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Paediatric Pathways

Meningitis - management of children aged ≥3 months with bacterial meningitis

Confirmed meningitis:
CSF WCC>5
+/- raised CSF protein
+/- low CSF glucose

Immediate empiric antibiotics IV as per local / national guidelines1,2

  • Ensure dose maximised for CNS infection
  • Dexamethasone if:
    • Purulent CSF
    • CSF WCC>1000
    • Bacteria seen on Gram stain
    • Not indicated if meningococcal disease suspected

INDICATIONS FOR URGENT NEUROIMAGING:
Reduced GCS
Symptoms / signs of raised intracranial pressure
Focal neurology
Seizures

No bacterial pathogen identified

Test for viral meningitis (enterovirus / parechovirus can be associated with polymorphonuclear cell predominant CSF pleocytosis)
Consider TB meningitis if lymphocyte predominant CSF, markedly raised protein and low glucose.

MANAGEMENT

Viral pathogen identified from CSF and clinical picture consistent with viral meningitis:
Stop antibiotics (if no concomitant bacterial infection)

Causative pathogen not identified, but still considered likely bacterial meningitis:
Antibiotic duration 10 days4 (consider stopping antibiotics at 5 days if rapid recovery). Total course IV – no oral step down.
Consider PICC or Midline IV access early, if antibiotic duration likely to be >5 days

Seek ID/Micro advice if:

  • Unusual pathogen (including TB meningitis)
  • Infection associated with implantable device
  • Clinical/epidemiological features suggestive of TB or imported infection
  • Failure to respond to empiric therapy or onset of secondary fever

Confirmed bacterial cause (culture or PCR)
Note: caution with false positive results with BioFire® array panel – esp. pneumococcus.3 Ideally confirm biofire result by performing targeted pneumococcal PCR on existing sample.

MANAGEMENT

  • Rationalise antibiotics as per organism and sensitivities
  • No oral antibiotic step down: total course IV
  • Consider PICC or Midline IV access early, if antibiotic duration likely to be >5 days
  • Suggested antibiotic duration for uncomplicated cases4:
    • N. meningitidis 7 days
    • S. pneumoniae 10-14 days
    • H. influenzae 7-10 days
    • E. coli 21 days

Early / acute complications of meningitis occur most frequently by days 2–3 and are rare after days 3–4. Fever lasts 5–9 days in 13% of patients.5 Consider ambulatory management if the patient is seizure free and apyrexial for >24 h. Be cautious about ambulating a child with meningitis before day 5 and if abnormal neurology persists6-8
Consider ambulation6 on IVAbx unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information
Ensure out-patient follow-up in place to monitor for long term effects of bacterial meningitis as per national guidance.

Seek ID/Micro advice if:

  • Unusual pathogen (including TB meningitis)
  • Infection associated with implantable device
  • Clinical/epidemiological features suggestive of TB or imported infection
  • Failure to respond to empiric therapy or onset of secondary fever

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Kim KS. Acute bacterial meningitis in infants and children. Lancet Infect Dis 2010; 10: 32-42.
  2. Sigfrid L, Perfect C, Rojek A et al. A systematic review of clinical guidelines on the management of acute, community-acquired CNS infections. BMC Med 2019; 17: 170.
  3. Tansarli GS, Chapin KC. Diagnostic test accuracy of the BioFire(R) FilmArray(R) meningitis/encephalitis panel: a systematic review and meta-analysis. Clin Microbiol Infect 2020; 26: 281-90.
  4. NICE (National Institute for Health and Care Excellence). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management. Clinical Guideline [CG102]. Available at https://www.nice.org.uk/guidance/cg102. 2010.
  5. Lin TY, Nelson JD, McCracken GH, Jr. Fever during treatment for bacterial meningitis. Pediatr Infect Dis 1984; 3: 319-22.
  6. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.
  7. Waler JA, Rathore MH. Outpatient management of pediatric bacterial meningitis. Pediatr Infect Dis J 1995; 14: 89-92.
  8. Marcy M. Outpatient management of bacterial meningitis. Pediatr Infect Dis J 1989; 8: 258-60.
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