Policy Directive

Department of Health, NSW

73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/

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Children and Infants with Bacterial Meningitis - Acute Management

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Document Number PD2005_383
Publication date 27-Jan-2005
Functional Sub group Clinical/ Patient Services - Baby and child
Clinical/ Patient Services - Medical Treatment
Summary Basic clinical practice guidelines for the management of acute bacterial
meningitis in children.
Author Branch Statewide Services Development
Branch contact Program Manager, Paediatric Services 9391 9470
Applies to Area Health Services/Chief Executive Governed Statutory Health
Corporation, Board Governed Statutory Health Corporations, Affiliated
Health Organisations - Non Declared, Community Health Centres,
Government Medical Officers, NSW Ambulance Service, NSW Dept of
Health, Private Hospitals and Day Procedure Centres, Public Hospitals
Distributed to Public Health System, Community Health Centres, Government Medical
Officers, NSW Ambulance Service, NSW Department of Health, Public
Hospitals, Private Hospitals and Day Procedure Centres, Tertiary
Education Institutes
Review date 27-Jan-2010
Policy Manual Not applicable
File No. 04/5528
Previous reference 2004/60
Issue date 21-Oct-2004
Status Active

Director-General
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This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.
CIRCULAR

File No 04/5528
Circular No 2004/60

Issued 21 December 2004

Ms Mary Crum (02) 9391 9100
Clinical Policy Branch
Contact Dr Elisabeth Murphy (02) 9391 9475
Primary Health and Community
Partnerships Branch

Acute Management of Infants and Children with Bacterial Meningitis

The attached clinical practice guideline applies to all facilities where paediatric patients are
managed and were prepared for the NSW Health Department by an expert clinical reference group
under the auspice of the Statewide Paediatric Steering Committee. Area Health Services are
required to have local guidelines in place in all hospitals and facilities likely to be required to assess
or manage children with acute meningitis. In developing local guidelines other relevant
Departmental circulars should also be considered eg. NSW Health Department Guidelines for the
Hospitalisation of Children Revised July 1998 (State Health Publication SWS 980088).

It should be noted that this document reflects what is currently regarded as a safe and
appropriate approach to care. 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 judgment
to each individual presentation.

In early 2004 the NSW Institute of Clinical Excellence commenced a Children’s Emergency
Care Project, which involves working with a number of pilot sites to implement the clinical
practice guidelines. Contact details are: Marilyn Cruickshank, Project Manager, Children’s
Emergency Care Project, NSW Institute for Clinical Excellence, GPO Box 1614, SYDNEY 2001,
Phone: (02) 9382 7658, Fax: (02) 9382 7615.

Robyn Kruk
Director-General

Distributed in accordance with circular list(s):

A 60 B C 57 D E 6 73 Miller Street North Sydney NSW 2060

F 17 G H 42 I J 41 Locked Mail Bag 961 North Sydney NSW 2059
K L 10 M N P 10 Telephone (02) 9391 9000 Facsimile (02) 9391 9101
In accordance with the provisions incorporated in the Accounts and Audit Determination, the Board of Directors, Chief Executive Officers and their
equivalents, within a public health organisation, shall be held responsible for ensuring the observance of Departmental policy (including circulars
and procedure manuals) as issued by the Minister and the Director-General of the Department of Health.
 Management of acute bacterial
meningitis in infants and children

Clinical Practice Guidelines

NSW DEPARTMENT OF HEALTH
73 Miller Street
NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000
Fax. (02) 9391 9101
TTY. (02) 9391 9900
www.health.nsw.gov.au

This work is copyright. It may be reproduced in whole or in part for

study 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 Department of Health.

© NSW Department of Health 2004

SHPN (SSD) 040157

ISBN 0 7347 3705 X
Circular No: 2004/60

For more copies contact:

Better Health Centre – Publications Warehouse
Locked Mail Bag 5003
Gladesville NSW 2111
Tel. (02) 9816 0452
Fax. (02) 9816 0492
TTY. (02) 9391 9900

Further copies of this document can be downloaded from the

NSW Health website: www.health.nsw.gov.au

A revision of this document is due in December 2006.

December 2004
Contents
Introduction...................................................2 Adjunctive therapy – Corticosteroids.......18

Summary .......................................................3 Nursing issues ............................................20

Key points in the acute management

Pyschological needs of the family............21
of bacterial meningitis in children ....................2

Transfer of patient to
Clinical presentations ..................................7
tertiary referral centre................................21
Common presentations ...................................7
Related issues ............................................22
Children who have received prior antibiotics....8
Infection control issues ..................................22
Complications..................................................8
Notification to public health ..........................22
Minimising delay in diagnosis.....................9
Chemoprophylaxis for contacts......................22

Initial management.....................................10
Glossary ......................................................23
Resuscitation .................................................10
Resources ...................................................24
Seizures .........................................................10

Blood glucose, urea and electrolytes ..............10 References ..................................................25

Diagnostic tests..........................................11 Parent information sheet...........................28

Investigations.................................................11
Working party members ............................30

The Lumbar Puncture (LP) ........................13

Indications to delay the LP .............................13

Interpreting the CSF.......................................14

Antibiotic management .............................16

General ........................................................16

Empiric antibiotic management

of suspected Streptococcus
pneumoniae meningitis ................................16

Antibiotic doses .............................................17

NSW Health Management of acute bacterial meningitis in infants and children 1

Introduction

These Guidelines are aimed at achieving the This document represents basic clinical practice
best possible paediatric care in all parts of the guidelines for the management of acute
State. The document should not be seen as a bacterial meningitis in children. Further
stringent set of rules to be applied without the information may be required in practice;
clinical input and discretion of the managing suitable widely available resources are listed
professionals. Each patient should be individually on page 24.
evaluated and a decision made as to appropriate
Each Area Health Service is responsible for
management in order to achieve the best
ensuring that local protocols based on these
clinical outcome.
guidelines are developed. Area Health Services
The formal definition of clinical practice are also responsible for ensuring that all staff
guidelines comes from the National Health and treating paediatric patients are educated in
Medical Research Council: the use of the locally developed paediatric
guidelines and protocols.
‘systematically developed statements to
assist practitioner and patient decisions In the interests of patient care it is critical
about appropriate health care for specific that contemporaneous, accurate and complete
clinical circumstances.’ (National Health documentation is maintained during the course
and Medical Research Council A Guide to of patient management from arrival to discharge.
the Development, implementation and
Parental anxiety should not be discounted:
evaluation of Clinical Practice Guidelines,
it is often of significance even if the child
Endorsed 16 November 1998, available
does not appear especially unwell.
from www.nhmrc.gov.au/publications/
synopses/cp65syn.htm)
It should be noted that this document reflects
what is currently regarded as a safe and
appropriate approach to care. 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 authorative statement
of procedures to be followed in respect of each
individual presentation. It does not replace the
need for the application of clinical judgment to
each individual presentation.

2 Management of acute bacterial meningitis in infants and children NSW Health

Summary
Suspected bacterial meningitis is a medical
emergency. Despite advances in antibacterial
therapy, acute bacterial meningitis continues to
be a disease with high mortality and morbidity.
Untreated bacterial meningitis has a uniformly
fatal outcome. Even with treatment, bacterial
meningitis in childhood is associated with
morbidity rates ~20 per cent and mortality
rates of ~5 per cent in developed countries.1
These guidelines describe basic clinical practice
in the acute assessment and management of
bacterial meningitis in otherwise healthy infants
and children. They are intended for medical
and nursing staff working in an Emergency
Department (ED) and focus on the acute
management in the ED. Follow-up management
is outside the scope of this document.
It is anticipated that modifications may be
required for local practice. Variations in
management may also be required in individual
cases. It is stressed that the guidelines are,
by necessity, general in nature and are not
intended as a substitute for clinical judgement.
Early consultation with a senior ED or
paediatric staff member is mandatory in all
cases of suspected meningitis.
Key points in the acute
management of bacterial
meningitis in children
First principals
■ Prompt recognition and early management
are the goals.
■ Early consultation with a senior paediatric
or senior emergency department staff
member should occur in all cases of
suspected meningitis.
NSW Health Management of acute bacterial meningitis in infants and children
Clinical presentation
■ Not all patients will have fever, neck
stiffness and altered mental status.
■ The younger the patient, the more subtle
the symptoms and signs and the higher
should be the level of suspicion.
■ Fever is not always present at presentation
in acute bacterial meningitis.
■ Clinical presentations can be acute (hours
to 1–2 days) to insidious (over a few days).
■ Preceding upper respiratory tract infection
to often present (~75 per cent).
■ Seizures occur in 20–30 per cent.
■ prior antibiotics modify presentation and
diagnostic yield, and should always be
part of the history.
Initial management
■ The priorities are ensuring the adequacy
of the Airway, Breathing, Circulation,
Disability (level of consciousness) and
Exposure (rash assessment and environmental
control) i.e. ‘ABCDE’.
■ The risks from inadequate cerebral circulation
may be higher than the risks of cerebral
oedema so volume expanders should be
titrated against the patient’s perfusion.
■ If venous access is significantly difficult,
an intraosseous needle can be used.
■ Seizures should be treated urgently.
■ A bedside whole blood glucose reading
(reflectance meter) e.g. ‘Dextrostix™’,
should be performed as part of the
early assessment, especially in infants.
■ Electrolyte and glucose abnormalities
should be addressed.
3
Summary
Diagnosis
■ Ensuring the adequacy of the ABCDEs has
priority over establishing a precise diagnosis.
■ CSF examination provides the definitive
diagnosis. Blood cultures may provide
supportive evidence. Ideally, CSF via lumbar
puncture (LP) and blood cultures should
be taken prior to antibiotic therapy.
Other investigations are helpful for acute
management of a sick child, but not
definitive in the diagnosis of meningitis.
■ The initiation of appropriate antibiotic
therapy assumes high priority. If the patient
is too sick or unstable for immediate
definitive investigations, then appropriate
antibiotics should be commenced.
■ The LP should be performed when
the patient is resuscitated and stable.
■ A cerebral computed tomogram (CT) scan is
not part of the routine workup and is indicated
only in specific situations (see text). It should
only be done when the patient is stable.
■ The limits of sensitivity of the CSF diagnostic
tests, especially if pre-treated with parenteral
antibiotics, should be recognised.
■ CSF samples should be expeditiously
transported to the laboratory and
urgently analysed.
Steroid therapy
A recent systematic review supports the early
use (just before or with first dose of antibiotics)
of adjunctive steroid therapy provided children
have not been pre-treated with antibiotics.
The benefit is an approximate two-thirds
reduction in severe hearing loss (Hib and
non-Hib). The impact on long term cognitive
function remains unanswered. There is insufficient
information to be certain about the benefit of
steroids in the 0–3 month age group given the
different aetiological agents and unknown
potential adverse effects of steroids in this age
group. The benefit is also less clear in children
who present late in the illness or in severe sepsis.
4 Management of acute bacterial meningitis in infants and children
Thus suggested criteria for steroid use in acute
bacterial meningitis:
■ > three months of age
■ not pre-treated with parenteral antibiotics.
Due to insufficient information, no clear
recommendations can be given about steroids
in the < 3 month age group and those presenting
with advanced meningitis or severe sepsis.
Suggested regimen:
■ Dexamethasone, 0.15 mg/kg/dose, IV,
six-hourly for four days.
■ Given as a ‘push’, followed by first dose
of antibiotics for practical purposes.
Antibiotic therapy
Recommended empiric antibiotic therapy is:
■ Neonates to three months: ampicillin
(or benzylpenicillin) plus cefotaxime
(not ceftriaxone in neonates).
■ > three months: cefotaxime or cetriaxone.
When infection with Streptococcus pneumoniae
is suspected, vancomycin* should be added to
the above regimens when:
■ CSF with Gram positive diplococci or
Gram positive cocci resembling streptococci
are seen on Gram stain
■ CSF is negative by Gram stain but the clinical
presentation and/or other CSF findings are
highly suspicious for bacterial meningitis
■ high clinical suspicion of bacterial meningitis,
but a lumbar puncture is contra-indicated
(see table 3).
* Single therapy with vancomycin is not recommended.
Further care
■ Once the patient is resuscitated and
stabilised, refining management and further
investigations can be arranged under
direction of the responsible team.
■ The decision to transfer the patient or to
continue to provide care locally will be
determined by the local resources and the
patient’s needs.
NSW Health
 Summary

■ If there is doubt, then a tertiary centre ■ If the patient is to be transferred, the

should be consulted as soon a possible. degree of urgency and the use of a retrieval
this can be done via the NETS Clincial team should also be discussed as soon as
Coordination Centre (1 300 362 500). possible. Use of the NETS line allows for
simultaneous consultation and transfer.

Practice flow chart for the management of children presenting to the emergency
departmet with suspected acute bacterial meningitis (Use in conjunction with text)

Triage

Initial acute management (page 10)

■ ABCDE
■ Seizures
■ Blood glucose, urea and electrolytes

Clinical presentations (page 7)

■ History and examination
■ Clinical presentation by age (page 7)
■ Presentation with prior antibiotics (page 8)
■ Complications (page 8)

Additional tests by
Diagnostic tests Essential Investigations
clinical indications
(pages 11–12) (page 11 and Table 1)
(page 12 and Table 2)

Lumbar Blood
+ Haematology + Biochemistry
puncture (LP) cultures

Indications to delay LP Interpreting the CSF

(page 13 and Table 3) (page 14 and Tables 4 and 5)

Specific therapies Steroids? Antibiotics

+
(pages 16–19) (‘Key points’ and page 18) (page 16)

Empire antibiotics Suspected S. pneumoniae Antibiotic doses

(page 16 and Table 6) (page 16 and Table 6) (page 17)

Related issues (page 22)

Psychosocial needs Consultation and transfer ■ Infection control
Nursing management
+ of the family + of patients +
(page 20) ■ PHU Notification
(page 21) (page 21)
■ Chemoprophylaxis

NSW Health Management of acute bacterial meningitis in infants and children 5

Summary

Algorithm: Acute management of suspected bacterial meningitis in children

Child clinically suspected of having meningitis (see page 7)

Assess and attend to ariways, breathing, circulation

and level of consciousness +/– seizures* (see page 10)

*Consider taking blood for

Patient stable investigation (see page 11)
at the time of establishing IV
access if practical

No Indication to delay LP? (see page 13) Yes

Lumbar puncture#
(See page 13)

■ Blood cultures
Plus other essential tests: (see Table 1)
■ Assess need for empiric
# Expeditious lab assay of the CSF
antibiotic cover before
■ M/C/S: urgent microscopy, culture and sensitivity
further investigations
■ Protein
■ Consult senior staff
■ Glucose – best interpreted with concurrent
serum glucose

■ Turbid CSF and/or Reassess at

If no other indications to
later stage and
■ High clinical suspicion delay LP, proceed to LP
LP when safe

No
Yes

Await CSF analysis

■ ?Steroids (See ‘Key points’
and pages 18 and 19)
■ Start empiric antibiotics by age
group (see page 16)

Normal or Equivocal CSF Abnormal CSF

High clinical suspicion Low clinical suspicion Consistent with

for bacterial meningitis for bacterial meningitis bacterial meningitis

■ ?Steroids (See ‘Key Points’ Discuss further

and pages 18) management with ■ ?Steroids (See ‘Key Points’
■ Commence empiric antibiotics senior staff and pages 18 and 19)
■ Discuss further management ■ Commence empiric antibiotics
with senior staff ADMIT
ADMIT

6 Management of acute bacterial meningitis in infants and children NSW Health

Clinical
presentations
While viral meningitis occurs more commonly maternal group B streptococcus status
than bacterial meningitis, it is often difficult if known
to distinguish from bacterial meningitis. ■ recent use of antibiotics
Mycobacterium tuberculousis (MTB) meningitis ■ drug allergies.
is rare in Australia2 but must also be considered
in the differential diagnosis particularly in the 0–3 months
context of overseas travel or immigrants from
areas with high MTB prevalence. As the clinical The diagnosis may be more difficult in the
manifestations of each can be indistinguishable very young as history and presentations can be
from bacterial meningitis, it is prudent to non-specific. Features include:
assume a bacterial cause in initial management. ■ fever or hypothermia
■ bulging fontanelle or acute increase in head
circumference. However, more useful in
Common presentations
children 2–12 months of age4
Clinical presentations of bacterial meningitis
■ irritability
vary, dependent on age, duration of illness,
■ high pitched cry
the patient’s response to infection, whether prior
antibiotics have been used and the infecting ■ lethargy
organism. The presentations could be insidious ■ altered mental state
(over a few days) or acute and sometimes ■ seizures
fulminant (a few hours).3 Overall, severity of ■ apnoea
illness at presentation appears most predictive ■ poor feeding
of outcome. ■ vomiting.
The history and examination of a child
A high index of suspicion for meningitis must
presenting with suspected meningitis is the
exist in sick, febrile or hypothermic newborns
same as any acutely unwell child, with attention
with or without the above features.
paid to neurological signs and associated
complications (see page 8). Apart from the
> 3 months
clinical presentations, the history should include
the following key elements: Symptoms become more CNS specific after
this age. Acute presentations include5–7:
■ age (~90 per cent of bacterial meningitis
occurs at age < five years) ■ fever (not always present on presentation
to ED ~50 per cent in infants6 and in
■ vaccination history
~45 per cent in older children in small
■ predisposing factors: recent infections,
case series7)
known contact with someone with
■ neck stiffness (60 80 per cent, more useful
meningitis, recent travel, head trauma
in children > 3 years) 8,9
or cranial surgery and maternal obstetric
history if child < three months, including

NSW Health Management of acute bacterial meningitis in infants and children 7

Clinical presentations

■ Kernig’s sign (inability to completely extend The time to diagnosis of acute bacterial meningitis
the leg) in older children. Absence does may be delayed in children pre-treated with
not exclude meningitis antibiotics, but the complication rate is not
■ Brudzinki’s sign (flexion at the hip and necessarily increased.12
knee in response to forward flexion of the
neck) in older children. Absence does not Complications
exclude meningitis
Patients may uncommonly present with
■ irritability or lethargy
early complications of sepsis or raised
■ altered mental state (highly variable) intracranial pressure:
■ anorexia, nausea and/or vomiting
■ Septic shock
(a common/non–specific symptom)
■ Disseminated intravascular coagulopathy
■ photophobia (older children)
■ Purpura fulminans
■ seizures (about 20–30 per cent incidence)
■ Waterhouse-Friderichsen syndrome
NB: Papilloedema in uncomplicated early ■ Cerebral herniation
bacterial meningitis is rare. The presence of
■ Neurogenic pulmonary oedema (rare).13,14
papilloedema suggests complications like
venous sinus thrombosis, abscess or subdural About 83 per cent of appropriately
empyema. treated children will have an uncomplicated
recovery. However, later complications include
cerebrovascular events, subdural effusions,
Children who have received hearing deficits and a range of
prior antibiotics neurological sequelae.1
The clinical presentations and CSF findings in
children who have received previous antibiotics
may be modified.10,11
Some features include:
■ less frequent presentations with
temperature > 38.50C
■ more frequent vomiting
■ less frequent alterations in mental status
■ the rate of positive CSF culture and
Gram stain recovery may decrease with
pre-treatment with antibiotics, but other
CSF parameters are not significantly
influenced
■ the relationship between
polymorphonuclear cells and lymphocytes
in CSF may be reversed.

8 Management of acute bacterial meningitis in infants and children NSW Health

Minimising delay
in diagnosis
To avoid a delay in the diagnosis of meningitis,
the following important points must be noted.
■ The early diagnosis of bacterial meningitis
can be difficult even for experienced
clinicians – a high index of suspicion should
be maintained. If doubts exist about a
diagnosis, consultation with a senior
staff member is strongly advocated.
■ Meningitis must be considered in any
child with unexplained fever
■ Meningitis needs to be considered in
all children presenting with seizures in
association with fever, particularly in
children aged < 12 months, or the fever
is prolonged in nature or refractory to
management. Not all children presenting
with fever and convulsions will
have meningitis.15
■ The presence of an apparent explanation
for fever eg pharyngitis or otitis media does
not rule out the possibility of meningitis.
A preceding history of an upper respiratory
tract infection may present in about
75 per cent.16
NSW Health Management of acute bacterial meningitis in infants and children
■ Maculopapular, petechial or purpuric
rashes may sometimes be associated
with Neisseria meningitidis meningitis/
septicaemia. Petechiae and/or purpura
have also (less commonly) been observed
in Haemophilus influenzae type b
or Streptococcus pneumoniae sepsis.
■ Prior oral antibiotics for unexplained
fever or other focus may confuse
and delay diagnosis.
■ Apparent improvement with paracetamol
is not helpful in excluding the diagnosis.
■ Examination of any CSF samples taken
is urgent. Thus, appropriate labelling
of requests, facilitation of delivery of
specimens and direct communication with
the pathology laboratory is recommended.
9
Initial management
The assessment of any critically unwell child
must always focus initially on resuscitation.
The diagnostic test for meningitis is the lumbar
puncture (LP). However, this test should not be
undertaken until the patient has been resuscitated
and stabilised. Assessing the ‘Airway,
Breathing, Circulation, Disability (level of
consciousness) and Environment (presence of
rash, temperature control)’ is thus the first
priority. Once the patient has been stabilised,
then the examination should include general
assessment looking for features of sepsis
and meningitis.
Resuscitation
Airway and Breathing
Ensure that there is an open airway and
adequate ventilation is established. Supplemental
oxygen should always be administered.
If ventilation or oxygenation is inadequate,
then respiratory support should be commenced
in the form of bag and mask technique,
followed by endotracheal intubation.
Circulation
Fluid restriction is not an issue in the initial
stabilisation of children with meningitis.
Patients with evidence of shock should be
treated with a rapid infusion intravenous/
interosseous crystalloid (Normal saline) 20ml/kg.
Considerations for fluid restriction (for Syndrome
of inappropriate anti–diuretic hormone, SIADH)
should only be undertaken once the patient is
no longer shocked.
10 Management of acute bacterial meningitis in infants and children
Disability (level of consciousness)
If there are signs of cerebral oedema
(decreasing level of conscious, bulging
fontanelle, papilloedema, rising blood pressure
with falling heart rate), Mannitol (0.5–1.0g/kg)
should be given. The bed should be elevated to
300C and ventilation controlled to maintain
PaCO2 between 30–35mmHg.
Environment
The presence of a rash may be indicative of
meningococcal sepsis. Regulation of temperature
is important in the acute management of
children presenting with sepsis.
Seizures
Seizures should be treated immediately
with a rapid injection of a benzodiazepine
(eg midazolam, 0.15mg/kg, IV). Alternatively,
IM midazolam (0.15mg/kg) or rectal diazepam
(0.5 mg/kg) could be used. Considerations to
a loading dose of phenytoin (20mg/kg over
20 minutes) should given if seizures continue.
Phenytoin has the benefit of avoiding sedation,
although phenobarbitone (20mg/kg) is more
commonly used in neonates.
Blood glucose, urea
and electrolytes
These must be checked early in the
management and corrected if necessary.
A bedside whole blood glucose (reflectance
meter) e.g. ‘Dextrostix™’ should be performed
in the early assessment, especially in infants.
NSW Health
Diagnostic tests

The laboratory gold standard for establishing

the diagnosis of bacterial meningitis is the
isolation of the causative bacteria from the
cerebrospinal fluid (CSF). 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.

Investigations
Table 1. Routine investigations for all patients with suspected bacterial meningitis

Category of test Tests Comments

Haematology Blood A WCC of <10 x 109/L does not exclude meningitis.

FBC, WCC Thrombocytopaenia can occur in DIC.
differential + film

Biochemistry Blood Monitor Na+ to detect SIADH. Renal and liver impairment can
Urea, Electrolytes, occur with sepsis and should be monitored.
Creatinine, BGL, LFTs

CSF See Table 4 for expected CSF protein and CSF:Blood

CSF protein, glucose glucose ratios.

Microbiology Blood
Blood cultures

CSF Microscopy includes Gram stain and WCC and differential

M/C/S (for urgent analysis)
(microscopy, culture and
sensitivity)

NSW Health Management of acute bacterial meningitis in infants and children 11

Diagnostic tests

Table 2. Possible additional tests based on clinical presentation

Category of test Tests Comments

Haematology Blood Indicated in patients with clinical evidence of a bleeding diathesis.

Coagulation profile including
FDPs, ESR*, CRP* *Inflammatory markers add useful information on clinical progress.

Biochemistry Urine If patient has hyponatraemia and SIADH is possible.

Urinary

Plasma
plasma osmolality

Radiology Head CT scan Indicated if space occupying lesion is suspected eg brain tumour.
It does not reliably exclude raised intracranial pressure.
Patient should be clinically stable.

Microbiology and Virology CSF

Bacterial antigen detection Limited sensitivity. Only occasionally indicated eg if previous
antibiotics used – discuss with senior staff or clinical microbiologist.

Viral culture If CSF pleocytosis and viral meningitis suspected.

Meningococcal PCR Very helpful if prior antibiotics used

Enteroviral PCR If viral meningitis is suspected

Herpes simplex PCR

Mycobacterium tuberculosis If MTB suspected . Adequate volumes should be obtained for

(MTB) stain, PCR and culture mycobacterial culture – aim for 5–10 mls minimum.

Cryptococcal stain and antigen Immunocompromised patients including HIV patients.

Cytology Consider asking lab to send to haematology for cytology for

suspected eosinophilic meningitis, as eosinophils are labile.
Also indicated if CNS leukaemia is possible.

Skin
Scrapings of skin lesions M/C/S. Gently deroof the skin lesion with a needle
Roll the sterile swab over the base of the lesion and then onto a
glass slide. Collect another swab and place into Stuart’s Transport
media for culture.

Blood
Neisseria meningitidis Helpful in aiding diagnosis. Utility for immediate diagnosis
IgM serology limited.May require convalescent serology.

Enteroviral serology If viral meningitis suspected.

Herpes simplex serology

In the context of emergency department care, samples may be taken and marked for storage
(particularly CSF) for the later addition of relevant studies to avoid haphazard ordering of tests.

12 Management of acute bacterial meningitis in infants and children NSW Health

The Lumbar Puncture (LP)

An LP for CSF analysis should be performed Indications to delay the LP

once the diagnosis of meningitis is suspected
Table 3. Indications to delay the LP
and after the patient is stabilised. If there
are reasons to delay LP (see below) and Broad categories Specific indications to delay LP
bacterial meningitis is clinically suspected, Local site for LP ■ Skin infection at site of LP
antibiotics should be given prior to the LP. ■ Anatomical abnormality at the
Antibiotics may sterilise the CSF within one LP site
hour in meningococcal meningitis and within Patient instability ■ Respiratory or cardiovascular
four hours in pneumococcal meningitis.17 compromise
However, instituting antibiotics 1–2 hours ■ Continuing seizure activity
prior to LP does not decrease the diagnostic
Suspicion of space ■ Focal seizures
sensitivity of the CSF culture if done in occupying lesion or ■ Focal neurological signs
conjunction with blood cultures and CSF raised intracranial ■ Reduced conscious state
bacterial antigens.18 pressure (some suggest a GCS of < 8)
and especially if the patient
The decision to perform cranial computed is comatose
tomogram (CT) before the LP is one factor ■ Decerebrate or decorticate
contributing to delayed diagnosis.19 Although posturing
concerns about herniation following an LP exist, ■ Fixed dilated or unequal pupils
herniation is unlikely in children unless they ■ Absent dolls eye movement
have focal neurological findings or are ■ Papilloedema
comatose.20 A CT scan cannot rule out raised ■ Hypertension or bradycardia
intracranial pressure and a normal CT does ■ Irregular respirations
not absolutely exclude subsequent risk of
Haematological ■ Bleeding diathesis
herniation.21 The potential disadvantage of
Logistics ■ No pathology service
transporting a sick child to the CT scanner
readily available
should be factored in as the transport itself
and the CT scanner area may pose risks to a
critically ill child. Movement artefact can also
lead to poor or useless image quality in the
unintubated child.

NSW Health Management of acute bacterial meningitis in infants and children 13

The Lumbar Puncture (LP)

Interpreting the CSF Guide to distinguishing a traumatic

If there is difficulty in interpreting the LP, tap from CSF pleocytosis
a clinical microbiologist, infectious disease A simple rule is that for every 500 RBC in the
physician or senior staff should be consulted. CSF, it is acceptable to have one WBC.
No CSF test is fully reliable in distinguishing However this depends on the peripheral white
bacterial from non-bacterial meningitis. In rare and red cell counts.
instances (< three per cent), ‘normal’ CSF
A more precise formula to estimate the WCC
findings have been associated with culture
in CSF has been described.25
proven bacterial meningitis. However, in most
cases, clinical indicators of meningitis or sepsis 1. The ratio of RBC to WBC in the periphery
will be present.22,23 A repeat LP at 24–48 hours is generally 1000 RBC: 1–2 WBC x 106/L.
may be indicated when clinical indicators of 2. Thus, number of WCs introduced into
meningitis are present but CSF examination is the CSF per L =
normal. Post-ictal CSF abnormalities (pleocytosis WBC(Peripheral) x RBC(CSF)
or raised protein) are rare, and should not be x 106/L
RBC(Peripheral)
readily accepted as a cause for an abnormal CSF.24

3. Compare result with actual number of

WCC in CSF.
4. 1000 x 106/L RBC in CSF raises CSF protein
by about 0.015g/L.
Modified from Lipton, 1993.

Table 4: CSF – Normal ranges and typical findings in patients with meningitis

Polymorphs Lymphocyte Protein Glucose Glucose

(x 106/L) (x 106/L) (g/L) mmol/L (CSF:Blood ratio)

Normal
≤ 1 month 0 ≤ 11 < 1.0 ≥ 2.1 ≥ 0.6
of age

Normal
> 1 month 0 ≤5 < 0.4 ≥ 2.5 ≥ 0.6
of age

Bacterial
meningitis 100–10,000 Usually > 1.0 Usually < 0.4
(but may < 100 (but may decreased (but may
be normal) be normal) be normal)

Viral meningitis Usually <100 10–1000 0.4–1 (but may Usually normal Usually normal
(but may be normal)
be normal)

Table from the Royal Children’s Hospital, Melbourne, ‘CSF interpretation’, Clinical Practice Guidelines, 2003
(reproduced with permission). http://www.rch.unimelb.edu.au/clinicalguide/pages/csf.php

14 Management of acute bacterial meningitis in infants and children NSW Health

 The Lumbar Puncture (LP)

White cells in CSF CSF protein concentration

The CSF characteristics in normal patients and
in acute bacterial and viral meningitis are outlined
in Table 4. The presence of polymorphonuclear
(PMN) cells is always abnormal and if present,
usually suggests bacterial meningitis. It may
also occur in the early phase of viral meningitis,
although lymphocytosis is more commonly
seen. In partially treated bacterial meningitis,
the relationship between PMNs and lymphocytes
may be reversed. In tuberculous (TB) meningitis,
the total WCC is usually < 500 x 106/L and
lymphocytes predominate (although PMNs
may predominate in the early stages).26
Characteristically, the CSF glucose is low
(< 50% of serum glucose) and CSF protein
raised (often 1.0–3.0 g/L),26 but normal values
do not exclude TB meningitis.27
CSF glucose concentration
Blood glucose levels obtained at the time of
the LP enables proper interpretation of the CSF
glucose as changes in the CSF glucose level
follow changes in the blood glucose by ≥ 30
minutes.28 CSF glucose < 2.2 mmol/L is found
in about 2/3rds of patients with bacterial
meningitis. CSF: blood ratio <0.3 is found in
70%.29 However, a normal glucose does not
exclude meningitis. While the CSF glucose
seldom influences treatment decisions,
the CSF glucose level was found useful in the
following situations.30
Again, the test was found valuable in the above
scenarios.30About 90 per cent of patients with
bacterial meningitis will have elevated protein
levels.18 The protein levels may be elevated in a
traumatic tap. There will be an approximate
0.01–0.015 g/L increase in protein levels for
every 1000 RBCs in uncentrifuged CSF samples.
Gram stain
This is the best single test for rapidly diagnosing
bacterial meningitis and initiating appropriate
therapy.28,29,31 The Gram stain will identify bacteria
in 60–90 per cent of cases.28 Occasionally, the
Gram stain will be positive despite the absence
of pleocytosis.29,32,33 Gram stain yields are
reduced if there has been prior treatment
with antibiotics, but other CSF indices may
still indicate a likely bacterial infection.34
Table 5. Gram stain results of common bacteria
causing community acquired bacterial meningitis
Organism CSF Gram Stain
Group B streptococcus Gram positive cocci
resembling streptococci
Streptococcus pneumoniae Gram positive diplococci or
GPC resembling streptococci
Neisseria meningitidis Gram negative diplococci or
gram negative cocci
Haemophilus influenzae Gram negative cocco-bacilli
Enterobacteriaceae eg E coli Gram negative rods

■ patients pre-treated with antibiotics Listeria monocytogenes Gram positive rods

Gram variable rods*
■ CSF pleocytosis – to aid in differentiating
between the most likely class of organism *Discuss with microbiologist
■ patients > eight weeks of age
■ patients at risk of unusual organisms.

NSW Health Management of acute bacterial meningitis in infants and children 15

Antibiotic management

General Empiric antibiotic management

Empiric antibiotics selection is dependent on of suspected Streptococcus
the likely bacterial organism and modified by pneumoniae meningitis
factors such as antibiotic resistance patterns.
When S. Pneumoniae meningitis is suspected,
Subsequent therapy is based on culture and
a third generation cephalosporin plus
sensitivities. A current version (version 12,
vancomycin as empiric antibiotic regimen
2003) of the Australian Antibiotic Therapeutic
is recommended in the following situations:
Guidelines should be consulted for antibiotic
treatment and doses. Therapy should be ■ CSF with Gram positive diplococci or
initiated immediately after LP results or Gram positive cocci resembling streptococci
immediately after the LP procedure if clinical seen on Gram stain.
suspicion for meningitis is high or the CSF is ■ CSF is negative by Gram stain but the
turbid. It is anticipated that the epidemiology clinical presentation and/or other CSF
of bacterial meningitis will change following the findings are highly suspicious for
wider uptake of the conjugate pneumococcal bacterial meningitis.
and meningococcal vaccines and/or perinatal ■ High clinical suspicion of bacterial
prevention strategies. The choice of antibiotics meningitis, but a lumbar puncture is
should not be influenced by previous contra-indicated (see Table 3).
pneumococcal or meningococcal vaccination as
vaccine serotype coverage is not complete.
Table 6 summarises the common bacterial
pathogens by age and antibiotic selection.
Multi-resistant Streptococcus pneumoniae
has been on the rise since the mid-1990s.
Approximately 25 per cent of Streptococcus
pneumoniae strains in metropolitan NSW
have reduced susceptibility to penicillin
(NSW Pneumococcal Network Data), with
regional variations. Rates of resistance in areas
change from year to year.

16 Management of acute bacterial meningitis in infants and children NSW Health

 Antibiotic management

Table 6. Empiric antibiotic selection

Age Group Common Organisms Antibiotic

0–3 months Group B streptococcus, Escherichia coli, Ampicillin (or benzyl penicillin) + cefotaxime
Listeria monocytogenes *NB: Ceftriaxone is contraindicated
in neonates.

> 3 months–15 years Neisseria meningitidis (Meningococcus) Cefotaxime or ceftriaxone

Haemophilus influenzae (now rare with
Hib vaccination)

NOTE: Streptococcus pneumoniae (Pneumococcus) Add Vancomycin to above regimens

Any age S. pneumoniae is a possible aetiological agent (Note: vancomycin must be used in
in any age group. If S. pneumoniae is suspected, combination with a third generation
indications to add vancomycin include: cephalosporin for penicillin resistant
■ CSF with Gram positive diplococci or S. pneumoniae meningitis, and not as a
Gram positive cocci resembling single agent.)
streptococci seen on Gram stain
■ CSF which is negative by Gram stain,
but the clinical presentation and/or other
CSF findings are highly suspicious for
bacterial meningitis
■ High clinical suspicion of bacterial meningitis,
but a lumbar puncture is contra-indicated
(see Table 3 above).

Antibiotic doses
Antibiotic doses are from the current version (12th edition) of the Australian Antibiotic
Therapeutic Guidelines.35

1. Benzylpenicillin 60mg/kg (max 2.4g) IV 4-hourly

2. Ampicillin 50mg/kg (max 2g) IV 4-hourly

3. Cefotaxime 50mg/kg (max 2g) IV 6-hourly

4. Ceftriaxone 100mg/kg (max 4g) IV Daily

5. Vancomycin 15mg/kg (max 500 mg) IV 6-hourly

NSW Health Management of acute bacterial meningitis in infants and children 17

Adjunctive therapy –
Corticosteroids
In adults, a recent randomised, prospective, protocol and study population, effect-sizes were
double-blind multicentre trial demonstrated calculated as (fixed) relative risks. Results showed
that the relative risk of morbidity was reduced statistical homogeneity in fixed effect-analysis.
by a third, and the relative risk of death was The findings of the review with respect to
halved if dexamethasone was used early children are summarised in Table 7.
(just before or with the first dose of antibiotics)
Several issues were not addressable.
in bacterial meningitis. Specifically, morbidity
These include the role of steroids in children
from S. pneumoniae meningitis was
presenting with both meningitis and severe
approximately halved.36 In children, a meta-
sepsis (where low ‘physiological’ doses of
analysis in 1997 found benefit of early
steroids may be beneficial),41 the impact of
dexamethasone in reducing severe hearing
steroids on optimal antibiotic effect in high-level
loss due to Haemophilus influenzae type b
penicillin resistant pneumococcal meningitis
(Hib) meningitis.37 The benefits of steroid in
(theoretical concerns about reduced penetration
childhood meningitis have however not been
of vancomycin into the CSF with steroid use),18
uniformly significant but some studies have
the impact of steroids on long term cognitive
been either in a developed setting or where
function (putative role of dexamethasone in
children have mainly presented late in the
aggravation of hippocampal neuronal cell death,
illness.38,39 Subsequent recommendations in the
animal studies),42 the minimum duration of
post–Hib vaccination era where S. pneumoniae
steroid therapy, the maximal time after antibiotics
and N. meningitidis have become pathogens of
are commenced before the benefit of steroids
concern have been indecisive.
wane, and potential adverse impact of treating
A systematic review examining the efficacy viral meningitis with steroids (although limited
and safety of early adjuvant corticosteroid data do not support a detrimental role of
therapy in children (and adults) with acute steroids in aseptic meningitis).43
bacterial meningitis has however recently
In summary, this analysis finds that early
become available.40 There were 18 randomised
steroids in acute bacterial meningitis caused
controlled trials, 14 of which included or were
by either Hib or non–Hib in children reduce
exclusive to children ≤16 years. Only one study
the risk of severe hearing loss by about two
included infants < 1 month of age. Eight studies
thirds. Impact on neurological sequelae
included infants 1–3 months of age, but the
remains uncertain. Steroids do not increase
relative proportion of the total cohort was not
mortality and is not associated with increased
stated. Most used a four day regimen of IV
adverse events.
dexamethasone (15 of 18 studies) at either
0.4 or 0.6 mg/kg/day in four divided doses.
Steroids were administered either before or
with the first dose of antibiotics or just after
antibiotics (timing not stated in 4). As studies
were heterogenous with respect to study

18 Management of acute bacterial meningitis in infants and children NSW Health

 Adjunctive therapy – Corticosteroids

Based on the findings, it seems reasonable to
use dexamethasone in acute bacterial meningitis
in children > three months of age, provided
that children have not been pre-treated with
parenteral antibiotics. There is insufficient
information about steroids in infants < three
months of age and in those presenting with
severe sepsis or delayed or advanced
meningitis. If steroids are indicated:
■ steroids should be given early. For practical
reasons, steroids should be given at the
time antibiotics are administered as a single
push to minimise potential delay in antibiotic
administration. The suggested dosing
regimen is 0.15mg/kg, IV, every six hours
for four days (as per the meta-analysis),
although beneficial results have also been
seen in two days regimens of similar dosages
(ie 0.15mg/kg, IV, every six hours for two
days).44
■ if steroids are used and resistant
pneumococcus is found (or suspected),
careful monitoring of patients during
therapy for indications of failure of drug
therapy should done. Consideration should
be given to a repeat LP to document a
sterile CSF 48–72 hours after the start of
therapy.

Table 7. Efficacy and safety of early adjuvant steroid therapy

Intervention Relative Risk (RR)

Outcome Number of participants with outcome (%) (95% confidence intervals (CI))

Steroid Placebo

Death 46/742 48/732

(6.2) (6.6) 0.95 (0.65–1.37)

Severe hearing loss

Overall# 15/514 49/499

(2.9) (9.8) 0.31 (0.18–0.54)

Hib Not stated Not stated 0.31 (0.15–0.62)

Non-Hib## 6/191 19/203

(3.1) (8.3) 0.42 (0.20– 0.89)

Neurological sequelae

Short term* Not stated Not stated 0.72 (0.48–1.06)

Long term** 36/596 51/576

(6.0) (9.0) 0.67 (0.45–1.00)

Adverse events§ Not stated Not stated 1.06 (0.88–1.27)

# Number needed to treat (NNT) = overall, treat 20 to spare one child from severe hearing loss.
## Specific organisms not stated; mainly S. pneumoniae and N. meningitidis.
* Neurological status between discharge and six weeks later (one adult, one mixed and six paediatric studies).
** Neurological status 6–12 months after discharge (one adult and nine paediatric studies).
§ Heterogenous definitions, including gastrointestinal bleed.

NSW Health Management of acute bacterial meningitis in infants and children 19

Nursing issues

The nursing issues in the ED setting
are summarised.
Step one
Triage according to clinical indicators.
Step two
Prioritise care. The nurse’s role is to prioritise
Airway, Breathing and Circulation, accompanied
by a rapid assessment of conscious level using
the AVPU# scale.
Step three
Follow with specific nursing assessments.
These should include the following:
■ Assess for decreased cerebral tissue
perfusion related to increased ICP:
– neurological observations, including
blood pressure should be performed
at intervals determined by the child’s
clinical state
– assess for increased ICP
– monitor fluid and electrolyte status.
■ Assess for ineffective breathing pattern
related to increased ICP:
– monitor respiratory rate, work of
breathing and pulse oximetry.
■ Assess for potential for injury related
to seizures:
– document characteristics of seizure
activity-duration, characteristics of
motor behaviour and post-ictal phase
– assess the patient’s environment
for potential hazards.
■ Assess for alteration in fluid and
electrolytes related to SIADH, DI, diuretics,
fluid restrictions:
– monitor haemodynamic parameters
– monitor urine output
– monitor SG, urine electrolytes
and osmolality.
■ Assess for alterations in comfort related
to meningeal irritation, headache,
photophobia, fever
– monitor temperature and assess
effectiveness of comfort measures.

# Is the patient Awake, responding to Voice, responding to

Pain or Unresponsive?

20 Management of acute bacterial meningitis in infants and children NSW Health

Pyschosocial needs
of the family
The diagnosis of bacterial meningitis is a
frightening one for families, especially if the
child is critically ill. When the child is stabilised,
staff should set aside time as soon as possible
to address family concerns.

Transfer of patient to
tertiary referral centre
Patients with bacterial meningitis will need
admission to hospital. If inpatient facilities are
not available locally, transfer to a regional
centre with specialist paediatric facilities may
be required. Most significantly unwell children
will require transfer to a paediatric intensive
care unit. If this facility is not available locally,
the NETS line should be called (1 300 362 500)
as soon as possible after presentation rather
than delaying till after the patient has been
fully assessed, investigated and stabilised.
Through this line, advice from both tertiary
and retrieval clinicians can be obtained and
decisions made about the timing and type
of transfer.

NSW Health Management of acute bacterial meningitis in infants and children 21

Related issues

Infection control issues Chemoprophylaxis for contacts

Infection control practices during patient care Antibiotic prophylaxis is recommended for
are outlined in NSW Department of Health meningococcal disease (strongly suspected
Circular 2002/45 – see Section 1, Standard and or proven) and invasive Haemophilus influenzae
Transmission based Precautions and Section 6, type b infection. The local Public Health Unit
Use of Personal Protective Equipment (PPE).45 should be consulted. The indications and
PPE must be worn when undertaking any regimen for prophylaxis and dosing is in the
procedure where the likelihood of splashing or Australian Antibiotic Therapeutic Guidelines
splattering of blood or other body substances (12th edition). The NHMRC Guidelines
exists. All cases of suspected bacterial meningitis for management of meningococcal disease
should be initially isolated in a single room. in Australia is also available on
Ongoing isolation requirements should be http://www.cda.gov.au/pubs/other/mening.htm.
determined by the hospital infection control Prophylaxis is not recommended for health care
team and is based on the likely causative workers unless direct contact with respiratory
organism. secretions of patient with suspected (or proven)
Neisseria meningitidis has occurred.
Notification to public health
In accordance with the NSW Public Health
Act, hospital staff are required to notify
suspected or confirmed invasive infections
(including meningitis) due to either
Haemophilus influenzae type b or Neisseria
meningitidis infection to their local Public
Health Unit. Cases are to be notified on clinical
suspicion. Cases of invasive pneumococcal
disease are laboratory notifiable. The need
for chemoprophylaxis for contacts of index
case should be discussed with the local
public health unit.

22 Management of acute bacterial meningitis in infants and children NSW Health

Glossary

AVPU Is the patient Awake, IV Intravenous

responding to Voice, responding
LFTs Liver function tests
to Pain or Unresponsive
LP Lumbar puncture
BGL Blood glucose level
MTB Mycobacterium tuberculosis
ED Emergency department
M/C/S Microscopy, culture and sensitivity
CNS Central nervous system
Na+ Serum sodium
CSF Cerebrospinal fluid
NETS NSW newborn and paediatric
CRP C-reactive protein
Emergency Transport Services
CT Computed tomography (Phone: 1300 36 2500)
DI Diabetes insipidus NHMRC National Health and Medical
Research Council
DIC Disseminated intravascular
coagulation PCR Polymerase chain reaction
ESR Erythrocyte sedimentation rate PPE Personal protective equipment
FBC Full blood count PHU Public Health Unit
FDPs Fibrin degradation products PMN Polymorphonuclear
GCS Glasgow Coma Scale RBC Red blood cell
Hib Haemophilus influenzae type b SIADH Syndrome of inappropriate
antidiuretic hormone
ICP Intracranial pressure
WBC White blood cell
IgM Immunoglobulin M
WCC White cell count
IM Intramuscular

NSW Health Management of acute bacterial meningitis in infants and children 23

Resources
The following sites have been accessed
in conjunction with peer reviewed journals
in preparing this document. As information
and/or treatment recommendations change
constantly, updates may also be sourced
from these sites.
■ The current edition of the Australian
Therapeutic Guidelines (for antibiotic
regimens and doses). The electronic
version is available to subscribers on
http://www.tg.com.au
■ CIAP site –
http://www.ciap.health.nsw.gov.au
MICROMEDEXR Healthcare Series
Integrated Index – DISEASEDEXTM
Emergency Medicine Clinical Reviews.
24 Management of acute bacterial meningitis in infants and children
■ National (NHMRC) guidelines for the
management of meningococcal disease on
http://www.cda.gov.au/pubs/other/mening.
htm. Meningococcal public health alerts,
updates and fact sheets are also accessible
on the Department of Health site on
http://www.health.nsw.gov.au/public-
health/alert/meningococcal.
■ Additional reviews and opinions on related
topics may be sourced on Medscape
http://www.medscape.com for subscribers.
■ A recent review provides updated
background reading.46
NSW Health
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NSW Health Management of acute bacterial meningitis in infants and children 27

Parent information
sheet – meningitis
Disclaimer: This fact sheet is for educational purposes only.
Please consult with your doctor or other health professional to
make sure this information is right for your child.
The brain and spinal cord are surrounded
by a lining called the meninges. Infectionor
inflammation of the meninges is called
meningitis. There is normally a fluid between
the meninges and the brain or spinal cord
called cerebrospinal fluid (CSF). In meningitis,
the CSF becomes infected.
Lumbar puncture
The CSF can be sampled to see if it is infected
by using a needle which is put into the back.
This is called a lumbar puncture. The needle is
inserted between two bones in the spine
(the vertebrae) and into the CSF. The needle
does not go into the spinal cord. The CSF from
the back is just like the CSF around the brain
and therefore gives you the same information
when tested.
Causes of meningitis
Most meningitis is due to infection with either
viruses or bacteria. Much rarer causes include
fungi or malignant (cancer) cells. In general,
meningitis due to bacteria (bacterial meningitis)
is more severe than meningitis caused by
viruses (viral meningitis). Almost all children
with viral meningitis recover completely. Some
children with bacterial meningitis may have
long–term problems, but this depends on the
bacteria involved and the age of the child. The
way a child is affected by the illness is different
for each child.
28 Management of acute bacterial meningitis in infants and children
Symptoms
Children with meningitis usually have a
high fever, headache, loss of appetite and
drowsiness or irritability. They may complain
that the light hurts their eyes. They may have
a stiff neck. Small babies may have a bulging
fontanelle (soft spot). Children with meningitis
may become increasingly confused, drowsy and
may develop fits (convulsions) or go into coma
(unconscious). A purple rash (either dots or
bruises) can occur, especially with one type of
meningitis, (meningococcal). Rashes also occur
with some viruses (enteroviruses), although
most children with meningitis have no rash.
If you are worried your child may have
meningitis, you must take your child to your
local doctor or hospital immediately.
Bacterial meningitis
The most common cause of bacterial meningitis
in Australia used to be Haemophilus influenzae
type b (Hib). Since a vaccine against Hib was
introduced in 1993, the number of cases each
year has fallen by more than 90 per cent.
Now, the two most common bacteria which
cause meningitis in children are the
meningococcus (see also the Meningococcal
infection fact sheet) and the pneumococcus.
All these bacteria live in the nose, and can
enter the bloodstream and then infect the
meninges on rare occasions.
Meningococcal and Hib meningitis can be
transmitted to other children although this
requires close contact and is uncommon.
Antibiotics may be given to family and close
friends to prevent it spreading. Pneumococcal
meningitis is hardly ever transmitted to others.
NSW Health

Usually, any major problem is obvious by the
time the child leaves hospital but even major
problems improve over time. It is important to
have hearing tests and follow-up to check your
child for minor problems.
Viral meningitis
Viral meningitis is usually much less severe
than bacterial meningitis, but some cases can
be severe causing encephalitis or brain
inflammation as well as meningitis. Diseases
which can cause viral meningitis or encephalitis
include mumps, measles and polio. These can
all be prevented with immunisation (see the
immunisation tables of the Immunisation fact
sheet). With high immunisation rates, now the
most common viruses causing meningitis are
the enteroviruses. They are related to polioviruses,
but virtually never cause paralysis. The viruses
get into the mouth from infected faeces
through contaminated hands, food or drink.
Hand washing should prevent spread of these
viruses. Children with viral meningitis have
the same symptoms as those with bacterial
meningitis, particularly fever, headache, neck
stiffness and not liking the light, but are usually
not so sick.
NSW Health Management of acute bacterial meningitis in infants and children
Parent information sheet – meningitis
Prevention
There are some causes of meningitis, such as
Hib, mumps, measles and polio, which can
be prevented by immunisation. Recently, new
vaccines have become available that prevent
most cases of pneumococcal meningitis and
one type (type C) of meningococccal meningitis.
Treatment
Bacterial meningitis can be treated with
antibiotics, and most children recover.
Viral meningitis usually gets better on its own.
Almost all healthy children or healthy adults
with viral meningitis make a complete recovery
without long-term problems unless they also
have encephalitis.
Remember
■ Most children with meningitis recover
completely.
■ If your child has bacterial meningitis,
follow up with your doctor is important.
■ Make sure your child is up-to-date with
their immunisations.
This parent information was developed by The Children’s
Hospital at Westmead, Sydney Children’s Hospital, Randwick
and John Hunter Children’s Hospital.
29
Working party members

Dr Pamela Palasanthiran (Chair).........Infectious Diseases Specialist, Department of Paediatric

Immunology & Infectious Diseases,
Sydney Children’s Hospital, Randwick
Dr Tom Grattan-Smith .......................Paediatric Intensive Care Specialist, St George Hospital, Kogarah
Dr Michael Watson ...........................Staff Specialist in Microbiology,
The Children’s Hospital at Westmead
Mary-Lou Morrit................................Clinical Nurse Consultant, Paediatric Intensive Care,
Sydney Children’s Hospital, Randwick
Dr Peter Grant ...................................Staff Specialist, Emergency Department,
St George Hospital, Kogarah
Dr Christopher Poon .........................General Paediatrician, The Children’s Hospital at Westmead
Dr Mark Lee ........................................Paediatric Physician, Emergency Department,
John Hunter Children’s Hospital
James Smith......................................Clinical Nurse Consultant, Neurology Department,
John Hunter Children’s Hospital

30 Management of acute bacterial meningitis in infants and children NSW Health

SHPN (SSD) 040157