Meningitis

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide Emergency Department (ED) staff with the assessment and management of meningitis.

Background^1,2,3,4

Despite advances in the diagnosis and prevention of meningitis it remains a major cause of morbidity and mortality in children.
It is impossible in the ED to distinguish clinically between viral and bacterial meningitis. Therefore, all cases of meningitis should initially be managed as if the cause were bacterial.
A significant reduction in the incidence of disease was achieved with the introduction of vaccines against Haemophilus influenza type b, Streptococcus pneumoniae and Neisseria meningitidis.
Despite this, meningitis continues to pose a risk of death or permanent disability to children.
Given the morbidity and mortality with herpes simplex and varicella zoster virus meningoencephalitis, antiviral therapies should be considered if suspected

The usual cause of meningitis in children differs according to age and immunisation status:

Age	Organism (in order of likelihood)
Age	Bacteria	Viruses
0 - 1 month	Group B Streptococcus, Escherichia coli and other gram negative bacilli, Streptococcus pneumoniae, Listeria monocytogenes, Neisseria meningitidis, Haemophilus influenzae type b (Hib)*	Enterovirus, Parechovirus, Herpes Simplex virus
1 -3 months	Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), Group B Streptococcus, Escherichia coli, Listeria monocytogenes*	Enterovirus, Parechovirus
3 months - 5 years	Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib)*	Enterovirus, Parechovirus
6 years and older	Neisseria meningitidis, Streptococcus pneumoniae	Enterovirus, Parechovirus
	* Rare since the introduction of Hib vaccine

Assessment^2,3,4

History

Obtain a general medical history.

Important questions to ask early:

Immunisation status, ensure immunisations are not 'alternative medicine' or 'homeopathic'
Recent antibiotic use - as it could be partially treated meningitis, and recent antibiotic use may also be a risk factor for carriage of relatively resistant pneumococci requiring addition of vancomycin to the treatment regimen.

Examination

The child may be obviously unwell, look septic, moribund, floppy and pale with a high pitch cry. Refer to Sepsis recognition and management – ED Guidelines.
High fever, vomiting, neck stiffness and photophobia may be evident. In young infants, classical signs of meningeal inflammation such as neck stiffness are often absent.
The child may have an altered level of consciousness or focal neurological signs - 20% will have seizures at some point during the course of the illness.

Early presentation

Children presenting early may have less obvious signs of meningitis
Fever is common and headache, irritability, anorexia or vomiting may be present.

Neonates and infants

Neonates and infants may present with non‐specific signs of infection such as poor feeding, irritability, lethargy, vomiting or fever without focus.
The clinician should have a high index of suspicion for the possibility of meningitis, and have a low threshold for performing a diagnostic lumber puncture.

Investigations

Lumbar Puncture (LP)^2,4

Refer to Lumbar puncture
LP is the only way to confirm the diagnosis of meningitis
It allows identification of the organism with antibiotic susceptibility testing, thus ensuring appropriate use of antibiotics
LP should (with few exceptions) be performed in every child who may have meningitis
A good rule of thumb is that if you are asking yourself "should this child have an LP?" the answer generally is "yes".

Contraindications for LP^2,4

Coma and/or decreasedlevel of consciousness
Signs of raised intracranial pressure: altered pupillary responses, absent Doll's eyes reflexes, decerebrate or decorticate posturing, papilloedema, Cushing's Triad (abnormal respiratory pattern, hypertension, bradycardia)
Seizures
Focal neurological signs
Evolving petechiae / purpuric rash or coagulopathy (e.g. disseminated intravascular coagulation in Meningococcal disease)
Shock, cardiovascular compromise
Respiratory compromise
Evolving petechiael/purpuric rash.

Not contraindications for LP

Brief tonic‐clonic, myoclonic, absence or atonic seizures, in isolation
Drowsiness
Irritability
Vomiting.

If LP is contraindicated start antibiotic treatment immediately and consider computerised tomography (CT) head.

Recommended tests to be requested on Cerebrospinal Fluid (CSF)

CSF microscopy, culture and susceptibility testing
CSF glucose and protein
A multliplex PCR (polymerase chain reaction) panel will be routinely performed on
- all CSF samples from all infants < 28 days
- all CSF samples where the total white cell count is > 5 cells per mm³
- all other CSF samples on request where the clinical suspicion of meningitis is high
A BioFire^® FilmArray^® Meningiits/Encephalitis (ME) Panel is a multiplex PCR panel used to identify multiple viral and bacterial pathogens.
Pathogens detected by this panel include:
- Bacteria: Escherichia coli K1; Haemophilus influenzae; Listeria monocytogenes; Neisseria meningitidis; Streptococus agalactiae; Streptococcus pneumoniae
- Viruses: Cytomegalovirus (CMV). Enterovirus (EV), Herpes Simplex Virus 1 and 2 (HSV-1; HSV-2); Human Herpesvirus 6 (HHV-6); Human Parechovirus (HPeV), Varicella Zoster Virus (VZV)
- Fungi: Cryptococus neoformans/gattii
Detection of any pathogenic bacteria, fungi and EV, HPeV, HSV-1, HSV-2 or VZV in a child with meningitis/encephalitis is highly suggestive of meningitis secondary to this pathogen
Detection of HHV-6 and CMV, both viruses associated with latent infection, need to be interpreted with caution. A discussion with a Clinical Microbiologist or Infectious Diseases Physician is recommended.

Cerebrospinal Fluid (CSF) Volumes Required

An absolute minimum of 500 microlitres (0.5mL) is required, with 1mL preferred
One drop of CSF = 30‐40 microlitres, thus a minimum of 15‐20 drops is needed (30-40 drops preferred), collected in three bottles.

Other tests

Test	Tube - Specimen Container and other comments
Blood culture	Where possible, blood should be cultured. Refer to Blood Culture Collection procedure – Clinical Practice Manual
PCR on EDTA blood	Meningococcal and Pneumococcal PCR – this requires a second separate EDTA tube (purple / lilac top)
Throat and rectal swabs	Enterovirus testing (and parechovirus testing if < 12months)
Full Blood Count (FBC)	EDTA tube (purple/lilac top)
C-Reactive Protein	Lithium heparin tube (green top)
Electrolytes	Especially for sodium - lithium heparin tube (green top)
Capillary / venous blood gas	Defines overall metabolic status of child
Coagulation studies	Blue top tube filled to and not beyond mark on tube
Group and hold	Pink top tube Requires handwritten patient information on the label, not patient sticker

Cranial CT

This is of limited use in acute bacterial meningitis
CT does not reliably exclude raised intracranial pressure, and a normal CT should not reassure one about the risk of coning following an LP
CT does have a role when the diagnosis is in doubt (e.g. posterior fossa tumours can also cause meningism), or when complications of meningitis (e.g. brain abscess) are suspected.

Management

Time to administration is crucial - early empirical antibiotics will decrease mortality
Ideally antibiotics should be given once the septic screen, (including the LP) is done, but if this is not possible do not delay antibiotic administration.

Antimicrobials

Refer to Meningitis and Meningoencephalitis Guideline - ChAMP
< 1 month of age:
- IV cefotaxime AND IV benzylpenicillin AND IV aciclovir – Refer to Cefotaxime, Benzylpenicillin, Aciclovir – Neonatal Medication Guidelines (internal WA Health only) for dosage and frequencies.
- Discuss all cases with Infectious Diseases or Clinical Microbiology Team
≥ 1 month of age:
- IV ceftriaxone
- ADD IV vancomycin if:
  - Gram-positive cocci are seen on Gram stain OR
  - the patient has known or suspected otitis media or sinusitis OR
  - the patient has been recently treated with a penicillin, cephalosporin or carbapenem antibiotic OR
  - the patient is too unwell to undergo a lumbar puncture.
In all children and especially neonates, consider adding IV aciclovir for suspected herpes simplex or varicella encephalitis.

Steroids^5,6

The role of steroids in the treatment of meningitis has been controversial.
A recent Cochrane review states that steroids may reduce neurological sequelae (particularly hearing loss) in meningitis in developed countries such as Australia.⁵
Current management at PCH is to give IV Dexamethasone: 3 months – 18 years, 0.15 mg/kg (maximum 10 mg) every 6 hours for 4 days.⁶
Where possible, give the first dose just prior to or at least concurrently with antibiotics.⁶
Antibiotics should never be delayed when dexamethasone is not immediately available.

Fluids

Patients with meningitis are at risk of hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH)^1,2
Therefore any maintenance or replacement fluid should be isotonic (sodium chloride 0.9%), with or without glucose 5%.
Intravenous fluid rate should be at 30‐70% maintenance rate.
Careful management of fluids and electrolytes is essential in the treatment of meningitis.
Under-hydration, over-hydration, and rapid shifts in cerebral fluid balance are all associated with an adverse neurological outcomes.
Maintaining a normal blood pressure and circulating volume is essential to maintain optimal cerebral perfusion.
If the child is hypotensive, this should be treated with a bolus of 10 mL/kg of sodium chloride 0.9%. If the child remains shocked, a further bolus of 10 mL/kg of sodium chloride 0.9% should be given, and advice should be sought from Paediatric Critical Care (PCC).
If the child was not initially hypotensive a more cautious approach is needed to avoid precipitating / exacerbating cerebral oedema, and boluses of IV fluid should be avoided.

Nursing Considerations and Observations

Standard, contact and droplet precautions are recommended in all children admitted with suspected or proven meningitis. Refer to Standard and Transmission Based Precautions Policy – Infection Prevention and Control Manual (internal WA Health only).
Complete and record a full set of observations on the Observation and Response Tool and record additional information on the Clinical Comments chart.
- Minimum hourly pulse respiratory rate, oxygen saturations and blood pressure as clinically indicated. Consider increasing frequency if unwell.
- Hourly temperature
Hourly full neurological observations
Hourly strict fluid balance chart (monitor for fluid overload)
Consider–topical local anaesthetic e.g. lidocaine (lignocaine) with prilocaine (e.g. EMLA®) application in preparation for insertion of IV access. IV insertion and treatment with antibiotics or fluids should not be delayed while waiting for the topical local anaesthetic to become effective.

Admission criteria

All children with suspected meningitis will be admitted under the General Paediatric Team or neurosurgical team if recent surgery or ventriculoperitoneal shunt.
- Refer to Ventriculoperitoneal shunt problems.
- Refer to Transmissible Diseases Index – Infection Prevention and Control Manual (internal WA Health only).

References

Muller, Martha L. "Pediatric Bacterial Meningitis." Medscape.com. Updated 16 Jan 2019. Ciyed:11 April 2022. Available from: Pediatric Bacterial Meningitis: Practice Essentials, Background, Pathophysiology (medscape.com)
Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine Eighth Edition. Journal of Pediatric Critical Care 8.2 (2021): 116. Web. Kundan Mittal.
Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier
Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
Cochrane Summary: Corticosteroids for Bacterial Meningitis Cited: 11 April 2022. Available from: Corticosteroids for bacterial meningitis | Cochrane
AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Dexamethasone; [Modified January 2022, Cited: 11 April 2022,] Available from: Dexamethasone - AMH Children's Dosing Companion (health.wa.gov.au)

Endorsed by:	CAHS MSC	Date:	Sept 2022
		Review date:	Jul 2025

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