arousal, poor feeding, nausea, www0.health.nsw.gov.au/
vomiting and irritability or a non- policies/pd/2011/PD2011_038.pdf.
blanching rash;
3. Repeated observation of vital
n Children with non-specific symptoms
signs provides the possibility of
at initial presentation, in whom
excluding some of the
conditions such as meningococcal
confounding signs and
disease cannot be excluded, should be
symptoms since these evolve
reassessed by a medical officer within
progressively within a 24hr
4 to 6 hours. This should result in the
time-span.
admission of any child in whom the
possibility of the diagnosis of n Nursing staff are encouraged to take a
meningitis is being considered and this proactive approach to parent/carer
admission may need to be to the advice throughout the assessment and
observation area of an ED or a management of the child;
paediatric ward. n Local arrangements for health care
need to be considered prior to
1. Ensure vital signs are
discharging a patient where a
documented on the age-
diagnosis of bacterial meningitis has
relevant Standard Paediatric
not been confirmed and is considered
Observation Chart (SPOC). In
unlikely. Before discharge, parents
children there are age related
should be given verbal and written
PAGE 26 NSW HEALTH Infants and children: Acute management of bacterial meningitis
advice (e.g. a fact sheet) regarding 11. Related issues
signs and symptoms of bacterial
meningitis which would necessitate 11.1 Infection control issues
the child’s return to ED;
n Infection control practices during
n If there are sufficient concerns such patient care are outlined in NSW
that parents/carers are advised to seek Health Infection Control Policy
further clinical advice if their child’s http://www0.health.nsw.gov.au/
condition deteriorates then, policies/pd/2007/PD2007_036.html
depending on the services available (see section 2, Infection Control
and the capacity of parents, a review Process).
within 24 hours or admission should
n The Infection Prevention and Control
be considered.
team for the facility are required to be
informed if invasive meningococcal
9. Psychosocial needs of the disease or Haemophilus influenzae
family type b infection is suspected;
n Personal Protective Equipment (PPE),
The diagnosis of bacterial meningitis is a
including surgical mask and eye
frightening one for families, especially if
protection, must be worn when
the child is critically ill. When the child is
undertaking any procedure where the
stabilised, staff should set aside time as
likelihood of splashing or splattering
soon as possible to address family
of any bodily fluids exists. Procedures
concerns.
such as venepuncture, intubation and
LP are indications for PPE (eye and face
10. T
ransfer of patient to protection as well as gloves and
tertiary referral centre apron/gown);
n All cases of suspected bacterial
Patients with bacterial meningitis will need
meningitis should be isolated initially
admission to hospital. If in-patient facilities
in a single room until 24 hours after a
are not available locally, transfer to a
third generation cephalosporin has
regional centre with specialist paediatric
been administered;
facilities may be required. Most
significantly unwell children will require n Ongoing isolation requirements
transfer to a paediatric intensive care unit. however, should be determined by the
If this facility is not available locally, the hospital infection control team and is
NETS line should be called (1300 36 based on the suspected or confirmed
2500) as soon as possible after organism.
presentation rather than delaying until the
patient has been fully assessed,
investigated and stabilised.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 27
11.2 N
otification to Public n Clearance antibiotics are not
Health Unit recommended for health care workers
unless direct contact with respiratory
n In accordance with the NSW Public
secretions of patient with suspected
Health Act (1991), hospital staff are
(or proven) Neisseria meningitidis has
required to notify suspected or
occurred;
confirmed invasive infections
(including meningitis) due to n The regimen for Haemophilus
Haemophilus influenzae type b, influenzae type b prophylaxis and
Neisseria meningitidis or invasive dosing can be found at eTG complete,
pneumococcal infection to their local available at http://etg.hcn.com.au/
Public Health Unit; desktop/index.htm.
PAGE 28 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Appendix One - References
1. Baraff LJ, Lee SI, Schriger DL. Outcomes 7. Roine I, Peltola H, Fernandez J, et al.
of bacterial meningitis in children: a Influence of admission findings on death
meta-analysis. PediatrInfectDisJ and neurological outcome from childhood
1993;12:389-94. bacterial meningitis. Clin Infect Dis
2008;46:1248-52.
2. Nigrovic LE, Kuppermann N, Malley R.
Children with bacterial meningitis 8. Kaplan SL. Clinical presentations,
presenting to the emergency department diagnosis, and prognostic factors of
during the pneumococcal conjugate bacterial meningitis. Infect Dis Clin North
vaccine era. Acad Emerg Med Am 1999;13:579-94, vi-vii.
2008;15:522-8.
9. Feigin RD, McCracken GH, Jr., Klein JO.
3. Arestis N, Tham YJ, McIntyre PB, et al. Diagnosis and management of meningitis.
A population-based study of children with PediatrInfectDisJ 1992;11:785-814.
cerebral tuberculosis in New South Wales.
MedJAust 1999;171:197-200. 10.Bonadio WA, Mannenbach M,
Krippendorf R. Bacterial meningitis in
4. Radetsky M. Duration of symptoms and older children. AmJDisChild
outcome in bacterial meningitis: an 1990;144:463-5.
analysis of causation and the implications
of a delay in diagnosis. PediatrInfectDisJ 11.Levy M, Wong E, Fried D. Diseases that
1992;11:694-8. mimic meningitis. Analysis of 650 lumbar
punctures. ClinPediatr(Phila)
5. Best J, Hughes S, Best J, Hughes S. 1990;29:254-61.
Evidence behind the WHO Guidelines:
hospital care for children--what are the 12.Dawson KP, Abbott GD, Mogridge N.
useful clinical features of bacterial Bacterial meningitis in childhood: a 13
meningitis found in infants and children? J year review. NZMedJ 1988;101:758-60.
Trop Pediatr 2008;54:83-6. 13.Rosenberg NM, Meert K, Marino D, De
6. Dawson KG, Emerson JC, Burns JL. Baker K. Seizures associated with
Fifteen years of experience with bacterial meningitis. Pediatr Emerg Care
meningitis. PediatrInfectDisJ 1992;8:67-9.
1999;18:816-22.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 29
14. Rothrock SG, Green SM, Wren J, Letai 21. Kilpi T, Anttila M, Kallio MJ, Peltola H.
D, Daniel-Underwood L, Pillar E. Pediatric Severity of childhood bacterial meningitis
bacterial meningitis: is prior antibiotic and duration of illness before diagnosis.
therapy associated with an altered clinical Lancet 1991;338:406-9.
presentation? AnnEmergMed
1992;21:146-52. 22. Maconochie I, Baumer H, Stewart ME,
Stewart MER. Fluid therapy for acute
15. Nigrovic LE, Malley R, Macias CG, et bacterial meningitis.[update of Cochrane
al. Effect of antibiotic pretreatment on Database Syst Rev. 2005;(3):CD004786;
cerebrospinal fluid profiles of children with PMID: 16034949]. Cochrane Database
bacterial meningitis. Pediatrics Syst Rev 2008:CD004786.
2008;122:726-30.
23. Kanegaye JT, Soliemanzadeh P,
16. Bonsu BK, Harper MB. Fever interval Bradley JS. Lumbar puncture in pediatric
before diagnosis, prior antibiotic bacterial meningitis: defining the time
treatment, and clinical outcome for young interval for recovery of cerebrospinal
children with bacterial meningitis. fluid pathogens after parenteral
ClinInfectDis 2001;32:566-72. antibiotic pretreatment. Pediatrics
2001;108:1169-74.
17. Chotmongkol V, Thiensiri C, Boonma P.
Neurogenic pulmonary edema associated 24. Quagliarello VJ, Scheld WM.
with meningitis. JMedAssocThai Treatment of bacterial meningitis.
1990;73:530-2. NEnglJMed 1997;336:708-16.
PAGE 30 NSW HEALTH Infants and children: Acute management of bacterial meningitis
28. Rennick G, Shann F, de Campo J. 37. Gutierrez-Macias A, Garcia-Jimenez N,
Cerebral herniation during bacterial Sanchez-Munoz L, Martinez-Ortiz Z.
meningitis in children. Pneumococcal meningitis with normal
BMJ 1993;306:953-5. cerebrospinal fluid in an
immunocompetent adult. AmJEmergMed
29. Polk DB, Steele RW. Bacterial 1999;17:219.
meningitis presenting with normal
cerebrospinal fluid. PediatrInfectDisJ 38. Central nervous system infections. In:
1987;6:1040-2. Therapeutic Guidelines: Antibiotics. 14 ed;
2010.
30. Nigrovic LE, Kuppermann N, Macias
CG, et al. Clinical prediction rule for 39. Roche P, Krause V, Cook H, et al.
identifying children with cerebrospinal Invasive pneumococcal disease in
fluid pleocytosis at very low risk of Australia, 2005. Commun Dis Intell
bacterial meningitis. Jama 2007;297: 2007;31:86-100.
52-60.
40. Tapsall J. Annual report of the
31. Dubos F, Martinot A, Gendrel D, et al. Australian Meningococcal Surveillance
Clinical decision rules for evaluating Programme, 2007--Amended. Commun
meningitis in children. Current Opinion in Dis Intell 2009;33:1-9.
Neurology 2009;22:288-93.
41. Hsu HE, Shutt KA, Moore MR, et al.
32. Wong M, Schlaggar BL, Landt M. Effect of pneumococcal conjugate vaccine
Postictal cerebrospinal fluid abnormalities on pneumococcal meningitis. N Engl J
in children. JPediatr 2001;138:373-7. Med 2009;360:244-56.
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 31
45. 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;330:1475.
PAGE 32 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Appendix Two - Glossary
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 33
Appendix Three - Resources
PAGE 34 NSW HEALTH Infants and children: Acute management of bacterial meningitis
Appendix Four - Parent information
http://www.sch.edu.au/health/factsheets/
joint/?meningij.htm
http://kidshealth.schn.health.nsw.gov.au/
fact-sheets/meningitis
http://kidshealth.schn.health.nsw.gov.au/
sites/kidshealth.schn.health.nsw.gov.au/
files/fact-sheets/pdf/meningitis.pdf
NSW HEALTH Infants and children: Acute management of bacterial meningitis PAGE 35
Appendix Five - Expert working party
membership
PAGE 36 NSW HEALTH Infants and children: Acute management of bacterial meningitis
SHPN: (NKF) 140090